Ines Khochtali

Evaluation of the renal function in type 2 diabetes: clearance calculation or cystatin C?

Screening for diabetic nephropathy is usually done by albuminuria/24h and the use of creatinine clearance. The objective of this study was to evaluate the renal function in Type 2 diabetes by using different formulas of creatinine clearance and to assess the contribution of cystatin C; 83 adults with type 2 diabetes (23 men and 60 women) and 83 adult controls (40 men and 43 women) were studied. Biochemical parameters were determinated on Coba 6000™ (Roche diagnostics). Diabetics showed a significant increase in blood glucose, cholesterol, triglycerides, LDLc, the ApoB, Lp(a), urea, uric acid, creatinine and cystatin C and lower HDLc. Cystatin was increased in patients with degenerative complications and in hypertensive patients. We found strong correlations of cystatin C with creatinine (r = 0.9454), urea (r = 0.8999) and uric acid (r = 0.8325). We found a significant exponentially increase of creatinine and cystatin C from one stage to another. Cystatin C has a strong association with MDRD (r = 0.8086) and CG (r = 0.7915) and a low one with creatinine clearance (r = 0.1044). In conclusion, the use of cystatin C for screening and early treatment of incipient diabetic nephropathy appears to be adequate. CG and MDRD formulas still hold their place, in regards to the classical determination of creatinine clearance, to monitor patients.

A case of Kallmann syndrome associated with a non-functional pituitary microadenoma

Summary Kallmann syndrome (KS) is a form of hypogonadotropic hypogonadism in combination with a defect in sense of smell, due to abnormal migration of gonadotropin-releasing hormone-producing neurons. We report a case of a 17-year-old Tunisian male who presented with eunuchoid body proportions, absence of facial, axillary and pubic hair, micropenis and surgically corrected cryptorchidism. Associated findings included anosmia. Karyotype was 46XY and hormonal measurement hypogonadotropic hypogonadism. MRI of the brain showed bilateral agenesis of the olfactory bulbs and 3.5 mm pituitary microadenoma. Hormonal assays showed no evidence of pituitary hypersecretion. Learning points: The main clinical characteristics of KS include hypogonadotropic hypogonadism and anosmia or hyposmia. MRI, as a non-irradiating technique, should be the first radiological step for investigating the pituitary gland as well as abnormalities of the ethmoid, olfactory bulbs and tracts in KS. KS may include anterior pituitary hypoplasia or an empty sella syndrome. The originality of our case is that a microadenoma also may be encountered in KS. Hormonal assessment indicated the microadenoma was non-functioning. This emphasizes the importance of visualizing the pituitary region in KS patients to assess for hypoplastic pituitary malformations or adenomas.

Pericarditis: uncommon onset of anti-neutrophil cytoplasmic antibody-associated vasculitis induced by methimazol

Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a group of small vessel vasculitides characterized by necrotizing inflammation, with few or no immune deposits associated with myeloperoxidase (MPO) ANCA or proteinase 3 (PR3) ANCA. It includes microscopic polyangiitis, granulomatosis with polyangiitis (Wegner’s), eosinophilic granulomatosis with polyangiitis (Churg-Strauss) and single-organ AAV (for renal example, renal-limited AAV) [1]. Even the etiology of this vasculitis is still unclear several factors have been reported to be associated with AAV with more consideration of drug-associated ANCAassociated vasculitis [2]. Antithyroid drugs (ATDs) which are generally well tolerated can be associated with minor side effect, but serious and potentially life-threatening complications can occurred in very rare cases with such AAV [3]. To date Propylthiouracil (PTU) is more likely to be associated with AAV than Carbimazole (CBZ) or his active metabolite Methimazole (MMI) [4]. Skin lesions and kidney involvement are the most common clinical features reported in this field. Here we present the first case report of a 25-yr-old woman who developed AAV initially presenting with pericarditis after 1 year of MMI use.

Hughes-Stovin syndrome revealing the presence of Behçet’s Disease

Background: Hughes-Stovin Syndrome (HSS) is a rare clinical disorder characterized by deep venous thrombosis and multiple pulmonary and/or bronchial aneurysms. Aneurysms in systemic circulation can also be seen. Case presentation: We report the first case of HSS with aortic aneurysm in a 55-year-old man who initially presented with deep venous thrombosis. The diagnosis of HSS revealing Behçet’s disease was made given the history of recurrent oral and genital ulcers. Treatment consisted of 3 daily pulses of methylprednisolone (1g) followed by oral prednisone (1mg/kg daily) and 6 monthly pulses of cyclophosphamide. Oral anticoagulation treatment was held 3 months and then was stopped with good outcome. Conclusion: Systemic aneurysms in Hughes Stovin is a worth knowing complication which may reveal Behçet’s disease.

One-Year Outcome of Intensive Insulin Therapy Combined to Glucose-Insulin-Potassium in Acute Coronary Syndrome: A Randomized Controlled Study.

Background A number of factors may offset the cardioprotective effects of glucose‐insulin‐potassium (GIK) on outcome of patients with acute coronary syndrome, such as hyperglycemia induced by this cocktail infusion. We performed a study to evaluate the effect of intensive insulin therapy in association with GIK on 1‐year outcome in patients hospitalized for acute coronary syndrome. Methods and Results In a randomized prospective controlled trial we included 772 patients with non–ST‐segment elevation acute coronary syndrome. Patients were randomized into 3 groups: GIKI2 group, who received GIK with intensive insulin therapy for 24 hours; GIK group, who received GIK with nonintensive insulin therapy; and control group, who received usual care. The primary outcome criteria were the rates of major cardiovascular events combining death, reinfarction, and stroke rate at 1 year. In addition, we measured platelet function assay‐100 and plasminogen activator inhibitor‐1 at admission and 24 hours later. Based on an intention‐to‐treat analysis, major cardiovascular events at 1 year was 12.8% in the GIKI2 group, 15.5% in the GIK group, and 20.5% in the placebo group; the difference was significant between the GIK2 and control groups (P=0.01). Platelet function assay‐100 at 24 hours decreased significantly from baseline in the control group but not in the GIKI2 group. Plasminogen activator inhibitor‐1 decreased significantly in the GIKI2 group but significantly increased in the control group. Minor hypoglycemic events were more frequent in the GIKI2 group compared with other groups. Conclusions GIKI2 led to improvement of 1‐year outcome rates in patients with non–ST‐segment elevation acute coronary syndrome. This beneficial effect was associated with a decrease in platelet reactivity and an increase on fibrinolysis tests. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00965406.

Does Lipid Profile Affect Thrombin Generation During Ramadan Fasting in Patients With Cardiovascular Risks

There is evidence that diet and variation in lipid metabolism can influence blood coagulation, but little is known about the effect of Ramadan fasting on plasmatic coagulation pattern. We investigated the effect of Ramadan fasting on thrombin generation (TG) in patients with cardiovascular disease (CVD) risks, and we aimed to assess the effect of lipid profile on TG parameters. The study was conducted in 36 adults having at least 2 CVD risks and in 30 healthy controls. Coagulation pattern was assessed by both classical clotting times and TG test. A complete lipid profile was performed simultaneously. Patients were invited 2 times: 1 week before Ramadan and during the last week of the Ramadan. The TG parameters were not different in patients with CVD risks compared to healthy controls. Fasting had no effect on plasmatic coagulation parameters and on TG profile. Individual analysis of the mean rate index (MRI) of TG revealed 3 groups: group 1 with no modification of MRI, group 2 with a significant increase in MRI (81.64 nM/min vs 136.07 nM/min; P < .001), and group 3 with a significant decrease in MRI (125.27 nM/min vs 73.18 nM/min; P = .001). Only in group 2, a significant increase was observed in total cholesterol and low-density lipoprotein cholesterol. Changes in lipid profile during Ramadan fasting did not influence the global coagulation pattern in patients with CVD risks. Whereas, a significant increase in the propagation phase of TG was associated with a significant increase in cholesterol levels, which was not found with the other TG parameters.

Syndrome de Münchhausen : hypoglycémie factice par glibenclamide

Introduction Les hypoglycemies factices (HF) sont secondaires a une auto-administration d’insuline ou d’un insulinosecretagogue. C’est le syndrome de Munchhausen le plus decrit. Patients et methodes Nous rapportons un cas d’HF a la suite d’une prise d’insulinosecretagogue. Cas clinique Patiente âge de 20 ans sans antecedents pathologiques notables hospitalisee pour hypoglycemie (HypoG) severe a 1,5 mmol/l. Au cours de l’hospitalisation, la patiente continue a a voir des hypoG severes a 2 mmol/l persistantes malgre une perfusion continue de SG10 %. Les dosages hormonaux faits au moment de l’hypoG ont revele une cortisolemie elevee adaptee, mais une insulinemie et un peptide c eleves et inadaptes. Une TDM pancreatique n’a pas revele d’anomalies. Un entretien psychologique revele la notion de conflit recent de la patiente avec son fiance. Les hypoG ont debute juste apres leur separation. Une HF par traitements hypoglycemiants (THG) est suspectee devant ce contexte et la notion de benefice secondaire en vue d’une prolongation de l’hospitalisation des l’arret de perfusion de SG10 % et la normalisation de la glycemie. La patiente nie toute prise medicamenteuse mais avoue qu’elle s’occupe de sa mere diabetique et lui donne quotidiennement le Glibenclamide (Glb). Lors d’un 1er dosage pharmacologique, la presence du glimepiride est detectee, mais a des concentrations plasmatiques faibles, pouvant cadrer avec une simple interference. Devant la forte suspicion diagnostic d’HF, la realisation d’une cinetique plasmatique avec recherche de Glb et glimepiride au moment de l’hypoglycemie et toutes les 30 min pendant 3 h a revelee la presence Glb. Sa concentration au moment de l’hypoG atteint un seuil supra-therapeutique. Le suivi de la concentration montre sa decroissance progressive. Discussion Les hypoglycemies factices constituent un trouble psychiatrique de diagnostic difficile. Il s’agit le plus souvent de patients de sexe feminin ayant un acces facile aux THG. Seuls 50 % des patients diagnostiques avouent la prise de THG apres confrontation. Un suivi psychiatrique est necessaire pour eviter les recidives qui peuvent engager dans cette situation le pronostic vital.

P119 L’insuffisance rénale en dehors de la néphropathie diabétique chez le diabétique de type 2

Introduction La proteinurie de 24 h est l’indicateur de la nephropathie diabetique qui peut evoluer vers l’insuffisance renale. Dans notre etude on a explore les patients diabetiques presentant une insuffisance renale en dehors d’une albuminurie positive. Patients et Methodes Il s’agit d’une etude retrospective menee sur 400 diabetiques tires au hasard chez qui on a recueilli les donnees cliniques et biologiques permettant un calcul des clairances par la formule de Cockcroft avec realisation de la proteinurie de 24 h Les patients presentant une uropathie ou une cause bien etablie d’insuffisance renale sont exclus de cette etude. Resultats Les patients avaient un âge moyen de 62 ans et une anciennete de diabete de 11 ans, 70 patients parmi eux etaient au stade d’insuffisance renale (soit 17,5 %). Quatorze patients avaient une insuffisance renale sans microalbuminurie (soit 3,5 %). L’âge de ces patients etait avance (70 ans en moyenne) avec une anciennete de diabete de 13 ans. Un seul parmi eux avait une clairance L’echographie renale avait montre une diminution de la taille des reins dans 10 cas. Les nephrites interstitielles chroniques en rapport avec des infections urinaires a repetition sont probables. L’HTA parait un element determinant dans l’apparition de l’insuffisance renale par nephroangiosclerose. Conclusion L’insuffisance renale n’est pas toujours en rapport avec une nephropathie glomerulaire, une exploration biologique, radiologique et parfois anatomopathologique est proposee en absence d’etiologie evidente.