Search

Lower limb arterial disease has unusual features when occurring before 50 years old. The most important one is the number of causes: atherosclerosis in 2/3 cases, Leo Buerger's disease in 1/4, but also sometimes embolic cardiopathies, antiphospholipid syndrome, myeloproliferative disorders, genetic or compressive diseases, inflammatory arterial disease. When peripheral arterial disease occurs before 50, explorations have to be performed according to anamnesis: duplex echography, EKG, blood sample. Afterwards other explorations may be performed such as other vascular imaging techniques, echocardiography or more complete biological investigation. Results from an ongoing multicenter study should be soon available and give more knowledge about these special peripheral arterial diseases., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

HEREDITARY DISEASE: Hereditary anomalies of homocysteine metabolism are quite uncommon and manifest by very high homocysteine levels (> 100 mumol/l) and associated homocysteinuria. The risk of premature cardiovascular disease is high. Clinical, biological and epidemiological data accumulated since the 70 s have demonstrated that a moderately elevated serum homocysteine level favors the development of atherothrombosis. PROVEN RISK: The risk of coronary or cerebral events is 1.5 to 3-fold higher for fasting homocysteine levels above 15 mumol/l. These data show that moderately elevated homocysteine level is a powerful cardiovascular risk factor. Further information is however needed to ascertain its frequency in the population and determine whether it is a truly independent risk factor., Therapeutic Options: Most cases of moderately elevated homocysteine can probably be explained by gene-environment interactions. Homocysteine levels can be lowered by oral administration of vitamin cofactors implicated in homocystein metabolisms: folic acid, vitamin B6, vitamin B12.

A group of 63 patients infected by HIV and presenting with CD8 hyperlymphocytosis (CD8+) has been studied. CD8 hyperlymphocytosis was defined by the presence, during at least three months, of at least 1,500 CD8 circulating lymphocytes. The CD8+ patients (n = 63) were identified and followed within the cohort (1,444 patients) of the "Groupe d'Epidémiologie Clinique du SIDA en Aquitaine " (GECSA). CD8+ patients were compared with a control group of 126 HIV infected patients without CD8 hyperlymphocytosis recruited within the GECSA cohort and followed in the same manner during two years. The occurrence of opportunistic infections was less frequent in CD8+ patients. The proportion of patients with a CD4 lymphocyte count below 200/mm3 was lower in the CD8+ group than in the CD8- group at inclusion and at the last check-up (P less than 0.01). A tendency for longer survival and delayed onset of AIDS was noted in CD8+ patients. Such a difference in prognosis might be due to a peculiar cytotoxic response against HIV among CD8+ patients. Further follow-up of a larger group of patients is needed to confirm this hypothesis.

Since 1928, approximately 30 cases of peripheral polyneuropathy consecutive to hypoglycaemia caused by insulinomas or islet cell pancreatic tumours have been published. We report a case of polyneuropathy in a young woman presenting with type I multiple endocrine neoplasia syndrome including multiple insulinomas and parathyroid adenomas. The predominantly motor polyneuropathy was symmetrical and involved both the upper and lower limbs. Biopsy showed muscular atrophy and, in particular non-specific acute axonal lesions. Twelve months after surgery the clinical situation was relatively favourable with resumption of physical activities but persistence of muscular atrophy. Wether hyperparathyroidism was responsible for the neuropathy was uncertain, the subacute post-hypoglycaemia axonal damage being a more likely suspect.

Following acute intoxication with alcohol, 8 patients developed 16 episodes of arrhythmia, including 15 supraventricular tachycardias and one torsade de pointe. Seven of the 8 patients were chronically abusing of alcoholic drinks. None of the patients had clinically obvious cardiac pathology nor echocardiographic evidence of myocardiopathy. In 7 of them, however, baseline electrocardiograms disclosed disorders of intra-atrial conduction. The role of the different factors which might determine the occurrence of arrhythmia (notably alcohol, the autonomic nervous system, associated metabolic abnormalities and absorption of medicines) is discussed.

The echocardiographic parameters of 10 patients with anorexia nervosa were studied at the time of admission and compared with those of 10 matched controls. There was a decrease of ventricular volumes and of the calculated left ventricular mass, but the haemodynamic values at rest showed a normal "pump function". The left ventricular mass correlated with the body mass, which indicates that the heart of anorectic patients is also involved by malnutrition. Two patients had asymptomatic mitral valve prolapse. These results are in agreement with the few published studies which report deep cardiac alterations with decrease of heart cavities volumes and reduction of wall thickness and myocardial mass. This results in altered exercise performance, despite a satisfactory haemodynamic status at rest. The high frequency of mitral valve prolapse due to disproportion between ventricle and valve must be noted.

The one-year outcome of syncope and transient loss of consciousness was studied prospectively in 188 patients aged over 65 admitted to internal medicine departments. Thirty-seven patients (19.6 p. 100) died. This mortality rate at one year was 2.34 times higher than that of a non-hospitalized french population of the same age group (standardized mortality ratio, SMR = 2.34, P less than 0.001). The frequency of sudden death (7 cases) was much higher than that observed in the reference population (0.05 expected deaths, P less than 0.0001). Overmortality was clearly apparent in groups with an initial diagnosis of heart disease (SMR = 2.36, P less than 0.01) or neurological disease (SMR = 4.25, P less than 0.001). The relapse rate was 28 p. 100 globally and up to 43 p. 100 in cardiac patients. In the group with iatrogenic symptoms treatment was appropriately corrected in 86 p. 100 of the patients, and none of these relapsed. One year after the initial episode 11 p. 100 of the surviving patients had been institutionalized.

In a prospective multicentre study a series of 188 patients over 65 years of age admitted for syncope (90) or transient loss of consciousness (98) was collected. There were 120 women and 68 men; mean age was 78.7 +/- 6.6 years; 140 patients had a significant history mainly of arterial hypertension and coronary disease; 81 patients were taking drugs (4.1 on average) and notably diuretics, antihypertensive agents, antiarrhythmic agents, nitrites and psychotropic drugs. The most frequent diagnoses were arrhythmia (20.2 p. 100), postural hypotension (15.4 p. 100), reflex and vasodepressive syncope (12.2 p. 100) and coronary disease (5.3 p. 100). Taken together, these diagnoses could be divided into cardiac diseases (26.5 p. 100), extracardiac diseases (54.2 p. 100), diagnosis unknown (19 p. 100). The condition was iatrogenic in 45 patients (24 p. 100). The means by which the diagnosis was reached were studied: in two-thirds of the cases, careful physical examination and electrocardiography alone provided a diagnosis. Seven patients died during their stay in hospital. Among the 181 survivors 148 (81.7 p. 100) were discharged and returned home.