Efficacy of rituximab in refractory polyarteritis nodosa: a case report.

Polyarteritis nodosa (PAN) is a systemic vasculitis affecting medium and small-sized vessels resulting in multiple organ involvement. Refractory PAN requires a different therapeutic approach. We herein report the case of a 42-year-old male presenting a non-virus-related refractory PAN with a favorable outcome on rituximab. He presented significant weight loss, muscle weakness, peripheral axonal neuropathy, and medium-sized cutaneous vessel necrotizing vasculitis. The patient received high-dose corticosteroids and cyclophosphamide with no significant clinical improvement while developing adverse side effects such as hypertension and diabetes. Rituximab was prescribed as an alternative therapy at 1000 mg on day 0 and day 15. This allowed for complete and rapid control of disease activity with regression of cutaneous injury and substantial improvement of neurological symptoms. In conclusion, using chimeric anti-CD20 monoclonal antibodies, such as rituximab, although rarely reported in refractory non-virus-related PAN, may be an effective alternative therapy, as portrayed in our case.

Brucellosis, an uncommon cause of acute acalculous cholecystitis: two new cases and concise review.

Acalculous cholecystitis etiologies while numerous, some of them are less-known such as brucellosis. In this report, we elaborate the clinical findings, investigations and management of two female patients presenting acalculous cholecystitis in whom diagnosis of acute brucellosis was retained. Both patients had fever, asthenia and abdominal tenderness. Laboratory results showed evidence of inflammation as well as hepatic cytolysis while cholestasis was noted in one patient. In both cases, ultrasound study and CT confirmed the presence of acalculous cholecystitis. Serology (tube agglutination test) led to the diagnosis of brucellosis. Diagnosis of brucellosis-related acute cholecystitis was established in both cases based on imaging findings as well as serology without resorting to cholecystectomy. Favourable clinical response to specific antibiotic therapy further supported our diagnosis as well as our decision to avoid surgery. Although few cases have been reported, brucellosis must be considered as a cause of acalculous cholecystitis, especially in endemic countries.

Autoimmune haemolytic anaemia in pancreatic adenocarcinoma: a potential paraneoplastic presentation.

While autoimmune haemolytic anaemia (AIHA) is a well-known paraneoplastic syndrome in haematological malignancies, it has been described far less in solid tumours. We hereby report the case of a 61-year-old male patient presenting AIHA related to pancreatic cancer. Investigations excluded infectious, autoimmune and toxic causes of AIHA. CT of the abdomen highlighted the presence of hypodense, infiltrating mass of the tail of the pancreas measuring 70×37×36 mm, compatible with pancreas neoplasm. Histological examination of two associated nodular lesions of the liver showed metastasis of pancreatic adenocarcinoma. The patient was started on corticosteroid without improvement of haemoglobin. Palliative chemotherapy was initiated; this led to significant improvement in haemoglobin comforting our diagnosis. This case illustrates the rare association between AIHA and pancreatic cancer. However, such association cannot be considered before excluding other, more frequent, aetiologies.

[Traumatic and psychosocial complications of falls in the elderly in Tunisia]. / Complications traumatiques et psychosociales des chutes chez le sujet âgé tunisien.

INTRODUCTION: Falls in the elderly are a major health problem due to their traumatic and psychosocial complications which may lead to a loss of autonomy and a state of dependency. This study aims to study the traumatic circumstances and psychosocial consequences of falls in the elderly. METHODS: We conducted a retrospective study of 40 patients aged 65 years and over with a history of at least one fall in the previous year between September 2014 and January 2016. They were enrolled among patients hospitalized or treated on an outpatient basis in the Department of Internal Medicine B in the Hospital Charles Nicolle. Data on circumstances and consequences of falls were collected through a retrospective interview with patients and their entourage about the fall. RESULTS: The average age of fallen patients was 75,7 years, with a female predominance (30F/10M). Precipitating factors were found in 38 patients. Extrinsic factors were found in 78.9% of cases while intrinsic factors in 50% of cases. Extended stay on the ground was reported in 10% of cases. Fractures were more frequent among women (12F/1M), especially involving upper limbs (61.5%). Psychosocial consequences were more frequent among women. Post-fall syndrome was found in 5 patients. CONCLUSION: The correction of the extrinsic and intrinsic precipitating factors of falls and the implementation of educational programs on how elderly should get up from the ground properly after a fall will prevent the risk of a fall as well as fall-related severe consequences.

Three scenarios of nasal obstruction revealing sarcoidosis.

The nasal location of sarcoidosis is rare. In this regard, we report three observations of sarcoidosis observed in three women with an average age of 53.6 years, revealed by annoying nasal manifestations. The presence of extra-nasal sites allowed us to suspect the diagnosis of sarcoidosis in all the patients.

Interstitial Cystitis: An uncommon revelation in primitive Sjögren syndrome.

Interstitial cystitis is an exceptional entity during primary Sjögren's syndrome. In this regard, we report the case of a 67-year-old patient in whom initially idiopathic interstitial cystitis revealed primary Sjögren's syndrome after 5 years of evolution in front of xerostomiaa, xerophtalmia and bilateral parotid hypertrophy with histological confirmation at the biopsy of accessory salivary glands.

[Hypercalcemia related to PTH-rP revealing malignant hepatic epithelioid hemangioendothelioma]. / Une hypercalcémie humorale maligne révélant un hémangioendothéliome épithélioïde du foie.

Hypercalcemia caused by tumor production of PTH-rp occurs most often in cases of squamous cell carcinoma of the lung, aerodigestive tract cancer, gynecological cancer and lymphoma. We report an exceptional case of PTH-rp related to a hepatic hemangioendothelioma. A 70 years-old male admitted for deterioration of the general state. The laboratory investigations revealed hypercalcemia, related to tumor production of PTH-rp. Imaging revealed tumoral hepatic lesions. Histopathological study and immunohistochemistry showed diffuse response for CD31 marker, CK20 (+) with CK7 (-) and hepatocyt antigen (-). The diagnosis of PTH-rp related to hepatic hemangioendothelioma was make. The patient died with recurrence of fatal hypercalcemia. Management of patients presenting with humoral hypercalcemia includes a vigorous search for tumor lesions. Elevated PTH-rp can be a bad prognostic factor. In front of tumoral liver lesions, a hepatic epithelioid hemangioendothelioma must be considered. Immunohistochemistry is necessary to make diagnosis.

[Characteristics of deep vein thrombosis in the elderly]. / Particularités de la thrombose veineuse profonde chez le sujet âgé.

PURPOSE OF THE STUDY: Deep vein thrombosis is a common condition in geriatric. The identification of risk factors for venous thrombosis in the elderly is important because it allows an appropriate prescription of preventive treatments. The purpose of this study is to identify the etiologic and therapeutic characteristics of deep vein thrombosis of the lower limbs in the elderly. PATIENTS AND METHODS: A retrospective study of 155 patients with lower limb deep vein thrombosis confirmed by venous Doppler. These patients were divided into two groups: group 1 (patients aged 65 years or more) and group 2 (patients whose age was below 65 years). A comparison between these two groups was performed. RESULTS: The average age of patients in group 1 was 74.89 years (± 6.43). The sex ratio in this group was 0.68. The thrombosis was more frequently proximal in patients of group 1. Patients of group 1 had significantly more risk factors than those of group 2 (p <0.05). Among risk factors studied, only the cancers were significantly more frequent in group 1 (p = 0.002). The frequency of hemorrhagic events in both groups was comparable but bleeding was more common in patients of group 1 with cancer. CONCLUSION: Our study confirms the multifactorial origin of deep vein thrombosis in the elderly and the incidence of malignant etiology. The results of this study also call for vigilance in the use of anticoagulants in the elderly especially in the presence of cancer because it is an additional risk factor for bleeding.

Deep vein thrombosis and tuberculosis: a causative link?

Pulmonary tuberculosis is very devastating in developing countries and its thrombogenic potential is a disturbing new entity. We report an 18-year-old woman who presented with a first episode of deep vein thrombosis. Pulmonary, hepatic and splenic tuberculosis was diagnosed while looking for secondary causes. The patient was treated with rifampicin, isoniazid, pyrazinamide and ethambutol along with low-molecular-weight heparin and antivitamin K. Tuberculosis has several mechanisms that induce a hypercoagulable state and can lead to thromboembolic complications.

Liver involvement in tuberous sclerosis.

Tuberous sclerosis complex (TSC) is a rare inherited disease that affects many organs and tissues, which explains the diversity of its clinical manifestations. This disease is often diagnosed at an early age when cutaneous angiofibromas, epilepsy and mental retardation are associated. The hepatic involvement in this phakomatosis is an uncommon location. In this context, we report the case of a tuberous sclerosis revealed in adulthood by abdominal pain and distension related to renal and hepatic angiomyolipomas associated with typical skin lesions.

Orbital metastasis as the inaugural presentation of occult rectal cancer.

Orbital metastasis is uncommon and occurs in 2-3% of patients with cancer. It is rarely the initial manifestation of a systemic malignancy. It usually indicates extensive haematogenous dissemination of a primary cancer and is associated with poor prognosis. Breast, lungs and prostate cancers are the most common primary cancers leading to orbital metastasis. However, orbital tumour revealing a rectal adenocarcinoma is exceptional. We describe a case of orbital tumour in a 67-year-old man with no history of systemic cancer while presenting with ophthalmic symptoms. Investigations revealed rectal adenocarcinoma as the primary malignant tumour.

[Syndrome d'activation macrophagique: une série de 11 cas tunisiens]. / Hemophagocytic syndrome: a study of 11 patients in tunisian population.

BACKGROUND: Hemophagocytic syndromes are mostly associated with underlying pathology, they can reveal: immunodeficiency, infections, hemopathies, cancers and auto-immune diseases. AIM: to investigate clinical, biological features, outcome characteristics and underlying pathology of Tunisian patients with hemophagocytic syndromes. METHODS: A retrospective study of patients with hemophagocytic syndromes admitted in an internal medicine department in Tunis over the period 2009-2012. RESULTS: There were 11 patients included, 4 men and and 7 women. Mean age was 47,3years. Purpura was observed in 3 cases, hepatosplenomegaly in 6 cases and peripheral lymph nodes in 3 cases. Hemorrhagic complication was noted in 2 cases. There were an increase of inflammatory indices in all the cases. Eight patients had pancytopenia and 3 had bicytopenia. Six patients developed intravascular dissiminated coagulation. High levels of triglyceridemia was noted in 5 cases and an hyperferritinaemia in all cases. Cytological examination of bone marrow confirmed hemophagocytosis in ten cases. Hemophagocytosis was associated to infectious diseases in 6 cases, there were 2 cases of leishmaniasis, septicemia to E.Coli and staphylococcus aureus and lymph nodes tuberculosis with HIV. We also noted a case of lymphoma, myelodysplasic syndrome, rheumatoid polyarthritis, adult onset still's disease. In one patient, the origin of hemophagocytosis remained indefinite. Visceral leishmaniose were treated by Glucantime®, adult Still's disease by corticosteroids and méthrotrexate®, lymphoma by chemotherapy. In lymph nodes tuberculosis, there were good evolution. Six patients died. CONCLUSION: Hemophagocytic syndrome is a rare and life-threatening disease. Pejorative prognosis requires an early therapy with etiological treatment.

Phalangeal lytic lesion: do not forget osseous sarcoidosis.

Sarcoidosis is a systemic granulomatous disease that most commonly involves the lung and thoracic lymph nodes. However, any organ can be affected. Osseous sarcoidosis has been reported in 3-13% of the cases. The skeletal involvement on radiographs is usually seen late in the course of the disease and is rarely the initial manifestation. We report a case of sarcoidosis revealed by a lytic lesion of the phalanx.

Isolated caecal tuberculosis mimicking a neoplastic tumour in an immunocompetent woman.

Although tuberculosis is endemic in Tunisia, only a few cases of intestinal disease have been reported. This entity is usually associated with pulmonary tuberculosis. Any part of the gastrointestinal tract may be affected but usually with ileocaecal involvement. Diagnosis is extremely difficult because the clinical presentation is so variable. The disease frequently mimics other chronic inflammatory intra-abdominal diseases or even malignancy. We report a case of isolated colonic tuberculosis presenting as circumferential ulcerovegetative lesions in the caecal region.