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Pneumococcal infections are frequent and potentially serious in patients with inflammatory diseases treated with immunosuppressants and/or biotherapies. This patient population considered to be at very high risk of infection is subject to national vaccination recommendations. The main objective of this study was to assess pneumococcal vaccine coverage in a day hospital (internal medicine and vascular disease) in patients treated with immunosuppressants.An observational, descriptive, retrospective, and single-center study. We included 150 consecutive patients for 3 months (February to April 2018). We studied pneumococcal vaccination coverage and the time elapsed between the date of vaccination with the 13-valent polysaccharide conjugate vaccine (PCV13) and the start of immunosuppressive therapy.Among the 150 patients included in the study, vaccination coverage with PCV13 was 85% (127/150) and decreased to 46.7% (70/150) for the recommended vaccination schedule. Taking into account vaccine efficacy according to the date of initiation of the treatment, only 28.7% (43/150) of the patients in the study were able to benefit from an optimal complete vaccination schedule, i.e. 33.8% (43/127) among patients vaccinated with PCV13.Despite official recommendations, vaccination coverage against pneumococcus remains insufficient in patients under immunosuppressants and/or biotherapies. In addition to the continued training of doctors, optimizing computer prescription of vaccines in view of facilitating vaccination tracing and having vaccination carried out at the site of consultation are avenues for improvement to be considered.

Resume Introduction La prise en charge des pathologies inflammatoires et thrombophiliques en cours de grossesse est souvent heterogene du fait d’une concertation insuffisante parmi les differents specialistes impliques. Le CHU de Bordeaux dispose depuis janvier 2018 d’une reunion de concertation pluridisciplinaire (RCP) « PREGNANT – PREGnancy and Auto-immunity, Nephropathy, Thrombophilic disorders » qui rassemble les professionnels de sante specialises dans ces thematiques (internistes, gynecologues-obstetriciens, rhumatologues, nephrologues, medecins vasculaires, anesthesistes, fœtopathologistes). L’objectif de cette etude etait d’evaluer, depuis sa mise en place, la qualite de cette RCP en termes de : conformite avec les criteres obligatoires d’une RCP, adequation des prises en charge avec les referentiels, homogeneite des prises en charge, devenir des propositions emises. Methodes Il s’agissait d’une etude observationnelle prospective incluant les patientes dont les dossiers ont ete presentes en RCP de janvier 2018 a juin 2019. Resultats Au total, 16 RCP se sont deroulees avec 152 dossiers presentes. Soixante-deux patientes etaient en cours de grossesse et 90 en preconceptionnel. Les motifs les plus frequents de presentation etaient les pathologies vasculo-placentaires (22,3 %), le lupus systemique (16,4 %), les maladies thromboemboliques veineuses (15,1 %) et les intervillites chroniques d’etiologies indeterminees (9,8 %). Les presentations pour syndrome des anticorps anti-phospholipides (SAPL) et fausses couches spontanees a repetition etaient moins frequentes. Les 16 reunions de RCP repondaient aux criteres obligatoires requis. Pour 89 dossiers (58,5 % des cas), les decisions prises pouvaient s’appuyer sur des recommandations existantes (societes savantes majoritairement), et etaient conformes a ces recommandations dans 89,8 % des cas. Pour 63 dossiers (41,5 % des cas) dont la prise en charge ne pouvait se referer a des recommandations, il existait une certaine homogeneite des propositions au sein de la RCP. Les propositions emises par la RCP ont ete appliquees dans 92,8 % des cas. Conclusion La RCP « PREGNANT » a demontre sa faisabilite et a permis a l’echelle locoregionale de structurer la prise en charge des patientes atteintes de pathologies auto-immunes, inflammatoires ou thrombophiliques dans un contexte de grossesse.

The pluridisciplinary meeting "PREGNANT - Pregnancy and Auto-immunity, Nephropathy, Thrombophilic Disorders" at the university hospital of Bordeaux is dedicated to inflammatory and thrombophilic disorders during pregnancy. The objective of our study was to evaluate the quality of this meeting in terms of: compliance with the mandatory criteria, adequacy with standard care, homogeneity of care, becoming of proposals issued.We conducted a prospective observational study including patients whose files were submitted to the meeting from January 2018 to June 2019.In all, 16 meeting were conducted with 152 cases presented. Sixty-two patients were pregnant and 90 were in preconception. The most common reasons for presentation were vasculo-placentary diseases (22.3%), systemic lupus (16.4%), venous thromboembolic diseases (15.1%) and chronic intervillositis of unknown etiology (9.8%). Other reasons were antiphospholipid antibody syndrome and repeated spontaneous miscarriages. The mandatory criteria for multidisciplinary meeting were met. For 89 cases (58.5%), the problem was dictated by recommendations. Decisions made were consistent with recommendations in 89.8% of cases. Among the 63 cases without any published recommendations (41.5%), there was some homogeneity of the proposals. In all, 92.8% of the proposals issued by the meeting were implemented.Multidisciplinary meeting "PREGNANT" has a prominent locoregional role in the management of patients with autoimmune, inflammatory or thrombophilic disorders in a pregnancy context.

Venous insufficiency is a very common disease affecting about 25% of the French population (if we combine all stages of its progression). It is a complex disease and its aetiology has not yet been fully elucidated. Some of its causes are well known, such as valvular dysfunction, vein wall defect, and the suctioning effect common to all varicose veins. These factors are generally associated and together lead to dysfunction of one or more of the saphenous veins. Saphenous vein dysfunction is revealed by ultrasound scan, a reflux lasting more than 0.5 seconds indicating venous incompetence. The potential consequences of saphenous vein dysfunction over time include: symptoms (heaviness, swellings, restlessness, cramps, itching of the lower limbs), acute complications (superficial venous thrombosis, varicose bleeding), chronic complications (changes in skin texture and colour, stasis dermatitis, eczema, vein atresia, leg ulcer), and appearance of unaesthetic varicose veins. It is not possible to repair an incompetent saphenous vein. The only therapeutic options at present are ultrasound-guided foam sclerotherapy, physical removal of the vein (saphenous stripping), or its thermal ablation (by laser or radiofrequency treatment), the latter strategy having now become the gold standard as recommended by international guidelines. Recommendations concerning thermal ablation of saphenous veins were published in 2014 by the Societe francaise de medecine vasculaire. Our society has now decided to update these recommendations, taking this opportunity to discuss unresolved issues and issues not addressed in the original guidelines. Thermal ablation of an incompetent saphenous vein consists in destroying this by means of a heating element introduced via ultrasound-guided venous puncture. The heating element comprises either a laser fibre or a radiofrequency catheter. The practitioner must provide the patient with full information about the procedure and obtain his/her consent prior to its implementation. The checklist concerning the interventional procedure issued by the HAS should be validated for each patient (see the appended document).

Resume Introduction La vasoreactivite cerebrale (VRC) est la capacite du systeme vasculaire cerebral de maintenir un debit sanguin cerebral constant. Une alteration de la VRC constitue un marqueur de risque d’accident vasculaire cerebral chez les patients porteurs d’une stenose carotidienne asymptomatique. La methode de reference pour l’etude de VRC en Doppler transcrânien est l’injection d’acetazolamide (ACTZ). Le test d’apnee (BHT pour breath holding test) pourrait constituer une alternative plus simple. Il a fait la preuve de sa pertinence en laboratoire de physiologie avec monitorage de la capnie, mais pas en soins courants. Objectif Evaluer la validite du BHT par rapport a l’injection d’ACTZ en soins courants au sein d’une unite d’explorations vasculaires, chez des patients porteurs de stenose carotidienne asymptomatique. Methode Etude de la VRC en aval de stenoses carotidiennes asymptomatiques chez un petit nombre de patients consecutifs, par BHT, puis par ACTZ le meme jour. Analyse de la concordance des resultats. Resultats L’etude portait sur 18 patients et 20 stenoses carotidiennes. Vingt pour cent de ces patients presentaient une absence de fenetre temporale. On se heurtait aussi a des difficultes liees au materiel. Seules 11 procedures sur 20 pouvaient etre analysees. Dans nos conditions d’examen, la concordance entre les deux methodes de provocation etait tres faible (k = 0,3714). Conclusion le BHT ne peut pretendre remplacer l’injection d’ACTZ. Il pourrait constituer un test de premiere intention, permettant de surseoir a l’injection d’ACTZ, s’il met en evidence une VRC conservee. Ces resultats sont a confirmer dans un echantillon beaucoup plus grand.

Resume Propos La sclerodermie systemique est caracterisee par une sclerose cutanee, une atteinte vasculaire et une dysfonction immunologique. La prevalence de l’atteinte macrovasculaire reste controversee. Patients et methode Il s’agit d’une etude descriptive prospective monocentrique realisee dans le service de medecine vasculaire du CHU de Bordeaux du 1er juillet au 1er septembre 2015. L’ensemble des patients sclerodermiques hospitalises dans le service etait inclus. Chaque patient a beneficie d’un echodoppler des troncs supra-aortiques, des arteres des membres superieurs, des arteres digitales, de l’aorte et des arteres des membres inferieurs. L’objectif de notre etude est de decrire la presence et la localisation des lesions arterielles chez les patients sclerodermiques. Resultats Sur les vingt patients inclus, il y avait 13 femmes et 7 hommes, la moyenne d’âge etait de 58 ± 16 ans. Au total, 16 patients (80 %) avaient un epaississement parietal, 10 (50 %) des plaques calcifiees, 3 (15 %) des stenoses hemodynamiquement significatives et 12 (60 %) des occlusions arterielles. L’indice de pression systolique (IPS) moyen etait de 0,98 ± 0,16 a droite et 0,99 ± 0,21 a gauche. Deux patients avaient des IPS inferieurs a 0,8. La pression arterielle systolique brachiale moyenne etait de 113 ± 14 mmHg. Les donnees de la cartographie arterielle (860 sites arteriels) ont trouve 93 arteres presentant un epaississement parietal (10 %), 47 des plaques calcifiees (5 %), 7 stenoses hemodynamiquement significatives et 22 occlusions. Les occlusions arterielles etaient localisees au niveau des arteres ulnaires (n = 2), des arteres digitales (n = 18), de l’artere tibiale posterieure (n = 1) et de l’artere pedieuse (n = 1). Conclusion Les donnees de notre etude sont correlees avec l’atteinte macrovasculaire decrite dans la litterature. Cette constatation permet de poser deux questions. Comment integrer cette notion avec la severite du phenomene de Raynaud, le risque d’ulceres digitaux et les variations du paysage capillaroscopique des patients au cours du suivi ? Quelle est la cause de ces anomalies vasculaires, dont certaines sont tres differentes de ce que l’on observe dans l’atherosclerose ?

Introduction Bien que la sclerodermie systemique (ScS) soit une maladie du reseau microvasculaire, certains patients presentent des complications macrovasculaires graves : coronaropathie, accident vasculaire cerebral et arteriopathie obliterante des membres inferieurs (AOMI). L’occlusion de l’artere ulnaire est decrite chez les patients ScS, alors que l’atteinte macrovasculaire des membres inferieurs est beaucoup moins rapportee. Elle peut conduire a une ischemie critique avec des echecs de revascularisation et une amputation. L’objectif de ce travail etait d’evaluer les caracteristiques de patients atteints de ScS souffrant d’une amputation d’un segment de membre inferieur, afin d’identifier des facteurs de risque associes. Materiels et methodes Nous avons realise une etude retrospective, cas-temoins, multicentrique au sein du GFRS. Chaque patient atteint de ScS ayant subi une amputation d’un segment d’un membre inferieur secondaire a une ischemie critique etait apparie sur le sexe, l’âge (±5 ans) et la forme cutanee a un autre patient ScS sans atteinte macrovasculaire clinique des membres inferieurs. Resultats Vingt-six patients ScS avec amputation d’un segment de membre inferieur ont ete inclus. L’âge moyen etait de 67,2 ans (± 10,9), 20 femmes et 5 formes cutanee diffuse. Le groupe temoin comportait 26 patients ScS sans atteinte macrovasculaire. Les patients ScS avec amputation avaient une duree d’evolution de la maladie plus elevee (15,8 ± 9,4 vs 7,4 ± 5,9 ans), plus d’UD (p = 0,048), et plus d’antecedents d’UD (p = 0,026) que le groupe temoin. Ils avaient egalement un score de Medsger plus eleve, sans tenir compte de l’item « vasculaire » (p = 0,02), du fait d’une prevalence plus elevee de l’hypertension pulmonaire (HTP) (p Conclusion Il s’agit de la plus grande serie de patients ScS avec amputation d’un segment d’un membre inferieur et la premiere comportant un groupe temoin. L’amputation est une complication plutot tardive de la maladie. En comparaison au groupe temoin, l’HTP, le tabac et l’utilisation de corticoides apparaissent comme des marqueurs independants associes a l’amputation. Il est important de detecter et corriger les FRCV des patients ScS, particulierement le tabac, et de ne jamais negliger un trouble trophique du membre inferieur. La place du depistage de la macroangiopathie par echoDoppler arteriel des membres inferieurs devra etre evaluee dans le suivi de la ScS.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of hematopoietic stem cells. Somatic mutation in the phosphatidylinositol glycan class A (PIG-A), X-linked gene, is responsible for a deficiency in glycosphosphatidylinositol-anchored proteins (GPI-AP). The lack of one of the GPI-AP complement regulatory proteins (CD55, CD59) leads to hemolysis. The disease is diagnosed with hemolytic anemia, marrow failure and thrombosis. Thromboembolic complication occurs in 30% of patient after 10 years of follow-up and is the first event in one out of 10 patients. The two most common sites are hepatic and cerebral veins. These locations are correlated with high risk of death. Currently, these data are balanced with the use of a monoclonal antibody (Eculizumab), which has significantly improved the prognosis with a survival similar to general population after 36 months of follow-up. Anticoagulant treatment is recommended after a thromboembolic event but has no place in primary prophylaxis.

Cerebral vasoreactivity (CVR) is the ability of the brain's vascular system to keep cerebral blood inflow stable. Impaired CVR is a risk marker of stroke in patients with asymptomatic carotid stenosis. The gold standard to assess CVR with transcranial ultrasound is acetazolamide (ACTZ) injection. The breath holding test (BHT) might be easier to perform. CVR proved to be efficient in laboratory conditions but not in routine practice.To study the validity of BHT versus ACTZ in routine practice in a vascular exploration unit in patients with asymptomatic carotid stenosis.Study of concordance of BHT and ACTZ, to assess CVR in patients consecutively explored on the same day.Eighteen patients with 20 carotid stenosis were included. The temporal window was missing in 20% of cases. Only 11 out of the 20 procedures were analyzed. Concordance was low between BHT and ACTZ to assess CVR (k=0.3714).BHT cannot replace ACTZ injection. It might be a first-step test so that ACTZ injection might be avoided if CVR is normal. Our present results must be confirmed by further study enrolling many more patients.

Pyomyositis is a primitive infection of the skeletal muscle usually caused by Staphylococcus aureus in tropical areas, and associated with immunodeficiency. We report a 49-year-old immunocompetent woman, living in a temperate climate presenting with a pyomyositis of adductor muscles caused by Escherichia coli. Diagnosis was obtained with magnetic resonance imaging (MRI). Disease course was uneventful after surgical debridement and antibiotics. This case report highlights the usefulness of MRI in the diagnosis of pyomyositis.

Systemic sclerosis is characterized by cutaneous sclerosis, vascular disease and immunological dysfunction. The prevalence of macrovascular disease remains controversial.This was a descriptive prospective single-center study conducted in the vascular medicine department of the University Hospital of Bordeaux from July 1 to September 1, 2015. All inpatients followed for systemic scleroderma were included. Each patient had a Doppler ultrasound of the supra-aortic, upper and lower limb, and digital arteries as well as the aorta. The main objective of the study was to describe the presence and location of arterial lesions in patients with systemic sclerosis.Of the twenty patients included, there were 13 women and 7 men; mean age was 58±16years. Patients exhibited wall thickening (n=16, 80%), calcified plaques (n=10, 50%), hemodynamically significant stenoses (n=3, 15%) and arterial occlusions (n=12, 60%). Ankle brachial pressure index (ABPI) was 0.98±0.16 on the right and 0.99±0.21 on the left. Two patients had ABPI0.8. The mean brachial systolic blood pressure was 113±14mmHg. Arterial mapping (860 arterial sites) found wall thickening (n=93 arteries, 10%), calcified plaques (n=47, 5%), hemodynamically significant stenoses (n=7) and occlusions (n=22). Arterial occlusions were located in the ulnar arteries (n=2), the digital arteries (n=18), the posterior tibial artery (n=1) and the dorsalis pedis artery (n=1).The data of our study correlate with macrovascular disease described in the literature. This finding raises two questions: how does this concept integrate with the severity of Raynaud's phenomenon and the risk of digital ulcers and changes in patients' capillaroscopic landscape during follow-up? What is the cause of these vascular anomalies, some of which are very different from what is observed in atherosclerosis?

Introduction Les patients en ischemie critique chronique des membres inferieurs souffrent de douleurs multifactorielles dont la physiopathologie est mal connue, sans recommandation sur leurs prises en charge diagnostique et therapeutique. L’objectif de notre etude etait de determiner la frequence des douleurs neuropathiques dans l’ischemie critique des membres inferieurs a l’aide du questionnaire DN4 dans notre service de medecine vasculaire du CHU de Bordeaux. Materiel et methode Il s’agissait d’une etude prospective monocentrique realisee dans le service de medecine vasculaire, au CHU Saint-Andre a Bordeaux, entre le 1er avril 2014 et le 6 juillet 2015. Les patients admis pour une ischemie critique des membres inferieurs (unilaterale ou bilaterale), selon les criteres de la conference de consensus de 1991 etaient inclus et ceux ne pouvant pas repondre au questionnaire DN4 en raison de troubles des fonctions superieures, d’incomprehension de la langue ou de refus etaient exclus. Chaque patient inclus avait une evaluation du questionnaire DN4 par un medecin, pour depister les douleurs neuropathiques. Le questionnaire DN4 etait dit positif lorsque les patients presentaient 4 reponses positives minimum. Resultats Vingt-cinq patients ont ete inclus dans l’etude. A j0, il y avait 17 patients avec un DN4 > 4 (68 % de la population). La valeur mediane du DN4 etait de 4 avec un ecart type de ± 1,98. Conclusion Cette etude confirme la presence de douleurs neuropathiques dans l’ischemie critique des membres inferieurs. L’utilisation du DN4 pourrait permettre d’ameliorer la prise en charge diagnostique et a terme therapeutique de ces douleurs dans l’ischemie critique des membres inferieurs.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare acquired disorder of hematopoietic stem cells. Somatic mutation in the phosphatidylinositol glycan class A (PIG-A), X-linked gene, is responsible for a deficiency in glycosphosphatidylinositol-anchored proteins (GPI-AP). The lack of one of the GPI-AP complement regulatory proteins (CD55, CD59) leads to hemolysis. The disease is diagnosed with hemolytic anemia, marrow failure and thrombosis. Thromboembolic complication occurs in 30% of patient after 10 years of follow-up and is the first event in one out of 10 patients. The two most common sites are hepatic and cerebral veins. These locations are correlated with high risk of death. Currently, these data are balanced with the use of a monoclonal antibody (Eculizumab), which has significantly improved the prognosis with a survival similar to general population after 36 months of follow-up. Anticoagulant treatment is recommended after a thromboembolic event but has no place in primary prophylaxis.

SummaryWe evaluated two clinical scores for the prediction of deep venous thrombosis (DVT) in hospitalized patients (Wells’ and Kahn’s). We included 273 patients referred to the vascular exploration unit for the suspicion of DVT. A clinical questionnaire was filled in by the practitioner and the scores were calculated from this form. 66 of the 273 patients had a DVT. When Wells’ score was 3, a DVT was found by duplex echography in 51% patients ; when the score was 0, a DVT was found in 9%. Kahn’s score was not adapted to this population. We then developed a new simple score (cancer, palsy or plaster immobilization, warmth, superficial venous dilation, unilateral pitting edema, other diagnosis). A DVT was found in 76% patients with a score of 3 and in 11% in those with a score of 0. We therefore propose a 6-item score whose main advantages are simplicity and usefulness in routine practice.

La maladie de Buerger est une arteriopathie du sujet jeune de mecanisme inconnu mais survenant presque exclusivement chez des sujets tabagiques. Le tabac est un element determinant pour le diagnostic de cette pathologie. Il est mentionne dans tous les scores utilises pour le diagnostic. Il est aussi associe avec le pronostic puisque de nombreux travaux montrent que les patients sont beaucoup plus souvent amputes lorsqu’ils poursuivent leur intoxication tabagique. Le sevrage tabagique de ces patients est difficile, sans doute en raison de caracteristiques psychologiques et sociales particulieres. L’etude ADDICTAO, actuellement en cours, devrait apporter des informations utiles pour comprendre la tres forte dependance au tabac de ces patients. La consommation de cannabis semble de plus en plus souvent associee chez les patients atteints de maladie de Leo Buerger. Une etude cas-temoins recente (A. Berard et al., Plos ONE, mars 2013) a montre une frequence plus elevee de la consommation et de la quantite consommee de cannabis chez les patients atteints de maladie de Buerger compares a ceux atteints d’arteriopathie atheromateuse des membres inferieurs « juvenile » et aux temoins. La consommation de cannabis a aussi ete rapportee comme facteur de risque de syndromes coronaires aigus et d’AVC mais les donnees animales sur la toxicite du tetra-hydro-cannabinol sont limitees. L’arsenic contenu dans les cigarettes pourrait etre un toxique important dans la maladie de Buerger mais les donnees sur ce sujet sont pour le moment tres limitees. En conclusion, le mecanisme de la maladie de Buerger n’est pas connu mais le tabac et le cannabis sont des facteurs etiologiques importants. Le sevrage est le seul traitement connu pour diminuer le risque d’amputation. Finalement, seule l’eviction des toxiques a pour le moment prouve une efficacite en traitement de fond de la maladie de Leo Buerger.

Introduction Le syndrome du marteau hypothenar est une cause possible d’ischemie digitale, classiquement unilateral. Il touche la main dominante lorsqu’elle est utilisee comme un marteau : certains travaux manuels (carreleurs, mecaniciens) ou sports (handball, golf). Il est la consequence de traumatismes repetes de l’artere ulnaire dans l’eminence hypothenar. Nous rapportons ici la premiere description a notre connaissance de ce syndrome, bilateral, chez un musicien percussionniste. Observation Un homme de 51 ans consulte pour phenomene de Raynaud bilateral recemment aggrave et rapporte un episode regressif de necrose pulpaire d’index. Antecedents : tabagisme et cannabis sevres, hepatite C guerie. Manœuvre de Allen positive de facon bilaterale. Capillaroscopie normale. Bilan biologique normal, dont auto-anticorps et cryoglobulinemie. Pressions digitales : ischemie de repos de deux doigts. Echo-Doppler : occlusions segmentaires, ectasies, epaississement parietal et collateralite sur les deux arteres ulnaires et les arcades palmaires superficielles. Cet aspect evoque un syndrome du marteau hypothenar bilateral. La seule activite a risque retrouvee est la pratique intensive des congas, sorte de tambours percutes a la main. Discussion Dans le syndrome du marteau hypothenar, l’artere ulnaire est decrite en angiographie comme tortueuse, a parois epaissies ou anevrismales, avec des occlusions segmentaires et developpement de collaterales. Il peut exister aussi une atteinte d’arcade palmaire et des occlusions d’arteres digitales par micro-emboles. Actuellement on realise plutot un echo-Doppler arteriel, complete par angioscanner ou angio-IRM, qui montrent le meme aspect. La clinique est celle d’une ischemie de doigt(s) : douleurs digitales, acrosyndrome, ulcerations. On peut retrouver une masse battante (anevrisme). Certaines formes sont asymptomatiques, par suppleance par l’artere radiale, les arcades palmaires et developpement de collaterales. Le traitement, controverse, est medical (eviction des traumatismes, antiagregants plaquettaires, iloprost…) et/ou chirurgical (exerese d’anevrisme, pontage…). Conclusion En cas d’ischemie de doigt, l’aspect en echo-Doppler peut orienter vers un syndrome du marteau hypothenar. Outre les traumatismes professionnels et sportifs, la pratique intensive d’un instrument de musique a percussion est une cause possible, pouvant engendrer une forme bilaterale.

Pyomyositis is a primitive infection of the skeletal muscle usually caused by Staphylococcus aureus in tropical areas, and associated with immunodeficiency. We report a 49-year-old immunocompetent woman, living in a temperate climate presenting with a pyomyositis of adductor muscles caused by Escherichia coli. Diagnosis was obtained with magnetic resonance imaging (MRI). Disease course was uneventful after surgical debridement and antibiotics. This case report highlights the usefulness of MRI in the diagnosis of pyomyositis.

L’echographie-doppler occupe une place incontournable dans la prise en charge de l’embolie pulmonaire (EP). Elle est utile dans deux grands cadres : – pour le diagnostic ; – pour la recherche d’une thrombose veineuse profonde (TVP) associee en cas d’EP averee. Pour le diagnostic, la place centrale revient aujourd’hui a l’angio-TDM ou en deuxieme intention a la scintigraphie de ventilation/perfusion mais l’echographie-doppler est un examen tres utile lorsqu’il met en evidence une TVP proximale. Dans ce cas, en cas de suspicion clinique d’EP, le diagnostic peut etre pose sur ce seul resultat. L’echographie-doppler est un examen de premiere intention en cas de suspicion d’EP chez une femme enceinte, en cas de contre-indication a l’injection de produit iode, en cas de doute apres un examen scintigraphique, ou encore lorsque l’accessibilite a cet examen est immediate. En cas de diagnostic avere d’EP, l’echo-doppler veineux doit etre realise pour diagnostiquer une TVP asymptomatique. En effet, dans ce cas, cet examen simplifie le diagnostic d’une TVP ulterieure et permet de mettre en place une prevention du syndrome post-thrombotique (compression elastique de classe III pendant 2 ans). De plus, l’etude OPTIMEV a montre que l’association d’une TVP a un EP est associee a un risque plus eleve de mortalite a 3 mois : risque relatif 2,6 (95 % IC [1,4–4,7]). En conclusion, si dans certains cas l’echo-doppler veineux aide au diagnostic d’EP, il doit etre systematiquement realise pour detecter une TVP asymptomatique.

The association between adult Henoch-Schonlein purpura and prostatic carcinoma is exceptional. We report a new case.The diagnosis of prostatic adenocarcinoma, suspected because of prostatic induration is made after anatomopathological study. The patient has all the clinical (purpura, polyarthralgia), biological (circulating monocmonal IgA), and histological (leukocytoclastic vasculitis, with IgA and C3 deposits) criteria of Henoch-Schonlein purpura too. The simultaneous appearance of vasculitis and neoplasia is known. The association between adult Henoch-Schonlein purpura and malignant neoplasm like lung carcinoma or lymphoma exists too. The initial events leading to the development of these vasculitis could be tumor antigens or abnormal IgA production.The simultaneous appearance of these two disease asks here the question of mechanisms implicated in these association.

Juvenile peripheral obstructive arterial diseases (POAD) have been poorly investigated but account for 1 to 7% of POAD. We analyzed retrospectively a cohort of patients with onset before the age of 50 years.Seventy-three patients (60 males and 13 females) were divided into 4 groups (Buerger's disease: TAO, atheromatous PAOD, auto-immune POAD, arteriopathy of undetermined origin).The first symptoms occurred at 38 +/- 8 years of age. Fourteen patients (20%) had TAO, 51 (70%) atheromatous POAD, 4 (5%) POAD with systemic or autoimmune disease, and 4 (5%) undetermined POAD. Age of onset was earlier in TAO (35 +/- 8 vs 40 +/- 8 years, p=0.046), smoking greater in the atheroma group (33 +/- 16 vs 24 +/- 14 pack-years, p=0.033). Fifty-three POAD patients had dyslipidaemia and 26% hypertension. Regular cannabis intake was more frequent in the TAO group (21 vs 8%). At the time of medical care, Fontaine's stage was more frequently stage II in atheroma patients (57 vs 14%) and stage IV in TAO patients (86 vs 35%). TAO was diagnosed in 43% cannabis users and in 19% non users.The main etiology of juvenile POAD is atheroma, followed by TAO. Cannabis users account for at least 10% of these patients. They are characterized by lower tobacco intake, more distal lesions, more frequent involvement of the upper limbs. They present more frequently as TAO.

Deep venous thrombosis is 50 times less frequent in upper than in lower limbs. Data remain poor in the literature. Forty consecutive patients (24 males, 16 females, mean age: 54.5 years) were retrospectively analysed from 161 subjects who underwent venous explorations of the upper extremity for a 3.5 year period in the same center. Diagnosis of thrombosis was made by duplex ultrasonography (n =37) or phlebography (n =3). Main clinical manifestations were edema (n =36) and pain (n =29). Location of thrombosis was humeral (n =1), axillary (n =2), or sub-clavian (n =37, 2 bilateral). The majority of thrombosis (n =29) were secondary to cancer and venous catheter (n =19, 15 implanted ports), to central catheter alone (n =3) or cancer alone (n =7). The 11 others were associated with thoracic outlet syndrome (n =6) or apparent primary thrombosis (n =5). Thrombophilia was identified in 6 out of these 11. During follow up [mean of 9 months (0,5-36)], two patients developed pulmonary embolism, 14 a post-thrombotic syndrome and 16 patients died. Initial therapy included heparin (n =36) or fibrinolysis (n =4). Upper extremity deep venous thrombosis are mostly associated with cancers and venous catheters. Thrombophilia is frequent in the other cases. Heparin followed by oral anticoagulation is the optimal therapy whose duration depends upon underlying condition. Fibrinolysis has not been useful for preventing post-thrombotic syndrome in our study.

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.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.

We report 6 cases of upper limb involvement in giant cell arteritis; upper limb involvement revealed the disease in 4 cases and clinical symptoms were present in 5 (upper limb pain, Raynaud's phenomenon). Upper limb pulses were not palpable and blood pressure unmeasurable in all. Duplex ultrasonography found signs of inflammatory arteriopathy in 4 cases (hypoechogenous halo of the arterial wall and acceleration of flow velocity). Arteriography was performed in 5 cases and showed long and regular stenoses. In the last case, arteriography was not done because the duplex exploration gave an easier diagnosis. With this technique, the diagnosis of upper limb involvement, frequent in autopsy series of giant cell arteritis, might be made more often. Corticosteroid therapy is indicated and surgery should be discussed only in emergency situations.

Resume Introduction. – L’association entre cancer de la prostate et purpura rhumatoide est exceptionnelle. Nous rapportons un nouveau cas. Exegese. – La neoplasie de la prostate, evoquee apres le toucher rectal devant une induration prostatique, est confirmee histologiquement. Le diagnostic de purpura rhumatoide est retenu sur des criteres cliniques (purpura declive, arthralgies migratrices), biologique (IgA monoclonale serique), et histologique (vascularite leucocytoclasique avec depots d’IgA et de C3). La survenue simultanee d’une vascularite et d’une neoplasie chez un meme patient est connue. Il en est de meme pour les vascularites a IgA de l’adulte qui peuvent etre associees a des syndromes lymphoproliferatifs ou des tumeurs solides. Les elements initiaux responsables du developpement de ces vascularites pourraient etre des antigenes tumoraux ou une production anormale d’IgA. Conclusion. – La survenue simultanee de ces deux pathologies pose donc le probleme des mecanismes impliques dans cette association.