[Use of biotherapy in the management of Behçet's disease in a department of internal medicine]

BACKGROUND

Behçet's disease (BD) is a recurrent multisystemic disease responsible for occlusive vasculitis with arterial, venous and capillary involvement. The aim of this study was to determine the frequency and the features associated with the use of biotherapy in the management of patients followed in our department for BD.

METHODS

This is a retrospective study of patients medical records followed for BD in a department of internal medicine from January 2005 to August 2018.

RESULTS

A total of 41 patients were included with a mean age at diagnosis of 42.5±12.1 years (range 16 to 63) and a sex ratio men/women of 1.05. Oral and/or genital aphtosis was present in 70.7% of the patients. Other lesions were: ocular (78.0%), articular (46.3%), cutaneous (41.5%), central neurological (34.1%), vascular (26.8%), digestive (7.3%), pericardial (2.4%) and epididymal (2.4%). A biotherapy, interferon α and monoclonal antibodies, was used in 15 patients (36.6%), after failure of conventional treatments. The monoclonal antibodies were anti-TNFα (infliximab, adalimumab, certolizumab and golimumab) except in one patient for whom ustekinumab was used. Biotherapy was used in 46.9% of the patients with ocular involvement and never used in those patients without ocular involvement (P=0.01).

CONCLUSION

Biotherapy is effective and represents a solution to the failures of conventional treatments in severe forms of Behçet's disease with ocular involvement.

[Eye and cat scratch disease: A case series]

INTRODUCTION

Cat scratch disease is a pleiomorphic condition, sometimes with isolated ophthalmic involvement. We report the clinical observations of seven cases with ophthalmologic manifestations of cat scratch disease.

OBSERVATIONS

There were seven patients, with a median age of 52 years, of whom five were women and three had unilateral involvement. Six exhibited Leber's stellate neuroretinitis, an incomplete syndrome in two cases, and one associated with chorioretinal foci. One patient had isolated retinal infiltrates. The diagnosis of cat scratch disease was confirmed by Bartonella henselae serology, positive in all cases. All patients received treatment with doxycycline. Ocular complications (with optic atrophy and macular retinal pigment epithelial changes) were noted in five cases.

DISCUSSION

Ocular bartonellosis is an atypical clinical form. It requires a directed ancillary work-up with serology or PCR, which has the peculiarity of being highly specific if not very sensitive. Treatment is above all preventive. Antibiotics may be initiated.

CONCLUSION

Cat scratch disease must be excluded in the work-up of posterior uveitis.

Heart involvement in Churg-Strauss syndrome: retrospective study in French Burgundy population in past 10 years

INTRODUCTION

Heart manifestations of Churg-Strauss syndrome (CSS) are varied. In the early stages of the disease, it is difficult to distinguish between lesions that are specific to CSS and those of other etiologies. The aim of our work was to compare the characteristics of patients with heart manifestations linked or not to Churg-Strauss syndrome.

MATERIAL AND METHODS

We recorded all clinical symptoms of patients with CSS hospitalized between 1998 and 2008 in Burgundy, France, and determined the possible relationships between heart symptoms and CSS.

RESULTS

From a cohort of 31 patients, we found 20 with heart lesions. When heart lesions were present, we noted fewer initial symptoms of digestive disorders (p<0.05), lower levels of lung infiltrates and fewer anti-MPO pANCA (p<0.05). Heart lesions were linked to CSS in 75% of cases. Their patients were thus younger than those in the other cardiac patients (p<0.05), were more likely to have clinical manifestations of heart involvement at diagnosis, were less likely to have lung infiltrates on the X-ray at diagnosis and during flare-ups and less likely to have lung abnormalities on X-rays during flare-ups (p<0.05) and higher level of leucocytes and eosinophils at diagnosis.

CONCLUSION

Heart lesions directly attributable to CSS are frequent, severe and probably underestimated. A specific physiopathology that is not mediated by ANCA seems to be involved in the genesis of CSS-related heart lesions.

Carcinomatous Meningitis from Unknown Primary Carcinoma

Carcinomatous meningitis (CM) occurs in 3 to 8% of cancer patients. Patients present with a focal symptom, and multifocal signs are often found following neurological examination. The gold standard for diagnosis remains the demonstration of carcinomatous cells in the cerebrospinal fluid on cytopathological examination. Despite the poor prognosis, palliative treatment could improve quality of life and, in some cases, overall survival. We report on a patient who presented with vertigo, tinnitus and left-sided hearing loss followed by progressive diffuse facial nerve paralysis. Lumbar cerebrospinal fluid confirmed the diagnosis of CM. However, no primary tumor was discovered, even after multiple invasive investigations. This is the first reported case in the English-language medical literature of CM resulting from a carcinoma of unknown primary origin.

[Heart and freezer: about one case of hypereosinophilia and coronary spasm]

We report the case of a 41-year-old woman, non-smoker, without cardiovascular risk, hospitalised for acute ST elevation myocardial infarction. The coronarography showed no significant coronary stenosis and a methylergometrine test performed was positive. After the discovery of a moderate chronic hypereosinophilia, a review of the literature about eosinophile and coronary pathology was realised in order to make a link between hypereosinophilia and coronary spasm.

[Treatment of cancer and hematological malignancy in elderly people: oncogeriatrics as a discipline for the future (Part I): geriatric evaluation and management of solid tumors]

PURPOSE

Fifty percent of cancer arise in people older than 65 year-old. Most clinical trials in cancer treatment are limited in patients younger than 65 year-old. We review literature describing particularity of cancer treatment in elderly patients.

CURRENT KNOWLEDGE AND KEY POINTS

Therapeutic decisions should be based on an estimation of the patient's life expectancy, and risks and benefits should be weighted up accordingly. Geriatric oncology is made of a geriatric evaluation of patient and of knowledge of clinical trial about elderly patients.

FUTURE PROSPECTS AND PROJECTS

We present in this issue the principle of geriatric evaluation and the results of recent clinical trial on elderly cancer patients.

[Treatment of cancer and hematological malignancy in elderly people (Part II)]

PURPOSE

Fifty percents of cancer arise in people older than 65-year-old. Most clinical trials in cancer treatment are limited in patients younger than 65-year-old. We review literature-describing particularity of cancer treatment in elderly patients.

CURRENT KNOWLEDGE AND KEY POINTS

Therapeutic decisions should be based on an estimation of the patient's life expectancy, and risks and benefits should be weighted up accordingly. Geriatric oncology is made of a geriatric evaluation of patient and of knowledge of clinical trial about elderly patients.

FUTURE PROSPECTS AND PROJECTS

We present in this issue the principle of geriatric evaluation and the results of recent clinical trial on elderly cancer patients.

[Elevation of serum lactate dehydrogenase. Diagnostic, prognostic and evolutive values]

OBJECTIVE

Determination of serum lactate dehydrogenase (LDH) levels is an usual practice. However, its place in the diagnosis process is not clear. We have collected serum LDH levels superior to 2-fold the normal rate and we tried to determine their diagnostics interest and, predictive and progressive values.

METHODS

Retrospective study during 3 months in hospitalized adults. LDH levels were measured by spectrophotometry (Normal rate: 313-618 UI/L).

RESULTS

196 cases with LDH level elevations higher than 1236 UI/L were analyzed. The etiology of LDH level elevations were was benign in 60% of cases, malignant in 36% and, undetermined in 5%. There was no difference in between average values of LDH level average values of benign and malignant etiology (2708 vs 2842 UI/l). LDH rates and high LDH level elevations were not helpful for in the diagnosis process (a variety of 43 etiology was able to elevate increased LDH rates). In 45% cases, LDH level was 2 to 3-fold the normal rate; in 47.5% cases, 3 to 10-fold normal rate, and in 7.5% cases, superior to 10-fold normal rate. LDH elevations superior to 10-fold the normal rate were caused by benign etiology in 11 cases and malignant disease in 4 cases. A level superior to 10-fold the normal rate was not helpful in determining to determine the benign or malignant characteristics of the initial disease. However, LDH rate superior to 10 normal rate was a pejorative predictive criteria (hospitalization in intensive careunity in 73% of cases and mortality rate of 53%). During follow up of a neoplasia or malignant hemopathy follow up, several LDH measurements LDH level determinations were determined in for a small number of patients. LDH level normalizations is are attributable to efficientan effective treatment; LDH level elevations are associated with a therapeutic failure echappment. Evolution in LDH levels evolution was influenced by progression in neoplasia and malignant hemopathy evolution and also by various several treatments such as like blood transfusions, growth factors, radiotherapy and chemotherapy.

CONCLUSION

LDH level elevation, however whatever its rate, don't seem to do not help in differentiating have interest to differentiate benign from malignant diseases. However, an elevation LDH elevation higher than 10-fold the normal rate is a pejorative predictive criteria, since because the mortality rate is superior toupper than 50%. During follow-up of in the neoplasia and malignant hemopathy follow up, so long as they are measured at distance from treatment, variations in LDH levels are a good marker of evolution, rate variations represent an evolutive marker conditionally the level determination would be realize remote several treatment.

[Sarcoidosis during the treatment of hepatitis C by interferon-alpha and ribavirin: 2 cases]

INTRODUCTION

Interferon-alpha (IFN alpha) used to treat chronic hepatitis C can be responsible for some side effects. We report two cases of sarcoidosis which appeared in patients treated with IFN alpha and ribavirin for chronic hepatitis C.

EXEGESIS

A first patient, treated for 5 months with IFN alpha and ribavirin because of chronic hepatitis C, after the failure of a first treatment with IFN alpha alone, was hospitalized for dyspnea. The chest X-ray and scanner revealed an interstitial syndrome and mediastinal adenopathies. Biopsies of bronchial spurs revealed epithelioid and giganto-cellular granuloma. After discontinuation of antiviral treatment and starting corticosteroid therapy, the evolution was favourable but viremia reappeared. A second patient with IFN alpha and ribavirin for 4 months because of chronic hepatitis C (after the failure of a first treatment with IFN alpha alone) was hospitalized for fever, arthralgias, erythema nodosa and modification of previous skin scars. The biopsy of a scar showed an epithelioid and giganto-cellular granuloma. After discontinuation of antiviral therapy and starting corticosteroid treatment, the evolution was favourable.

CONCLUSION

Some publications mention occurrence of sarcoidosis during IFN alpha therapy, occasionally associated with ribavirin, disappearing after discontinuation of the treatment, though sometimes corticotherapy is necessary. The roles of IFN alpha and ribavirin are discussed.

[Adult cutaneous periarteritis nodosa and dental infections. Role of streptococci]

INTRODUCTION

Periarteritis nodosa can be associated with streptococcal infections in children. We report two cases of adult cutaneous periarteritis nodosa that disappeared after the treatment of dental infection.

EXEGESIS

A 23-year-old woman presented with necrotic ulceration on the legs for 6 months, with a histology of necrotizing vasculitis. Many sites of dental infections could be noted. Immunological data were negative and so were serologies of hepatitis. Corticosteroid therapy failed. The teeth removal with antibiotic therapy allowed the disappearance of cutaneous lesions in a month. A 26-year-old woman was hospitalized for growing thin, fever, diffuse arthralgia and myalgia and cutaneous nodules on the legs with necrotizing vasculitis on dermal vessels at histological analysis. The biology showed no pecularity. Radiography of the teeth showed many dental infection sites. The removal of six teeth with antibiotic therapy led to the disappearance of vasculitis in 6 weeks.

CONCLUSION

The search for an infectious problem is important when vasculitis is diagnosed, in particular periarteritis nodosa. The treatment of dental infection could occasionally mean avoiding immunosuppressive therapy in certain cases.

[Yersinia bacteremia and iron overload]

A retrospective multicentric study was conducted to determine the real prevalence of underlying iron overloads during Yersinia bacteremias. Ninety-seven cases of bacteremias (84 Yersinia enterocolitica, 13 Yersinia pseudotuberculosis) were registered between 1990 and 1996 in eastern France. Available data were collected in 70 cases (72.2%). Laboratory investigations of iron status were done in 53% (37/70). Three patients had a past record of known hemochromatosis, meanwhile in nine other cases an iron overload was discovered during the Yersinia bacteremia. Two cases of hemochromatosis were confirmed by liver histology. In all of these 12 cases, Yersinia enterocolitica was the causal agent. The effective prevalence of underlying iron overload in Yersinia bacteremias is 40% when researched, greater than data commonly published (1.8-14%), showing both epidemiological and clinical under estimation of iron's importance in Yersinia infection pathogenesis. A Yersinia bacteremia must be considered as an indicator of possible iron overload. Yersinia infection must be suspected in febrile hemochromatosic patients. A multicentric study must be conducted to evaluate incidence and characteristics of bacteremias in hemochromatosic patients.

Bilateral loss of vision and macular ischemia related to Behçet disease

PURPOSE

To report a 61-year-old man with sudden onset of visual loss in both eyes related to bilateral macular ischemia.

METHODS

The patient underwent comprehensive ophthalmic examination including slit-lamp and fundus examination, fluorescein angiography, and visual field testing as well as biologic screening.

RESULTS

Bilateral macular ischemia associated with peripheral retinal vasculitis was confirmed by angiography. We diagnosed Behçet disease by association of ocular, oral, and cutaneous involvement according to the criteria of the international study group for Behçet disease. The patient was treated with corticosteroids.

CONCLUSION

In Behçet disease, sudden onset of bilateral vision loss may be associated with bilateral retinal vascular disease and macular ischemia. Prompt diagnosis and treatment with systemic corticosteroids may be beneficial.

[Systemic scleroderma and cancers: 21 cases and review of the literature]

Twenty one cases of the association systemic scleroderma and cancer are reported. Neoplasic localisations were the following: pulmonary five cases; breast two cases; esophageal cancer one case; stomach one case; colon one case; uterus four cases; ovarian cancer one case; prostatic cancer one case; renal cancer one case; malignant hemopathies six cases. In the literature, more than three hundred cases of such an association have been reported since 1886, essentially lung cancers (more than 100). Recent epidemiological studies allow to conclude to a higher frequency of lung and breast cancers. We suggest that systemic scleroderma patients should be examined attentively and carefully for these risks.

Vertebral osteomyelitis due to Capnocytophaga species in immunocompetent patients: report of two cases and review

Vertebral osteomyelitis caused by Capnocytophaga species was diagnosed in two adults. One of these infections was due to C. ochracea and the other was due to C. sputigena. Both patients were immunocompetent and presented with concomitant periodontitis and gingivitis. The infections were eradicated by means of prolonged antibiotic therapy, combined in one case with surgical treatment. Capnocytophaga species should be considered a potential cause of vertebral osteomyelitis in immunocompetent patients, especially in the presence of oral pathology.

[Monoclonal gammopathies of undetermined significance in the elderly: apropos of 80 cases]

The authors reviewed the medical records of 80 patients with monoclonal gammopathy of undetermined significance who were examined at the hospital of Dijon between July 1990 and December 1992. The study included 43 males and 37 females with a mean age of 81.0 +/- 5.5 years. Type of M-component was IgG in 65% of the cases, IgA in 19% and IgM in 13.5%. A biclonal gammopathy was found in 2.5% of the cases. The follow-up duration was 24.6 +/- 10.8 months (range: 1-42 months). The survival probability of patients with monoclonal gammopathy of undetermined significance was 66.6% at 36 months compared with 75.6% in a control population. Lymphoplasmacytic disease developed in four patients (5%). There is a dramatic increase in monoclonal gammopathy with increasing age and the risk of malignant transformation must be continued whatever the age of patients. Further studies are required to determine routine follow-up in the elderly patient with monoclonal gammopathy of undetermined significance until the long term utility and cost/benefit ratio of screening techniques are known.

[Secondary hyperparathyroidism in the elderly. Apropos of 200 assays of intact parathormone]

OBJECTIVES

To evaluate the frequency of high levels of intact parathormone in an elderly population of hospitalized patients and to determine whether there are any correlations with different factors involved in phosphocalcium metabolism, nutritional status and renal function.

METHODS

Intact parathormone was assayed in all patients admitted to a geriatric ward (n = 200). Other laboratory tests included serum phosphorus, calcium, total albumin, prealbumin, ionized calcium, creatinine with calculation of the clearance and in 50 patients radioimmunoassay for 25 hydroxyvitamin D.

RESULTS

Intact parathormone was abnormally high (> 65 pg/ml) in 40 patients. Mean levels increased significantly with age and reached 70.5 pg/ml in patients 90 years of age and over. No correlation was found between intact parathormone and total serum calcium, corrected serum calcium, albumin or prealbumin. Inversely there was a significant correlation with serum phosphorus and creatinine and creatinine clearance. Serum levels of 25 hydroxyvitamin D were abnormally low in 82% of the patients. There was a constant and significant decrease in intact parathormone level 15 days after calcium and calcifediol substitution therapy in 13 patients.

CONCLUSION

The frequency of hyperparathyroidism increases with age to affect nearly 1 out of 2 subjects over 90. It would be useful to determine a threshold level for elderly subjects with a major risk of bone fracture.

[Bone metastasis of hepatocellular carcinoma. Apropos of 22 cases]

There have been few studies and case-reports of bone metastases from hepatocellular carcinoma. To determine the characteristics of these metastases, we retrospectively studied 22 patients in whom the diagnosis was established either on the basis of concomitant occurrence of malignant bone lesions and hepatocellular carcinoma in the absence of other detectable malignant disease (n = 15) or on the basis of histological evidence of bone metastasis from an hepatocellular carcinoma (n = 7). There were 21 males and one female. Mean age was 62.5 years. Most patients (88.2%) had chronic alcohol abuse. The bone metastases occurred as the first manifestation of the liver cancer in half the cases (11/22). Time interval between onset of bone symptoms and admission was less than one month in 6 of 11 patients; mean interval was 7.4 weeks. Hepatomegaly was found upon initial physical evaluation in 9 of 11 patients. Pain was the main symptom of bone disease (18/22). Palpable bone masses were found in 6 of 22 patients. Purely osteolytic lesions were seen on roentgenograms in every case; rupture of the cortex and spread to adjacent soft tissues were common findings. The radionuclide bone scan was normal in four of 12 patients. An advanced primary hepatic tumor was found in 84.2% of cases. Histologic examination of bone specimens established the diagnosis of metastasis from a hepatocellular carcinoma in 7 of 9 patients (77.8%). Severe bleeding occurred during one of the nine biopsy procedures. Patients were given symptomatic treatment. Systemic chemotherapy was used in five patients, unsuccessfully. Median survival was three months.

Primary hyperparathyroidism in very old patients

OBJECTIVES

To evaluate the clinical presentation and biological features of primary hyperparathyroidism (pHPT) in very old subjects.

METHODS

Thirty patients aged 75 years or more, with pHPT were analyzed retrospectively. The diagnosis of pHPT was based on usual biological signs and was always confirmed by the finding of morphological abnormalities with parathyroid imaging or neck surgical exploration.

RESULTS

At initial examination, recent general symptoms and neuromuscular symptoms were observed in 87% and 83% of the cases, respectively. Neuropsychiatric manifestations were noted in 73% of the cases. Confusion and depression were the most frequent findings, observed in 30% and 27% of the cases, respectively. In one of two patients with dementia like state, the mental status improved dramatically after surgery of the parathyroid adenoma. Serum calcium levels were in the normal range in 13% of the cases and equal or below 110 mg/L in 47% of the cases. There was no correlation between serum calcium level and the severity of mental changes. Serum parathyroid hormone determinations were abnormal in 93% of the patients. Thirteen patients underwent surgery with biological improvement in all cases. An ultrasonically guided percutaneous ethanol injection of parathyroid adenoma was performed in 10 patients with a biological cure rate of 50%.

CONCLUSION

This study shows the major prevalence and potential severity of neuropsychiatric disorders in pHPT in very old patients. Because neuropsychiatric disturbances can respond favourably to surgical treatment, the clinician must systematically look for pHPT in elderly patients with cognitive impairment.

[Secondary hyperparathyroidism in hospitalized aged patients: apropos of 200 assays of intact parathyroid hormone]

Plasma intact parathyroid hormone (PTH) determinations were performed in 200 elderly patients admitted in a geriatric care unit. Abnormally high levels of PTH were observed in 40 subjects. There was a significant correlation between plasma ionized calcium determinations or creatinine clearance and PTH levels. Subjects with high PTH levels exhibited constantly reduced levels of 25 OH-D3. A calcium and vitamin D supplement, performed in 13 patients, was constantly followed by a decrease of the PTH level.

Relationship of interleukin-4 to isotypic distribution of anti-double-stranded DNA antibodies in systemic lupus erythematosus

IgG subclasses of anti-double-stranded DNA antibodies were determined in 182 patients with systemic lupus erythematosus. All isotypes were detected, but IgG1 and IgG3 were predominant (62 and 51% of the cases, respectively). An average of 64 +/- 27% was IgG1, 16 +/- 22% IgG2, 16 +/- 19% IgG3 and 4 +/- 10% IgG4. The rank order or frequency was IgG1, IgG3, IgG2 and IgG4 in patients with musculoskeletal involvement; IgG1, IgG2, IgG3 and IgG4 in those with renal complications; IgG3, IgG1, IgG2 and IgG4 in those with cutaneous involvement; and IgG1, IgG3, IgG2 and IgG4 in those with hematological manifestations. Interleukin-4 (IL-4) was detectable in 17 of 36 selected patients, as opposed to 1 of 40 normal controls. The percentage of the total autoantibody contributed by IgG1 was significantly higher (p < 0.03) in these patients than in the remainder with undetectable levels of IL-4.

[Right cardiac insufficiency disclosing systemic mastocytosis]

The authors report the case of a 54-year old woman presenting with right cardiac failure in whom the diagnosis of contemporaneous cutaneous-systemic mast cell disease was made. The cardiac symptoms regressed concomitantly with the vasomotor manifestations of the mast cell disease. Following a review of the principal mast cell mediators, the cardiovascular manifestations of the disease are studied and pathogenetic hypotheses are being put forward.

[Current aspects of paraneoplastic acute polyarthritis]

Paraneoplastic acute polyarthritis (PAP) is a recognized rheumatological entity with semeiological features that are based only on a few published cases. We thought that it would be of interest to review the literature and present the current characteristics of PAP, taking into account only those cases where the acute polyarthritis and a neoplastic disease followed parallel courses. The clinical manifestations of PAP are extremely varied, making it difficult to distinguish this disease from some forms of rheumatoid arthritis, the RS3 PE syndrome or polymyalgia rheumatica. Clinicians must be vigilant when they are faced with a particularly progressive acute polyarthritis in a patient aged over 60, and particularly when this patient's general condition is altered and when fever and a clear-cut inflammatory syndrome are present. In such circumstances, it is mandatory to investigate for an underlying neoplasia.

[False hyperphosphoremia in multiple myeloma. Interference of monoclonal immunoglobulin G with the determination of blood phosphorus level]

A case of pseudohyperphosphataemia detected in a male patient with multiple IgG myeloma is reported. Phosphataemia, measured by a technique without previous deproteinization, reached 5.66 mM before any treatment and varied with treatment-induced changes in monoclonal immunoglobulin levels. Conversely, normal phosphataemia levels were found in blood samples taken before and after treatment when serum was deproteinized. This pseudohyperphosphataemia resulted from an increase in optic density due to interference between monoclonal immunoglobulin and the molybdic reagent used to determine phosphataemia. A retrospective investigation yielded three similar cases: two in patients with myeloma and one in a patient with non-myelomatous monoclonal dysglobulinaemia. A brief prospective study showed that this phenomenon was relatively frequent, as it was found in 2 out of 9 patients with monoclonal immunoglobulin (IgG in all 9 cases). These data indicate that the finding of marked hyperphosphataemia in subjects with monoclonal dysglobulinaemia should always prompt a control assay performed on deproteinized blood.

[Physiopathologic and clinical implications of protein C deficiencies]

The protein C system--a complex physiological coagulation inhibition system--is a major regulator which controls thrombin production. Nowadays, its exploration is indispensable for the detection of constitutional or acquired protein C deficiency, side by side with a search for antithrombin III deficiency. This approach, based on the frequent association of recurrent thrombosis, mainly venous, in young subjects with congenital deficiencies, makes it possible to initiate, beside a family survey, an individual and efficient prophylaxis of recurrent thrombosis.

Variations of sotalol kinetics in renal insufficiency

Decreased elimination of sotalol (160 mg) is found in patients with renal insufficiency. Simulation of plasma concentrations at steady-state exhibits moderately higher concentrations when creatinine clearance is between 10 and 30 ml/min and very high plasma concentrations when creatinine clearance is less than 10 ml/min suggesting, if treatment is absolutely necessary, monitoring in these cases and the reduction of the dose in major renal insufficiency.

[Circulating anticoagulants excluding hemophilia. Multicenter survey undertaken under the aegis of the French National Society of Internal Medicine apropos of 207 cases]

A retrospective multicentre study, undertaken under the aegis of the French National Society of Internal Medicine, involved 200 subjects with acquired circulating anticoagulants; 130 were female and 77 were male; mean age was 45 +/- 23 years (range: 10 months to 80 years). Mean duration of follow-up was 23 months. In 130 subjects the anticoagulants were detected as a result of a systematic screening examination. The main overt clinical manifestations were haemorrhages, venous or arterial thrombosis and spontaneous abortion. Typing of the anticoagulant, performed in 166 cases, showed the presence of an antiprothrombinase in 141; this enzyme is not responsible for severe bleeding unless it is associated with other disorders of coagulation; less frequent were an anti-factor VIIIc (n = 16) and an anti-factor V (n = 2) anticoagulants. An underlying pathology was found in 172 subjects, including systemic lupus erythematosus (n = 60), induced lupus (n = 11), discoid lupus (n = 3), infection (n = 23), blood disease (n = 19), cancer (n = 15) and vasculitis (n = 15); other factors were pregnancy (n = 5) and medicines (n = 6). The anticoagulant disappeared spontaneously in 10 cases and in 33 of the 115 subjects treated. In subjects with lupus and in children under twelve years of age, an antiprothrombinase was regularly identified at typing.