L. Chaieb

La mucormycose chez le diabétique

Resume Introduction La mucormycose est une infection fungique rare, rapidement extensive, touchant avec predilection les diabetiques non controles, notamment en acidocetose. Sa localisation est le plus souvent rhino-cerebrale, parfois pulmonaire ou disseminee. Observations Nous rapportons 4 observations consecutives, survenues chez des patientes diabetiques, hospitalisees au Centre hospitalo-universitaire Farhat Hached, Sousse, Tunisie, entre janvier 2001 et novembre 2002. Trois patientes etaient en acidocetose et une patiente en insuffisance renale avec hyperosmolarite. L’atteinte etait rhino-sinusienne isolee dans 2 cas, pulmonaire dans 1 cas et vraisemblablement disseminee dans le 4e cas. Le diagnostic a ete confirme par l’examen mycologique et histologique dans les 4 cas. Le traitement a repose sur l’amphotericine B par voie systemique, associee au debridement chirurgical des lesions dans les formes rhino-sinusiennes. Discussion En depit des mesures therapeutiques agressives, la mortalite a ete elevee: 3 patientes sur 4. La mucormycose du diabetique est une affection grave, d’evolution souvent fatale.

Non-traumatic fractures following seizures: two case reports

IntroductionSeizures with or without trauma may cause fractures that occur commonly in epileptic seizures. Fracture risk is less reported in non-epileptic seizures. Some metabolic conditions leading to a decrease in bone mineral density may cause fractures secondary to non-epileptic seizure.Case presentationWe describe two cases of non-traumatic acetabular and vertebrae fractures following seizures without history of epilepsy. They occurred in two male patients, 18 and 48 years old suffering respectively from hypercorticism and poorly controlled diabetes mellitus. Seizures, occurring inside hospital, were secondary to hypertensive encephalopathy crisis with hypokaliemia in the first case and severe hypoglycaemia in the second one. Fracture was promoted by a decrease in mineral bone density caused respectively by hypercorticism and diabetic chronic renal failure.ConclusionThese observations emphasize that fracture prevention among patients with decreased mineral bone density should include the avoidance of metabolic causes of seizure.

Corticomedullary mixed tumor of the adrenal gland.

A 34-year-old woman presented with weight gain, hirsutism, recent hypertension and secondary amenorrhea. Laboratory findings showed hypokalemia, elevated cortisol and androgen levels with normal urine metanephrines and normal aldosteronemia. Abdominal magnetic resonance imaging showed a right heterogeneous adrenal mass measuring 4 x 6 cm with mixed component of fat and adrenal tissue suggesting corticosurrenaloma. After right adrenalectomy, blood pressure normalized and hypokalemia resolved. In the postoperative course, the patient presented adrenal insufficiency treated with hydrocortisone hemisuccinate. Histological examination showed a single tumor mass composed of an admixed population of adrenal cortical and medullary cells. Immunohistochemical evaluation was positive for chromogranin A.

Circadian leptin, insulin and cortisol rhythms in obese subjects

Abstract The recent discovery of leptin, the product of the “ob” gene has greatly advanced the understanding of body adiposity and energy balance regulation. Serum leptin levels follow a circadian rhythm, which seems to be regulated predominantly by insulin increases levels and the circadian rhythm of cortisol. The aims of this study were to: (1) determine the effect of obesity on leptin 24 hours pattern; (2) determine the biological rhythm of leptin, insulin and cortisol. Thirteen subjects (10 women, three men) participated in this study. Serum samples were drawn at four hour intervals for a total of 24 hours. Leptin showed diurnal rhythmicity with peaks at 04.00 h (91.7±12.9 ng/ml) and troughs at 12.00 h (73.1±9.7 ng/ml). There was a strong association between leptin levels and BMI (r = 0.34; p < 0.001). The high levels of leptin may contribute to leptin resistance in obesity. Our data show the negative correlation over time between leptin and cortisol (r = −0.28, p = 0.005), and we demonstrate also that leptin and insulin are not correlated over time.

Abcès hépatique chez le diabétique: 2 observations

INTRODUCTION Over the past few years, the hepatic abscess appears as a privileged septic localisation in the case of diabetes mellitus, particularly in the elderly. OBSERVATIONS Two, 75 year-old and 82 year-old, diabetic patients were hospitalised for non-ketonic decompensation of type 2 diabetes mellitus. Examination revealed a sub-febrile state, the absence of clinical hepatic signs and a biological infectious syndrome The abscesses were discovered during the systematic hepatic sonography. Liver puncture was only possible in one patient and revealed Klebsiella oxytoca. The progression with antibiotics alone in one patient, and associated with surgical draining in the other, was positive. The origin appeared to be bilary in one patient and arterial on the other. COMMENTS These case reports underline the interest of the systematic evocation of an abscessed hepatic localisation in cases of imbalance in diabetes, particularly when associated with an unexplained infectious syndrome.

Benzylthiouracil-Induced Glomerulonephritis

Vasculitis is a rare complication of antithyroid drugs (ATDs). It was first described with Propylthiouracil (PTU). We report a new case of antineutrophil cytoplasmic antibody (ANCA) vasculitis with glomerulonephritis induced by Benzylthiouracile (BTU). A 50-year-old man with Graves disease treated with BTU developed general malaise and haematuria without skin rash or respiratory involvement. Laboratory data revealed acute renal failure with proteinuria and haematuria. An indirect immunofluorescence test for ANCA was positive, showing a perinuclear pattern with specificity antimyeloperoxidase (MPO). A renal biopsy was performed and revealed pauci-immune extracapillary glomerular nephropathy and necrotic vasculitis lesions. Based on these findings we concluded to the diagnosis of rapidly progressive glomerulonephritis associated with ANCA induced by BTU therapy. The drug was therefore discontinued and the patient was treated with steroids and immunosuppressive treatment during 3 months. Renal failure, proteinuria and haematuria significantly improved within 2 months. However, P-ANCA remained positive until 10 months after drug withdrawal. Thyroid function was kept within normal range using iodine solution. We demonstrated clearly that BTU may induce severe forms of vasculitis with glomerulonephritis. Thus, the ANCA must be measured when confronted to systemic manifestation during treatment.

IRM et adénomes hypophysaires

Pituitary is the most important gland of the organism which can be affected by many diseases, especially by adenomatous processes. Classically macroadenoma, microadenoma and picoadenoma are described, according to the size of the pituitary adenoma. The diagnosis of microadenoma was long considered a highly difficult task and that of picoadenoma was impossible by computed tomography. Recently, the high resolution of multiplanar MRI has enabled the diagnosis of microadenomas measuring less than 3 mm (picoadenoma). For macroadenoma, MRI not only contributes to diagnosis but is particularly important to assess the extension and to detect possible complications. The aim of our study is to illustrate MRI features in pituitary adenoma.

Diagnosis and treatment difficulties of psychiatric symptoms in Klinefelter syndrome: a case report.

Klinefelter syndrome (KS) can involve various psychiatric symptoms that are often heterogeneous and atypical. To illustrate the diagnosis and treatment difficulties of psychiatric non-specific symptoms occurring in KS, we report a 17-year-old man presenting with gynaecomastia and marfanoid features. Investigations showed high concentrations of gonadotrophins and a 47,XXY karyotype. Although his serum testosterone was normal, the patient had clinical hypogonadism and suffered from recent headache. Magnetic resonance imaging revealed pituitary non-invasive macroadenoma. Treatment with Cabergolin resulted in a normalisation of prolactin levels and a decrease in tumour size. During follow-up, the patient presented a permanent state of passivity and disinterest in imaginative experiences, without any obvious specific diagnoses, according to psychiatric examination. Further investigations showed major depression, schizotypical personality and patterns of psychotic functioning. Initial treatment with selective serotonin re-uptake inhibitors was not effective and he was switched to an atypical antipsychotic drug that was not tolerated and rapidly stopped by the patient.

P159 Relation entre les paramètres cliniques, hormonaux et métaboliques et impact de l’insulinorésistance dans le syndrome des ovaires polykystiques

Introduction L’insulinoresistance (IR) est incriminee dans la survenue des anomalies metaboliques et hormonales accompagnant le syndrome des ovaires polykystiques (SOPK). Elle expose a un risque accru de developpement du diabete de type 2 et de pathologies cardio-vasculaires. Notre etude se propose de decrire les caracteristiques cliniques, hormonales et metaboliques du SOPK et d’analyser la correlation entre les differents parametres cliniques metaboliques et hormonaux, afin de faire ressortir l’implication de l’IR dans ces anomalies. Patients et methodes Notre etude etait prospective et a porte sur 40 femmes âgees de 14 a 35 ans, ayant consulte pour prise en charge d’un SOPK et ayant beneficie d’un bilan metabolique et hormonal. Resultats L’IR suspectee en presence d’une repartition androide des graisses, chez 47,5 % des patientes et d’un acanthosis nigricans, dans 25 % des cas, a ete confirmee par un indice de HOMA superieur a 1,97 chez 84 % des patientes. Le diabete patent et la baisse de la tolerance glucidique etaient notes dans 7,5 % et 10 % des cas. Une dyslipidemie etait presente dans 35 % des cas. Le syndrome metabolique a ete identifie chez 10 % des patientes. Il n’y avait pas de correlation entre l’IMC d’une part et le score de Ferriman et la testosteronemie totale d’autre part. Cependant, une correlation negative et significative a ete trouvee entre l’IMC et la SHBG. Le taux de SHBG etait correle negativement et de facon significative avec l’indice de HOMA d’une part, et la testosteronemie d’autre part. Une correlation positive a aussi ete objectivee entre les taux d’insulinemie d’une part et ceux d’IGF1 et d’IGFBP3. Conclusion Le pronostic du SOPK reste domine par le risque de complications metaboliques et cardiovasculaires survenant a un âge jeune. L’IR peut etre presente en l’absence d’obesite. Son role dans la genese du SOPK est bien etabli. La diminution de la SHBG plasmatique est un temoin potentiel d’IR.

Increased cardiovascular risk in Sheehan's syndrome

ntroduction.– Les données concernant les grossesses chez les patientes acroégales sont peu nombreuses et les variations de la fonction somatotrope ont arement été étudiées. bjectifs.– Rapporter six nouvelles grossesses chez cinq patientes acromégales. atientes et méthodes.– Trois des cinq patientes avaient été opérées et toutes taient traitées par analogues de la somatostatine avant la grossesse ; ce traiement était arrêté au diagnostic de grossesse spontanée. Nous avons analysé étrospectivement les signes cliniques (tension artérielle, céphalées, troubles du hamp visuel), biologiques (glycémie), hormonaux (GH, IGF-1) à chaque triestre de la grossesse et en post-partum, les IRM hypophysaires au deuxième rimestre (sans injection de gadolinium) et en post-partum, comparés aux donées pré-gestationnelles. ésultats.– Toutes les grossesses ont été normales sans diabète gestationnel, ypertension artérielle gravidique, ni syndrome tumoral hypophysaire. Au preier trimestre, une amélioration des signes cliniques était constatée dans la oitié des cas et les concentrations moyennes d’IGF-1 diminuaient de 18 % ans variation significative des concentrations de GH. Aucun nouveau-né ne résentait de malformation congénitale. onclusion.– Chez ces 5 patientes traitées pour une acromégalie, les 6 grossesses e s’accompagnent pas de complications obstétricales ni fœtales. Au cours du 1er rimestre de la grossesse, une amélioration des signes cliniques d’acromégalie eut être rattachée à la diminution des concentrations d’IGF-1 liée à la résistance épatique à la GH due à la sécrétion physiologique d’estrogènes.