[Unexplained diffuse arteriosclerosis in a 26-year-old patient]. / Artériosclérose diffuse inexpliquée chez une jeune patiente de 26 ans.

Arteriosclerosis is an alteration of the blood vessels whose walls calcify, lose their elasticity and thicken. The result is a decrease in circulating blood flow and ischemic manifestations. Calcification of the arteries is a physiological phenomenon in the elderly but young subjects may also be affected. Indeed, certain risk factors can favor the formation of plaques at the level of the vessels. These include classic cardiovascular risk factors, as well as systemic inflammatory diseases, connective tissue diseases, chronic hypercalcemia… We report the case of a 26-year-old female patient with diffuse arteriosclerosis discovered accidentally, and whose exhaustive etiological investigation remained negative.

Anti-C1q antibodies and systemic lupus erythematosus in the Tunisian population.

OBJECTIVES: The presence of a wide variety of autoantibodies is a characteristic feature of systemic lupus erythematosus (SLE). Although non-specific, anti-complement C1q (anti-C1q) were shown to correlate with the occurrence of active nephritis. The present study aimed to investigate the prevalence of anti-C1q in Tunisian SLE patients and their association with clinical manifestations, especially renal involvement. PATIENTS AND METHODS: IgG anti-C1q antibodies were assessed by Elisa in 98 SLE patients, 55 patients with rheumatoid arthritis (RA) and 65 healthy individuals (HI). RESULTS: Anti-C1q were found in 53 (54.1%) patients with SLE, three (5%) patients with RA and six (9.3%) HI. Among the 65 patients with renal involvement, anti-C1q were present in 35 (53.8%) patients. There was no significant association between anti-C1q and renal or extrarenal manifestations. In addition, there was no correlation between anti-C1q titer and SLEDAI index. Anti-C1q were significantly associated with anti-nucleosome (P=0.001), anti-Sm (P=0.01) and a low C4 level (P=0.046). Concomitant presence of anti-C1q and anti-dsDNA antibodies was not associated with renal manifestations. CONCLUSION: Our study shows that prevalence of anti-C1q was comparable with that previously reported in Caucasian populations. These antibodies were associated with a low C4 level. However, there was no association between anti-C1q and renal involvement or severity of nephritis.

[Primary retroperitoneal fibrosis: a report of 7 cases]. / La fibrose rétropéritonéale idiopathique: à propos de sept cas.

Retroperitoneal fibrosis is a rare fibrosing disease of the retroperitoneal tissue characterized by a significant clinico-biological polymorphism. No codified treatment exists, particularly for the primary type which is the most frequent. We retrospectively report on 7 cases of primary retroperitoneal fibrosis seen over a period of 10 years. There were 4 men and 3 women (mean age: 58 years).The most common presenting symptom was lumbar pain. A biological inflammatory syndrome and a renal insufficiency were found in 4 cases. The diagnosis was confirmed by abdominal CT scan and/or histology. Etiological investigations remained negative. The evolution was generally favourable under corticosteroids. Retroperitoneal fibrosis requires a careful etiological investigation before it is considered primary. Prognosis is good in spite of the absence of a well codified treatment.

[Vertebral primary malignant germ cell tumor of thoracic spine: an exceptional observation]. / Tumeur germinale primitive à localisation vertébrale dorsale chez un adulte : une observation exceptionnelle.

Vertebral primary malignant germ cell tumors are rarely located in thoracic spine. We report the case of a 44-year-old female, in which a symptomatology including dorsal rachidial pain, intercostal neuralgia, straight and transit disorder revealed a thoracic vertebral primary malignant germ cell tumor. The sole location of a vertebral primary malignant germ cell tumor in adult, exceptionally reported in the literature, prompted us to relate this observation.

[Screening for depression in an elderly population living at home. Interest of the Mini-Geriatric Depression Scale]. / Dépistage de la dépression chez une population âgée vivant à domicile. Intérêt de la « Mini-Geriatric Depression Scale ¼

BACKGROUND: Depression is the most usual mental disorder in the elderly, but underdiagnosed and undertreated. Its prevalence is variable. Symptoms of depression present in the elderly can be masked and difficult to recognize. The purpose of this study was to examine prevalence and risk factors for depression in elderly living in their home. METHODS: A cross-sectional study of randomly selected homes in randomly selected geographical islets was carried out Monastir City (Tunisia). Questionnaire-based interviews were conducted among the elderly aged more than 65 years living in their home. Depression symptoms were assessed using a Mini-Geriatric Depression Scale. The relationship between the risk of depression and sociodemographic and health-related variables was studied using logistic regression. RESULTS: Out of 598 (female 66 %, mean (SD) age 72.3 (7.4) years) elderly persons interviewed, 136 (22.7 %) were screened to have a Mini-Geriatric Depression Scale more than or equal to 1. Multiple logistic regression analysis revealed that the following were significant (P<0.01) independent predictors of risk of depression: female sex (OR=2.36 [95 % CI=1.43-3.94]), having a low level of education (OR=4.02 [95 % CI=1.38-11.65]), disability (OR=3.50 [95 % CI=1.94-6.46]), a history of stroke (OR=2.90 [95 % CI=1.20-7.72]) and the use of hypnotic medications (OR=2.47 [95 % CI=1.38-4.42]). CONCLUSION: This study suggests that the risk of depression is a common psychiatric disorder in elderly living in their home, and underlines the usefulness of the Mini-Geriatric Depression Scale to detect the risk of depression in the elderly. This clinical approach should be encouraged in all medical practices to improve the prognosis of depression in the elderly.

[Isolated abdominal pain revealing a paraprosthetic fistula in a patient with Takayasu arteritis]. / Douleur abdominale isolée révélant une fistule paraprothétique au cours d'une maladie de Takayasu.

Aortic aneurysms and stenosis occurring in Takayasu arteritis may require aortic prosthesis that can be complicated by aorto-digestive fistula. We report a 41-year-old female who presented with an isolated abdominal pain revealing a para-prosthetic aorto-duodenal fistula complicating a Takayasu arteritis. The diagnosis of aorto-digestive fistula may be difficult if abdominal pain is isolated and imaging inconclusive. Surgical procedure may be necessary to obtain the diagnosis and constitutes the main part of the treatment before fatal outcome.

[Hereditary multiple exostosis revealed by deep vein and arterial popliteal thrombosis]. / Maladie des exostoses multiples révélée par une thrombose poplitée veineuse et artérielle.

We report a 38-year-old man who presented successively a thrombosis of the right popliteal vein and the right popliteal artery, responsible of a painful edema of the leg. There was no known thrombophilic predisposing condition. Radiologic assessment, guided by clinical findings, evidenced bilateral femoral and tibial exostosis resulting in a diagnosis of hereditary multiples exostosis. Although anticoagulant treatment with unfractioned heparin was instituted, distal ischemia of the right lower limb developed. Resection of the compressive osteochondroma and an arterial femorotibial bypass venous graft were performed in addition to prolonged anticoagulant therapy. Outcome was eventually favorable. Hereditary multiple exostosis may be asymptomatic for long time. Compression of adjacent vascular structures by an osteochondroma is a rare and potentially serious complication.

[Takayasu's disease in central Tunisia: 27 cases]. / La maladie de Takayasu dans la région centre de la Tunisie. A propos de 27 cas.

BACKGROUND: Takayasu's arteritis is a rare inflammatory disease and few data are available in Tunisia. The aim of this study is to evaluate clinical and radiological features of the disease in the centre of Tunisia. METHODS: We retrospectively studied medical records of patients treated in departments of internal medicine or cardiology from three university hospitals in Sousse and Monastir over the period 1985-2005. The criteria for inclusion were those proposed by the American College of Rheumatology. RESULTS: Twenty-seven patients were identified. The mean age at presentation was 33.2 years (range 16-68 years) and 88.9% were female. The mean delay from the onset of the symptoms to the time of diagnosis was 4.2 years. Intermittent claudication was the most common presentation (81.5%) and hypertension was noted in 40.7% of cases. Arterial localization most frequently involved was subclavian artery. The aorta was involved in 52.3% and renal arteries in 36.3% of cases. Stenosis or occlusions was constant but aneurysms were noted in 7.4%. Functional difficulty was the main complaint in the follow-up, death related to Takayasu's disease was noted in 3.7%. The mean follow-up time was 75.8 months (6.3 years). CONCLUSION: There is no epidemiologic particularity of Takayasu's disease in Tunisia, however involvement of the subclavian artery was more frequent than the aortic localization.

[Polymyositis and dermatomyositis in adults. Tunisian multicentre study]. / Les polymyosites et dermatomyosites de l'adulte. Etude multicentrique tunisienne.

INTRODUCTION: To study the clinical features and the outcome of polymyositis (PM) and dermatomyositis (DM) in Tunisia. METHODS: Retrospective multicentre study conducted by the Tunisian Society of Internal Medicine. Adult patients with confirmed and probable PM and DM, according to the Bohan and Peter's criteria, were included in the study and followed-up between 1987 and 2005. RESULTS: Twenty cases of PM and 50 cases of DM were included. Female/male sex-ratio was 2.5. The mean age at diagnosis was 40.7 years. Muscle weakness concerned girdle muscles in 94.3% and pharyngeal muscles in 42.8% of the patients. Interstitial lung disease and heart involvement occurred respectively in 35.7 and 20%. Eyelid erythema, peri-ungual erythema and Gottron's sign occurred in respectively 86, 50 and 36% of the cases of DM. Malignant disease was found in 12.8% of the patients (mainly gynecological and nasopharyngeal cancers). All patients received high dose corticosteroids with additional immunosuppressive drugs in 40% of the cases. The outcome was stabilization or partial improvement in 71.5% of the cases. Death occurred in 20% and was caused by respiratory failure, sepsis and cardiac failure. CONCLUSION: The particularities of PM and DM in Tunisia are the preponderance of DM, early onset of the disease and high frequency of the nasopharyngeal cancer.

[Metronidazole-induced reversible cerebellar lesions and peripheral neuropathy]. / Lésions cérébelleuses réversibles et neuropathie périphérique induites par le métronidazole.

INTRODUCTION: Metronidazole is a widely prescribed treatment for amoebic and anaerobic germ infections. Its neurologic toxicity is rare but can be serious. CASE REPORT: We report the case of a 27-year-old male patient, treated with metronidazole for a cerebral abscess. He presented with a cerebellar syndrome and peripheral neuropathy at a cumulative metronidazole dose of 60g. The MRI aspect of the cerebellar lesions in addition to their reversibility after treatment cessation led to the diagnosis of metronidazole induced neurologic toxicity. CONCLUSION: The occurrence of neurologic disorders in patients treated with metronidazole must suggest drug toxicity and lead to cessation of treatment.

[Diagnostic strategy and management of anemia: a consensus from a detailed study of 100 patients followed in internal medicine]. / Strategie diagnostique et conduite pratique devant une anemie: d'apres une etude approfon- die de 100 patients suivis en medecine interne.

Anemia is a frequent reason for seeking medical care in Internal Medicine. It is not a diagnosis, but rather a symptom that needs to be investigated in order to find an etiology. In a retrospective review of 100 cases of anemia, the cause was found in 86 % of cases. The etiologic profile was varied. Iron deficiency remained by far the most frequent cause seen in 47% of case. Other etiologies have been found such as neoplasm in 13 % of cases, chronic renal failure in 8% of cases and endocrinal cause in 5 % of cases. We recommend a diagnostic decision tree that provides a tool for rational and cost effective approach for anemia.

[Antiphospholipid antibodies in 146 women with repeated pregnancy losses]. / Anticorps antiphospholipides et pertes foetales: étude rétrospective de 146 cas.

Antiphospholipid antibodies are associated with arterial and venous thrombosis and recurrent abortions. However, the prevalence of these antibodies in repeated miscarriages varies in different reports. To obtain quantitative data with restricted criteria and discuss the origin of the variability on the literature, we investigated the presence of antiphospholipid antibodies in 146 women who had 2 or more consecutive pregnancy losses and in 99 women whose pregnancies were successful. Antiphospholipid antibodies (lupus anti-coagulant or anticardiolipin antibodies of 20 or more IgG units) were found in 45% of women with pregnancy losses and in 9% of controls (p < 0.001). The type of loss was determined according to the trimester of pregnancy and the time of the fetal loss. 68% of patients with antiphospholipid antibodies had at least one fetal loss on the second or third trimester compared with 45% of patients without fetal loss (p < 0.01). Further studies should be conducted using more rigorous definition of clinical and laboratory characteristics in a way to allow better comparison between studies.

[Vital capacity and peak expiratory flow rates in a North-African population aged 60 years and over: influence of anthropometric data and parity]. / Capacité vitale et débits maximaux expiratoires dans une population nord-africaine âgée de plus de 60 ans: influence des données anthropométriques et de la parité.

INTRODUCTION: The aims of this study were to calculate predictive equations for respiratory variables (FVC, FEV1, FEF25%-75%, and PEFR) in elderly north-African people and to study the effect of parity on the respiratory function. METHODS: FVC and forced expiratory flows were measured in a "healthy" sample of 186 subjects aged 60 years and over (66% women). The measurements were made in health centres using portable spirometers. Predictive equations were determined by the technique of multiple linear regression using standing height and age as independent variables. The effect of parity on ventilatory function was studied by comparing two groups defined by a parity greater or less than 4. RESULTS: The respiratory variables measured in this elderly north-african population were significantly different from those established references ranges. CONCLUSIONS: High parity is associated with a significant reduction in peak flow rate.

[Superior caval syndrome in adults in central Tunisia. Apropos of 26 cases]. / Le syndrome cave supérieur de l'adulte en Tunisie centrale. A propos de 26 cas.

We report 26 cases of superior vena cava obstruction (SVC) observed in Sousse University Hospital (TUNISIA). The diagnosis was confirmed by CT scan and/or superior vena cava angiography. The underlying disease was revealed by SVC on 76.9% of cases. Malignant underlying disease was noted on 61.53% of cases. Non malignant causes of SVC was Behçet disease (4 cases) and mediastinal fibrosis (5 cases). SVC revealed Behçet disease in the 4 cases.

[Osteoarticular amyloidosis in hemodialyzed patients. Report of 4 cases]. / Amylose ostéoarticulaire des hémodialysés. A propos de 4 cas.

Chronic hemodialysis is sometimes complicated by an osteoarticular amyloidosis, which happens after a middle delay of ten years, it can be expressed by a tunnel carpal syndrome, a shoulder pariarthritis, bony cysts, and erosive spondylarthropathy. The authors reported their experience about four cases, and insisted on some évocatoring radiologic aspects.

[Continuous ambulatory peritoneal dialysis in Tunisia]. / La dialyse péritonéale continue ambulatoire en Tunisie.

CAPD covers about 4% of renal replacement therapy patients in Tunisia. From February 1983 to 1988, 47 patients, 21 males and 26 females whose mean age was 36, 14 +/- 15 were treated. Their socio-cultural level was variable. The mean duration of therapy was 14.5 months/patient/year. The five years patient survival rate was 46% and the technique survival rate 21%. Most patients had a good general condition and were professionally rehabilitated. Peritonitis was the main complication: its incidence was 1.8 episodes/patient/year. Yeasts peritonitis were relatively frequent, specially in patients who had previously been treated with antibiotics. Peritonitis was often cured with a local and general treatment. Yearly CAPD cost was 1/3 lower than center hemodialysis and a better management allowed to decrease the expenses due to laboratory and X ray investigations and to hospitalization. On the basis of this clinical experience, we believe that CAPD is an efficient and valid therapeutic modality, less expensive than hemodialysis. It is probably a suitable renal replacement therapy in other centers in Tunisia and in other developing countries.

[The first thirty months of kidney transplantation in Tunisia]. / Les trente premiers mois de transplantation rénale en Tunisie.

Kidney transplantation is actually the best replacement therapy for the end stage renal failure. It sets free the hemodialysed patient from the hemodialysis restraint and contributes to solve the socio-economic problems risen by chronic hemodialysis. The authors report the results of this technic during the first 30 months of kidney transplantation in the "Hôpital Charles Nicolle" of Tunis. They describe the first steps which led to kidney transplantation, the therapeutic regimens, the medico-legal problems and the specific complications observed during this start period.