Acute tubulointerstitial nephritis and uveitis syndrome: A report on four adult cases.

Acute tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disease, generally presenting in children and young women. The interstitial nephritis may precede, follow, or develop concurrent to the uveitis. We report the clinical features and outcomes of four adult patients, aged 41-70 years with the TINU syndrome.

[Dermatomyositis and Panniculitis: the function of immunoglobulins]. / Dermatomyosite et panniculite: place des immunoglobulines.

Panniculitis is an inflammatory disease of subcutaneous adipose tissue which is rarely associated with dermatomyositis. It can occur before, after or simultaneously with muscle damage. In most cases, the evolution of panniculitis and of other dermatomyositis affections is favorable with corticosteroids and/or immunosuppressants. We report the case of a 48 year-old patient who developed panniculitis lesions 2 months before having muscular signs. Skin involvement was resistant to corticosteroid treatment associated with immunosuppressants drugs. This led to the use of polyvalent immunoglobulin treatment improving both skin and muscle damage.

Sarcoidosis with heart involvement: a rare association of terrible prognosis, a report of two cases.

Sarcoidosis is a multisystemic disorder of unknown etiology which is characterized by the formation of non-caseating granulomas in involved tissues. Cardiac involvement is one of the least common manifestations and it can occur at any point of time during the course of sarcoidosis. Here we present the case of 2 patients with known sarcoidosis who develop cardiac abnormalities in the absence of known primary cardiac cause. In our report, we would like to draw attention to the importance of considering heart involvement in any case with systemic sarcoidosis especially in young age.

Coexistence of pyoderma gangrenosum and sweet's syndrome in a patient with ulcerative colitis.

Pyoderma gangrenosum (PG) and Sweet's Syndrome (SS) are inflammatory skin diseases caused by the accumulation of neutrophils in the skin and, rarely, in internal organs. These neutrophilic dermatosis (NDs) are distinguished by the existence of forms of transition or overlap. They are frequently associated to systemic diseases especially hematologic and gastrointestinal ones. We report a case of a patient with ulcerative colitis (UC) who successively developed two types of NDs: PG then SS. A 66 years old patient with a history of UC consulted in July 2012 for an erythematous swelling of the back of the right hand treated with antibiotics without improvement. At that time, bacteriological samples were negative. In October 2012, he was hospitalized for polyarthralgia and impaired general condition. In physical examination, he had vesiculobullous plaque of 10 cm long of the right hand and wrist, infiltrated erythematous plaque on the right leg and another topped with a large pustule at the left ankle. Skin biopsy showed at the back of the right hand an aspect of PG and at the infiltrated plaques of the ankle an aspect of SS. Prednisone was started with improvement of the skin lesions and a recovery condition. The combination of PG and SS has already been described in cases of hematologic malignancy and rarely in UC. There is also the notion of passage from a neutrophilic dermatosis to another. Indeed, a typical lesion initially of SS can evolve to a future PG. This case demonstrates that neutrophilic dermatoses form a continous spectrum of entities that may occur in UC.

The effect of an integrated syndromic respiratory disease guideline in primary health care settings.

RATIONALE, AIMS AND OBJECTIVES: The use of integrated syndromic guidelines (ISG) aims to improve the quality of care for patients with respiratory diseases. The impact of such ISG in clinical practice can be potentially significant in primary health care (PHC) settings. We report the impact of the use by general practitioners (GPs) of a Tunisian ISG for respiratory diseases in management of respiratory patients in PHC. METHODS: The short-term impact was assessed through the results of the feasibility study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG. The same 73 GPs practicing within 28 PHCs were involved in the two surveys at an interval of 6 weeks. Information on each patient mentioned gender, age, underlying conditions, symptoms, referral, diagnosis and drug prescription details. RESULTS: During the periods of the baseline and impact surveys, 36.0 and 31.1% of PHC attendees, respectively, sought care for respiratory symptoms. Acute respiratory infection (ARI) cases accounted for more than 85% of patients with respiratory disease. In the impact survey, chronic respiratory disease (CRD) diagnosis increased by approximately 50%. In the same way, the proportion of tuberculosis suspects increased 5.5 times. The number of drugs prescribed per patient decreased by 18.8%, and the proportion of patients who were prescribed antibiotics decreased by 19.0%. The prescription of steroids also significantly decreased while inhaled ß-agonist prescription increased. The average cost of drug prescription was reduced by 19%. CONCLUSION: Training on ISG for respiratory diseases improved the diagnosis of CRD and tuberculosis, and lead to a more rational use of drugs for ARIs in PHCs.

Renovascular hypertension: a report of 21 cases.

Renovascular hypertension (RVH) is among the most common forms of secondary hypertension. We studied 21 patients (eight male and 13 female) with RVH who were encountered during a period of 16 years. The average age of the patients was 34.75 years. Trans-renal Doppler ultrasound confirmed the diagnosis of renovascular stenosis (RAS) as the cause of RVH in 95% of the patients. Computed tomography angiography was performed in ten cases, which confirmed the diagnosis in all these cases. Magnetic resonance angiography was performed in only three patients. Renal scintigraphy was performed in 11 patients, with DTPA in nine patients and with MAG3 in two cases. Arteriography was performed in 15 cases for therapeutic end points. In two patients, we treated the arteries of both kidneys and in 19 cases we treated only one kidney artery. Percutaneous transluminal angioplasty was performed in ten cases. Renal arterial stent placement was performed in three cases in which RAS was from an atherosclerosis etiology. Surgical revascularization was performed in four cases. Nephrectomy was necessary in four cases. After interventional treatment, medical treatment using antihypertensive drugs was necessary in 17 of the patients. After treatment, three patients returned to normal kidney function, while worsening of glomerular filtration rate was noted in four patients. Some complications such as a kidney infarct after treatment, a nephrectomy, artery thrombosis, an ischemic stroke and recurrent RAS were also noted.

Malaria in tunisian military personnel after returning from external operation.

Introduction. Malaria had been eliminated in Tunisia since 1979, but there are currently 40 to 50 imported cases annually. Soldiers are no exception as the incidence of imported malaria is increasing in Tunisian military personnel after returning from malaria-endemic area, often in Sub-Saharan Africa. Methods. We retrospectively analyzed the clinical and biological presentations, treatment, and outcomes of 37 Tunisian military personnel hospitalized at the Department of Internal Medicine, the Military Hospital of Tunis, between January 1993 and January 2011, for imported malaria. The clinical and laboratory features were obtained from the medical records and a questionnaire was filled by the patients about the compliance of malaria prophylaxis. Results. Thirty-seven male patients, with a mean age of 41 years, were treated for malaria infection. Twenty-two were due to Plasmodium falciparum. The outcome was favourable for all patients, despite two severe access. The long-term use of chemoprophylaxis has been adopted by only 21 (51%) of expatriate military for daily stresses. Moreover, poor adherence was found in 32 patients. Conclusion. The risk of acquiring malaria infection in Tunisian military personnel can largely be prevented by the regular use of chemoprophylactic drugs combined with protective measures against mosquito bites.

Spinal cord compression revealing an intraosseous schwannoma.

A 68-year-old female presented with inflammatory lumbalgia and cruralgia. Physical examination revealed a lumbar stiffness without neurological deficit. Secondarily, paraplegia and urinary retention appeared. Magnetic resonance imaging showed a vertebral compaction of L3 vertebra with medullar compression. Emergent surgery revealed an epidural tumor involving largely the L3 vertebral body. Histology found schwannoma with positive protein S100 on the immunohistochemical study. Metastasis screening revealed bilateral nodular lesions of the lungs and a trochanter high scintigraphic signal. It was a malignant schwannoma. The patient underwent radiotherapy in addition to the total tumor resection.

[Idiopathic portal hypertension associated with celiac disease: one case]. / Hypertension portale idiopathique associée à une maladie coeliaque: à propos d'un cas.

We describe for the first time a case of idiopathic portal hypertension (IPH) in a 31 year old patient with coeliac disease (CD). She had splenomegaly, pancytopenia and an unexplained portal hypertension in the absence of any histological abnormalities of the liver. The diagnosis of coeliac disease was based on histological and serological data. Treatment included a splenectomy and a splenorenal shunt.

Acute renal failure due to lymphomatous infiltration: an unusual presentation.

Renal lymphoma occurs most often as a part of a multi-systemic disseminated lymphoma or as a recurrence of the tumor. Renal involvement usually occurs late in the course of the disease and is clinically silent. Acute renal failure (ARF) from lymphomatous infiltration has been described but is quite rare. We report a 50-year-old Caucasian woman, who presented with features of ARF. Physical examination showed that her arterial blood pressure was 190/100 mm Hg with no lymphadenopathy or hepatosplenomegaly. Her urine output was about 100 ml/day, and urinanalysis revealed + proteinuria and microscopic hematuria. Biochemical findings revealed severely impaired renal function with a serum creatinine of 693 micromol/L. The patient's lactate dehydrogenase was elevated at 632 U/L. An abdominal ultrasound showed bilateral, large non-obstructed kidneys and a hypoechoic mass arising in the right lobe of the liver. An ultrasound-guided percutaneous liver biopsy showed typical features of B-cell lymphoblastic lymphoma. The patient expired two days later, even before any specific treatment could be started.

[Neuro-psychiatric disorders revealed pernicious disease without anemia. About three cases]. / Tableau neuro-psychiatrique révélant une maladie de Biermer en l'absence d'anémie. A propos de 3 observations.

In addition to an anemic syndrome, pernicious disease can also include neuropsychiatric manifestations. We report here three cases diagnosed as pernicious disease revealed by neuropsychiatric symptoms and even without anemia. Our patients were made of a man and two women with a mean age of 55 years. They consulted for progressively worsening troubles of step which were related to a combined degeneration of the cord. This degeneration was associated to a cerebellar syndrome in one case. An isolated macrocytosis with a mean MGV at 109 fl, was noticed allowing thus to evoke the Biermer pernicious disease. This diagnosis was confirmed by the marrow puncture which showed a medullar megaloblastosis in two cases and an erythroblastic nucleocytoplasmic maturation's asynchronism. Treated by vitamin B12, the evolution was favorable in two cases with a total neurological recovery after six months in two patients. One patient died after six days of treatment following an acute myocardial infarction. If faced to symptoms made of a combined degeneration of the spinal card, a peripheral neuropathy and/or psychiatric troubles, pernicious disease is a diagnosis that we must evoke even in absence of anemia.

[Association of systemic lupus erythematosis and myasthenia gravis. A new case report]. / Association lupus érythémateux systémique et myasthénie. A propos d'une nouvelle observation.

The association of myasthenia gravis (MG) and systemic lupus erythematosus (SLE) is a quite rare one. We report here one case and try to discuss the physiopathologic mechanisms and also the clinical, evolutive and therapeutic features of this morbid association. It's the case of a woman of 43 years old followed in our department since 1999. The patient has been treated by corticosteroids (prednisone) with monthly administered cyclophospamide pulses. Nine months lately, she develops a diplopia with a ptosis, a dysphagia and a muscular weakness. The treatment was mainly based on intravenous immunoglobulins. The later evolution was favourable. The coexistence of SLE and MG is not casual. It must be considered in every lupic patient developing neuromuscular troubles.

[Interpretation of hypertransaminasemia]. / Interprétation d'une hypertransaminasémie.

Raised serum level of transaminases aspartate (aminotransferase and alanine aminotransferase) is a frequent situation in medical practice. It is considered as moderate when the level is under 10 times normal and as chronic when it lasts for more than 6 months. The most common etiologies for chronically elevated transaminases are alcohol use, viral hepatitis, liver steatosis, diabetes, obesity and medications. Many non invasive tests, including history, physical examination, blood tests (markers for hepatitis A and B, muscular enzymes), and imaging procedures (abdominal ultrasonography) are usually done and lead to a correct diagnosis in 80% of patients. When the diagnosis cannot be determined non invasively a liver biopsy is recommended in order to make diagnosis, to evaluate the prognosis and to start an adapted treatment.