Les manifestations rénales de la spondylarthrite ankylosante : à propos de 210 cas

PURPOSE

To define the epidemiology, clinical, biological and histological features of renal diseases in ankylosing spondylitis, ginving special attention to unusual forms.

METHODS

We retrospectively reviewed the medical record of 28 cases with renal involvement among 210 cases of ankylosing spondylitis seen over a 27 year period who met the Amor criteria.

RESULTS

Twenty-eight of 210 patients (13,3%) presented one or more signs of renal involvement: macroscopic hematuria (4 patients), microscopic hematuria (8 patients), proteinuria (15 patients), nephrotic syndrome (6 patients), decreased renal function (13 patients). Secondary renal amyloidosis and nephrolithiasis (8 patients) were the most common cause of renal involvement in ankylosing spondylitis followed by IgA nephropathy (3 patients).

CONCLUSION

The funding of renal abnormalities in 13,3% of our patients suggests that in this illness evidence of renal involvement should be actively investigated in ankylosing spondylitis.

[Indications, complications and cost of internal jugular catheters in hemodialysed patients: study of 533 cases]

INTRODUCTION

Central venous catheters for hemodialysis are very useful as blood accesses when arteriovenous fistulas (AVF) are not available. The aim of this study is to analyse the clinical impact of internal jugular catheters (IJC) in hemodialysed patients and to assess their economic consequences.

PATIENTS AND METHODS

It is a prospective study realised from July 1998 to March 2002 including 533 hemodialysed patients without functional AVF: 280 males and 253 females aged between 17 and 87 years (mean age: 54.1 +/- 15 years). Single lumen polyurethane Vygon were used. All catheters were placed using Seldinger procedure and the posterior route of Jernigan which is more comfortable for patient.

RESULTS

Indications of IJC placement were new hemodialysed patients without AVF in 73.5% cases and no functional AVF in 26.5% cases. During the period of the study. IJC was placed in 533 patients. We failed to place the IJC at the first attempt in 42 patients but we succeed in placing it on the controlateral side. During IJC placement, we observed 50 (9.4%) cases of accidental puncture of carotid artery. The median duration use of IJC was 41 days (extreme: 1 to 413 days). IJC were removed mainly because of the use of AVF in 469 (88%) cases and the catheter infection in 41 (77%) cases. Bacteriological analysis were made only for 25 patients: staphylococci were identified in 16 cases and catheter cultures were negative in the 9 other cases. All patients were treated with antibiotics. Outcome was favourable for 39 of them and we had 2 deaths by septicemia. The IJC cost was 44,287 Tunisian Dinars (DT) coresponding to 31.633 Euro including 10125 DT (7,232 Euro) for infectious treatment.

CONCLUSION

The use of IJC is frequent in our center with a high rate of infectious complications which increased the hemodialysis cost. The realisation of AVF, in patients with chronic renal failure before the beginning of hemodialysis, is the best way to limit the use of catheters.

La fibrose rétropéritonéale

OBJECTIVE

We studied the clinical, therapeutic and progressive characteristics of retroperitoneal fibrosis.

METHODS

We analysed the observations of retroperitoneal fibrosis diagnosed between 1980 and 2002 in our hospital, from the summaries of 15 patients exhibiting retroperitoneal fibrosis (RPF). Therapeutical supervision was based on biology and radiology.

RESULTS

There were 11 men and 4 women with a mean age of 44.5 years ranging from 28-64 years. Pain was predominantly lumbar or abdominal in all patients. An inflammatory syndrome was observed in all patients and renal failure in 11. Radiological examinations revealed single or bilateral in 14 cases and the fibrosis plaque in 13 cases. Treatment consisted in corticosteroids alone in 9 patients, surgery alone in 3 cases and surgery with corticosteroids in 3 patients. Ten relapses (range: 1-5) occurred in 4 patients when corticosteroids were stopped. After a mean follow-up of 36 months (range:18 days-11 years), one death was observed, 12 patients had normal renal function and 2 patients had persistent moderate renal failure.

CONCLUSION

This study confirms the rarity of retroperitoneal fibrosis, the difficulty in its diagnosis, the frequency of pain, inflammatory syndrome and renal failure. Corticosteroids are efficient and regular follow-up is required.

[Abdominal polyarteritis nodosa: angiographic features]

PURPOSE

Polyarteritis nodosa (PAN) is a systemic vasculitis of small and medium size arteries. The purpose of this study is to evaluate imaging findings, especially angiographic features, of 17 patients with abdominal involvement from polyarteritis nodosa.

PATIENTS AND METHODS

We reviewed the medical records and imaging findings of 17 patients with PAN involving the abdomen. All patients underwent digital subtraction angiography of the renal or visceral arteries completed by a post-angiographic KUB. Abdominal CT scan was available in three patients. All patients underwent muscle biopsy. A surgical biopsy of the gallbladder was obtained in one patient.

RESULTS

Multiple small aneurysms involving small and medium sized arteries were detected at angiography in 12 patients. CT showed a renal subcapsular hematoma in two patients and acute pancreatitis in one patient.

CONCLUSION

Involvement of gastrointestinal and renal arteries is frequent in polyarteritis nodosa. The diagnosis of PAN should be considered when multiple small-sized aneurysms are present at angiography even if biopsy is negative.

Impact of initial blood pressure on the mortality of diabetics undergoing renal replacement therapy

The aim of this study was to determine the blood pressure (BP) profiles and their impact on mortality among a cohort of uremic diabetics treated by hemodialysis. The studied population includes all type II diabetics starting hemodialysis for end-stage renal disease between 1990 and 1996. There were 221 patients (144 men, 77 women) aged from 37 to 78 years, were all followed until death or December 2003 without any censored data. Survival analysis to identify predictors of death was performed using the actuarial method, Cox proportional model, including systolic, diastolic, mean, and pulse blood pressures (SBP, DBP, MBP, PP). One hundred seventy-eight patients (80.5%) were hypertensive at the start of dialysis. Hypertension preceded the diagnosis of diabetes in eight cases (4.5%); 154 patients (86.5%) received antihypertensive drugs and only 23 (14.9%) had well-controlled hypertension. Our population was subdivided into four groups according to their BP levels at the time of beginning of dialysis; G1 (19.5%): normal BP (SBP [90 to 140] and DBP [60 to 90]); G2 (30.3%): Hypertension stage 1 (SBP [140 to 160] and/or DBP [90 to 100]); G3 (32.1%): hypertension stage 2 (SBP [160 to 180] and/or DBP [100 to 110]); G4 (18.1%) hypertension stage 3 (SBP [180 to 220] and/or DBP [110 to 120]). Mean age and comorbidities were similar among the four groups. During a cumulative follow-up period of 872 patient-years, 191 patients died, representing a rate of 21.9 per 100 patient-years; 20.42% of these deaths occurred during the first 3 months of dialysis. Normotensive patients showed lower survival rates without any significant difference in comparison with those of other hypertensive groups. None of the initial BP parameters (SBP, DBP, PP, MBP, hypertension stages) seemed to influence early or global mortalities, which were rather related to the urgent onset of renal replacement therapy, to age, to serum albumin, and to the score of associated morbidities. We conclude that mortality of our hemodialyzed diabetics was not influenced by the blood pressure parameters recorded at the onset of dialysis.

Métastase sternale révélatrice d'un hépatocarcinome

INTRODUCTION

Bone metastasis from hepatocarcinoma are rare, their elective seats are the ribs, the vertebra and rarely the sternum. We report a case of a sternal metastasis which makes discovery of a hepatocarcinoma.

EXEGESIS

A 64 year-old man, alcoholic with a previous history of jaundice who developed since 1999 an anterior chest tumor with excellent clinical condition. Laboratory examination showed cytolysis, cholestasis, positive antihepatitis C virus antibodies and elevated serum alphafetoprotein level. Standard radiography and computed tomography of the chest showed an osteolytic lesion of the sternum spread to the adjacent soft tissues and voluminous right hepatic lesion. Pathologic examination of the sternal tumor concluded to a differential adenocarcinoma. Etiologic investigations to find the primitive tumor were negative. Operative procedure was not possible in consideration of the infiltration of the tumor and its situation near the main blood vessels. Radiotherapy gives rise to partial regression of the tumor. A second reading of the tumor biopsy established the diagnosis of metastasis from a hepatocellular carcinoma. The patient died 22 months after the appearance of the sternal metastasis.

CONCLUSION

Hepatocarcinoma is rarely disclosed by a sternal metastasis, our case-report is particular by its prolonged survival and the good clinical condition during its follow up.

[Particularities of visceral leishmaniasis in adults not infected by HIV in Tunisia]

The incidence of adult visceral leishmaniasis in Tunisia has increased in recent years. As a result the epidemiological profile of the disease in our country is now closer to those observed in other Mediterranean countries. Most of the increase involves adults not infected by human immunodeficiency virus (HIV) although 56% of patients presented concurrent disease. In comparison with pediatric visceral leishmaniasis, adult disease is characterized by inconsistence occurrence of some major symptoms such as fever and spleen enlargement. For this reason the clinical disease syndrome may be incomplete and diagnosis may be difficult. Laboratory tests are essential for definitive diagnosis. Although no test is specific, some findings are highly useful, e.g, elevated g-globulins which was observed in 94% of patients in our series. Standard serology is less sensitive in adults with 18% of false negatives in our series probably as a result of immunodeficiency in some patients.

[Central diabetes insipidus with Behçet disease. A case report]

Vasculitis with central diabetes insipidus is a rare condition which must be recognized for an appropriate management. We report a case of Behçet disease with central diabetes insipidus. A forty seven year old men presented recurring oral and genital ulcers, skin lesions, polyarthralgia. Two years later, he showed right uveitis and central diabetes insipidus without dysfunction of the pituitary gland. Computed tomographic scan showed normal neurohypophysis and pituitary gland. Later on, he presented hemiplegia. The cerebral computed tomographic scan showed hypodense lesions. Central diabetes insipidus should not be systematically searched because it is a rare feature of the Behçet disease.

[Virilism during pregnancy]

We discuss the causes of virilism in pregnancy and the impact of hyperandrogeny on the female foetus. We report a case of virilism in a 28-year-old, gravida 1, para 1 patient with normal pregnancy and review the literature. After conception, the patient had been well until the 18th week of gestation, when she developed signs of virilization; her serum testosterone was markedly elevated. She delivered of a normal male infant at term. After delivery, signs of virilization regressed with normalization of testosterone level but a wide mass of the left ovary that persisted for 8 months. The histological study of the tumor showed luteinized thecoma. Luteomas and hyper-reactio luteinalis were the principal causes of virilism in pregnancy, thecomas are rare.

[Obstructive acute renal failure revealing visceral leishmaniasis in a diabetic patient]

We report a case of a 22 years old type 1 diabetic man with a history of weight loss, weakness, anorexia, fever and recurrent urinary tract infection since February 2001. In April 2001, he presented anuria due to obstructive acute renal failure. Hepatosplenomegaly and lymphadenopathy were absent at physical examination. Laboratory tests revealed a high level of gamma globulin (53.4 g/l) and anaemia (haemoglobin 7.7 g/100 ml) without leukopenia and thrombocytopenia. CT scan showed multiple retroperitoneal lymphadenopathies causing compression of the two ureters, hydro-ureter associated with hydronephrosis, hepatosplenomegaly and multiple pulmonary nodes. Lymphadenopathies, anaemia, high level of gamma globulin, high titres of anti-leishmanial antibodies and the excellent outcome after treatment with meglumine antimoniate (Glucantime) confirmed visceral leishmaniasis. This report documented an unusual clinical presentation of Visceral leishmaniasis in a diabetic patient.

[Renal amyloidosis secondary to hydatid cyst of the liver. Clinical remission after surgical excision]

Revelation or risk of aggravation of renal amyloidosis after surgery has been published, particularly after pneumonectomy for tuberculosis. A few cases of improvement of renal amyloidosis following treatment of amylogenic focus have been published. We report the case of a 57 year-old woman who presented with nephrotic syndrome occurred twenty days after surgical resection of an hydatid cyst of the liver secondary to echinococcus granulosus. The renal biopsy showed deposits of amyloidosis. Amyloidosis typing (using anti AA sera) revealed an AA type. The patient received colchicine during nine years. A complete clinical remission of nephrotic syndrome was obtained four years after the surgical act. We discuss the association of hydatidosis and amyloidosis, surgery and amyloidosis, and remission of renal amyloid and colchicine therapy.

[Vasculitis with renal and pulmonary involvement in a patient receiving benzylthiouracil for Graves disease]

INTRODUCTION

Vasculitis is a rare complication of antithyroid drugs reported with propylthiouracil, carbimazole, methimazole and we describe the first case with benzylthyouracil. Renal involvement during thyroid auto-immune diseases and during vasculitis as complication of antithyroid drugs will be discussed.

EXEGESIS

We present a case study of 28-year-old female patient with Graves' disease diagnosed in 1996 and treated by benzylthiouracil for 2 years. The thyroid function was poorly controlled, so surgical treatment was indicated in May 1998. One month later, she developed vasculitis with pulmonary and renal involvement. Her renal function deteriorated rapidly. On admission, the additional laboratory findings showed hematuria, proteinuria of 1.44 g/day and serum creatinine level at 1000 mumol/l. She had myeloperoxidase-anti neutrophil cytoplasmic antibody, antithyroglobulin and antimicrosome antibodies. A renal biopsy revealed pauci-immune crescentic glomerulonephritis with 75% sclerous crescents. Chest-X-ray showed unilateral alveolar shadowing and a bronchio-alveolar lavage revealed lymphocytic alveolitis. She was treated with high dose of prednisolone and cyclophosphamide. After a follow-up of 18 months, the serum creatinine level decreased at 186 mumol/l and chest-X-ray returned to normal.

CONCLUSION

Some cases of vasculitis associated with anti-thyroid drug treatment are reported.

[Diabetic fibrous mastopathy: a case report]

Diabetic fibrous mastoplasty or diabetic fibrous breast disease is a benign condition rarely observed. First described in 1984, it can lead to misdiagnosis because it simulates breast cancer. Diabetic fibrous mastoplasty usually occurs in patients with autoimmune disorders, particularly in patients with longstanding and complicated insulin-dependent diabetes mellitus. We present a case of fibrous mastoplasty in a patient with insulin-dependent diabetes mellitus known for 17 years. The clinical and radiological features and the clinical course are illustrative. We discuss the different pathogenic theories put forward.

[Neurological manifestations in Behcet's disease. Forty observations in a cohort of 300 patients]

PURPOSE

To analyse and discuss neurological involvement of Behçet' disease and therapeutical possibilities giving special attention to unusual forms.

METHODS

We retrospectively reviewed the medical records of 40 cases with neurological manifestations among 300 cases of Behçet's disease seen over a 20 years period who met the international study group of Behçet's disease criteria.

RESULTS

Central nervous system involvement was found in 39 patients and peripheral nervous involvement in one. Dominant symptoms in 40 patients with neurological manifestations of Behçet's disease were meningo-encephalitis (27 cases), intracranial hypertension (9 cases), psychic disturbances (2 cases), and polyneuritis of the lower limb (1 case). Headache and focal deficits were the major presenting signs (87%). Cerebral venous thrombosis was identified in 8 patients (6 certain and 2 probable). These could be differentiated from meningoencephalitis by their symptomatology predominaly that of intracranial hypertension. In meningoencephalitis, the cerebrospinal fluid findings were lymphocytic pleocytosis and elevated protein level cerebral CT scan, performed in 20 patients, was normal in 30% of cases. MRI performed in 2 patients, showed in one case a tumor like lesion.

CONCLUSION

Neurobehçet's disease can be classified into 2 clinical aspects: meningoencephalitis and cerebral venous thrombosis. Treatment is aimed initially at reducing the inflammation with corticosteroids and preventing relapse with adjunction of an immunosuppressor.

[Pseudotumoral neurobehçet: a case report]

Neurological involvement occurs in 5.3% to 30% of patients with Behçet's disease. Neurological manifestations can be secondary to direct central nervous system involvement (encephalitis, encephalomyelitis) or vascular angeitis (essentially cerebral venous, thrombosis and, rarely, intracranial aneurysms). Neurological pseudotumoral presentation is rarely reported. We report a case of 26-year-old woman suffering from left hemiplegia. MRI was performed and showed pseudotumoral lesion in the protuberance and the right cerebral pedicule. Oral and genital aphtous ulcers were found. HLAB51 was positive. The patient improved with steroid therapy.

[Adult Still's disease: study of a series of 11 cases]

Adult Still's disease is a systemic disease of unknown etiology. We report a retrospective study of 11 cases (9 females and 2 males) of adult Still's disease collected during 25 years. The mean age was 36 years. Fever, arthritis and skin rash was constant. Adenopathies and splenomegaly were observed in 2 patients. The laboratory findings was characterized by a constant inflammatory syndrome and leucocytosis. Hypertransaminasemia and hyperferritinemia were observed respectively in 7 cases and 3 cases. Corticosteroids were prescribed in all patients. Methotrexate was administered in 3 patients. Outcome was favorable in 10 cases, death incurred in one patient, secondary to acute hepatitis.

[Tumorous calcinosis in hemodialysis: anatomo-clinical study apropos of 3 cases]

Three patients (2 females, 1 male) with a mean age of 51.4 years receiving long term hemodialysis affected by tumoral calcinosis were analysed. Clinical, radiological and pathological features were evaluated and pathogenic were reviewed. The joints involved int the cases presented in this report were the hip shoulder and finger. The lesions were bilateral in shoulder. An increased calcium-phosphorus product (Ca x P) was observed in all patients with secondary hyperparathyroidism in one case. Surgery was carried out in all patients. No relapse of the tumoral calcinosis was observed after surgery. The most important pathogenic factor involved in uremic tumoral calcinosis is an increase in calcium-phosphorus product (Ca x P) not necessarily related to hyperparathyroidism. Therefore, maintaining the calcium x phosphate product within the normal range appears to be the most important factor ito prevent the appearance of uraemic tumoral calcinosis.

[Arterial aneurysm in Behçet's disease. Report of 5 cases]

Behçet's disease is a systemic vasculitis generally involving the venous system. Arterial manifestations, usually aneurysm or more rarely occlusion, are less common. We analysed 5 cases of Behçet's disease with arterial aneurysm complications. There were 4 men and 1 woman, mean age 34.6 years. Mean delay to arterial complications was 7.8 years after the first sign of the disease. Four patients showed evidence aneurysms of the pulmonary arteries. One patient developed an aneurysm of the aortic and iliac artery. Phlebitis was associated with arterial involvement in 4 patients. Combined corticosteroid and cyclophosphamide therapy enabled regression of pulmonary aneurysms in 2 patients. One patient was operated, outcome was favorable. Histology showed fragmentation of the media associated with vasculitis. Two patients with pulmonary aneurysms died of massive hemoptysis.

Renal replacement therapy for diabetic end-stage renal disease. Experience of a Tunisian hospital centre

OBJECTIVE

To determine the epidemiological and clinical characteristics of 299 uremic diabetics at the initiation of renal replacement therapy (RRT) and to evaluate their morbidity and the factors influencing their mortality during the dialysis period.

PATIENTS AND METHODS

All patients starting RRT for diabetic end-stage renal disease (ESRD) at Charles Nicolle Hospital of Tunis during a period of seven years (1990-1996) constituted the study population. During the follow-up period ended on December 31, 2000, all morbid events, hospitalizations and deaths were recorded. Multivariate analysis according to the Cox proportional hazards model was performed to identify the predictors of mortality.

RESULTS

There were 238 type 2 (79.6%) and 61 type 1 diabetics (20.4%) representing 20.3% of all patients accepted for RRT. The mean age at the onset of RRT was 53.16 +/- 12.43 years (range: 23 to 80 years). A poor glycemic control was observed in 46.7% of type 2 diabetics and in 67.3% of type 1 diabetics (p=0.0055). A third of patients started RRT in emergency conditions and 91% required a temporary vascular access. At the time of onset of RRT, 86.7% of patients were hypertensive and 52.1% had a nephrotic syndrome. Blindness was observed in 22.9% of type 1 diabetics and in 7.5% of type 2 diabetics (p=0.0014). During the follow-up period, 217 patients died representing a rate of 22% patient-years, 26.7% of these deaths occurred during the first 3 months of RRT and 53% were attributed to infectious or cardiovascular complications. Actuarial survival rates were 68.4%, 59.6% and 45.3% at 1, 2 and 4 years, respectively. Age, co-morbidities and conditions of onset of RRT were independently correlated with survival time.

CONCLUSION

Diabetes is a frequent cause of ESRD in Tunisia, the delayed referral to a nephrologist and coexistence of serious co-morbidities at the initiation of RRT resulted in a high rate of early death. Greater efforts should be made in our country in view of improving the quality of medical care of uremic diabetics before and during RRT.

[Rheumatologic manifestations of Behcet's disease: report of 309 cases]

PURPOSE

To define the epidemiology and clinical features of Behçet's disease, giving special attention to unusual forms.

METHODS

We retrospectively reviewed the medical records of 309 cases with joint manifestations among 450 cases of Behçet's disease seen over a 20-year period who met the International Study Group of Behçet's disease criteria.

RESULTS

Joint manifestations were present in 68.3% and were inaugural in 34.5%. The knee and ankles were the joints most commonly affected. Monoarthritis, oligoarthritis and polyarthritis were seen respectively in 12, 13.5 and 19.8%. Sacroiliitis is observed in 6%. Unusual forms included destructive polyarthritis (two cases), popliteal cyst (two cases), myositis (two cases) and ankylosing spondylitis (two cases).

CONCLUSION

Joint manifestations are common in Behçet's disease. They are frequently associated with erythema nodosum and necrotic pseudofolliculitis. Polyarthritis is not rare. Their unusual forms deserve to be known.

Hypertension in primary chronic glomerulonephritis analysis of 359 cases

The incidence of hypertension was evaluated in 359 patients with primary chronic glomerulonephritis who underwent renal biopsy. It was compared to a control group of 7,468 subjects who were obtained from an epidemiologic study performed in the same area at the same period. The prevalence of hypertension was 42%. On the basis of multiple regression analysis, the level of blood pressure was shown to be positively correlated to four independent variables: age, body mass index, degree of renal insufficiency and presence of proliferative glomerulonephritis. It was concluded that, although renal insufficiency increases the incidence of hypertension, proliferative lesions play an important contributive role in the development of hypertension.

[Study of 104 patients with renal polycystic disease (author's transl)]

Hereditary factors were observed in 43% of patients. Hypertension was observed in 45% of cases and was not correlated with the degree of renal insufficiency. Serum creatinine was significantly correlated with calcemia and uricemia. Identical correlations were observed in a population of patients whose renal insufficiency was not related to renal polycystic disease. The study provides evidence that, in polycystic kidneys: 1) Hypertension is not related to the degree of renal failure. 2) Hypocalcemia and hyperuricemia are not specific factors of the disease.