THU0602 EXTENDED BONE HYDATIDOSIS IN THE HIP AND FEMUR WITH EXTENSION TO THE SOFT PARTS: A CASE REPORT

Background:

Osseous hydatid cyst is an uncommon disease with weak response to treatment.hydatid disease should be included in the differential diagnosis of cystic lesions of bone in endemic regions. Bone cysts account for only 0.5 to 2.5% of all hydatid cysts in humans.

Objectives:

To report a case of osseous hydatid disease extended on hip and femur

Methods:

We report a case of osseous hydatid disease

Results:

A 49 YEAR OLD BRICKLAYER, with no past-medical history and no animal contact, was admitted to our department for a left hip pain. the patient was apyretic and in a good general health condition. He had a very painful walk. the mobilility of the left hip joint was very painful and restricted.

The pelvis X-rays showed osteolytic lesions in the ischiopubic branch and in the left femur and proximal extremity of the tibia.

The C-Reactive protein value, the protein electrophoresis were normal. tumor markers test was negative.

An ultrasound of the hip showed a low abondance intra-articular effusion. The Pelvic MRI showed multilocular appearance extending over the bone and muscle with breach of the bone cortex of the femur very suggesting of the diagnosis of a bony and muscular echinococcosis.

NO other localization of hydatidosis were detected, body ct scan was normal

Conclusion:

Hydatid disease occurs worldwide and mainly associated with sheep farming. The liver and lungs are the most common locations. Bone cysts are uncommon but severe. Although immunofluorescent assays are useful, the final diagnosis depends on histology. The treatment is almost surgery. Recurrence is common

Disclosure of Interests:

None declared

AB0962 LOW BACK PAIN AMONG MEDICAL STUDENTS: PREVALENCE AND RISK FACTORS

Background:

Low back pain (LBP) is a common health problem among all age groups. Medical students do not seem to be spared. In fact LBP is one of the most common musculoskeletal disorder and its prevalence is variable ranging from 41% to 72%.

Objectives:

The aim of our study was to determine the prevalence of LBP among Tunisian medical students and to assess its associated factors.

Methods:

We conducted a cross-sectional study over 2 months carried out on medical students in a Tunisian medical college. A digital questionnaire entered by Google forms was sent by e-mail and was completed by the students. Our study included students from the first year of the first cycle of medical studies up to the third year of the second cycle. Socio-demographic, personal characteristics and life habits were collected. LBP was assessed using the Nordic musculoskeletal health questionnaire. The impact of low back pain was assessed using the Oswestry disability index (ODI).

Results:

One hundred and seventy-nine students were included. The mean age was 22.9 ± 2.3 years [19.64-38.21]. The sex ratio was 0.29. The average body mass index was 23.55 ± 4.22 kg / m2 [17.67-43.07]. 82% of the students were in the second cycle of medical studies. 26.4% of the students had a regular sports activity. 91.2% spent more than 4 hours a day in a sitting position. The point, annual, and lifetime prevalence of LBP among medical students was 41.2%, 80.4% and 90.6%, respectively. Low back pain was acute in more than 58.8%, subacute in 14.9% and chronic in 26.3%. The mean ODI score was 10.32% ± 8.48% [0-32%]. Students with LBP were significantly younger than students without LBP (p = 0.015). LBP was more common in students who spent more than 4 hours in a sitting position with a difference at the limit of significance (p = 0.059). Being in the 2nd cycle was significantly associated with the occurrence of LBP (p = 0.006). Poor screen projection in the amphitheater was significantly associated with the occurrence of LBP (p = 0.029).We found a statistically very significant relationship between the occurrence of LBP and the poor layout of the amphitheaters (p = 0.000). The feeling of depression was significantly higher among LBP students (p = 0.018). Feelings of fatigue, being overwhelmed, irritability and worry were more frequently found in LBP students, but this difference was not statistically significant. In a multivariate analysis, the only factors that remained statistically significant were feeling of depression (p = 0.046, OR = 3.88; CI = [1,3-11,55]) and the poor layout of the amphitheaters (p = 0.006, OR = 8.99; CI = [2.55-31.69]).

Conclusion:

The annual prevalence of LBP was 80.4%. These results testify to the magnitude of this health problem. The factors associated to LBP seemed to be essentially modifiable factors. This encourages special attention from medical schools to increase students’ awareness of low back pain and to provide appropriate measures at reduce this musculoskeletal disorder.

Disclosure of Interests:

None declared

THU0606 RHEUMATOID ARTHRITIS INDUCED BY ALPHA-INTERFERON THERAPY: A RARE CASE PRESENTATION

Background:

Interferon-α (IFN-α) is known for its antiviral and antiproliferative effects, used mainly for the treatment of chronic hepatitis C infection [1]. Immunomodulatory effects have been reported in patients treated with IFN-α, including hematological, immunological, rheumatological and dermatological disorders [2]. In fact, IFN-α may lead to the induction or exacerbation of autoimmune diseases such as psoriasis, systemic lupus erythematosus, and rarely rheumatoid arthritis (RA).

Objectives:

We report the case of a Caucasian who developed anticyclic citrullinated peptide antibody (anti-CCP)-positive RA following treatment of chronic hepatitis C infection with pegylated IFN-α2a.

Methods:

A 57-year-old women was diagnosed of chronic hepatitis C infection after detection of abnormal liver function. She has a genotype Ib with a high viral load: RNA was 100,000 UI/ml. Liver histology showed advanced fibrosis and portal fibrosis (A3 F4 according to metavir score). A history of blood transfusion was found. The patient was placed on a 24-week course of PEGylated -IFN-α2a 180 µg weekly and a 1000 mg daily dose of ribavirin. After two months of antiviral treatment, she developed symmetrical polyarthritis, with pain and edema in the wrists, elbows, shoulders and metacarpophalangeal joints, associated with prolonged morning stiffness. The musculoskeletal examination was notable for active synovitis of the proximal phalangeal joints, metacarpophalangeal joints, wrists, elbows. Distal interphalangeal joints were spared. She had no musculoskeletal symptoms prior to antiviral therapy. Review of systems was otherwise unremarkable. X-ray showed no remarkable findings. Ultrasonography of the hands revealed diffuse synovitis as well as tenosynovitis of the ulnar extensor tendons in both wrists. Laboratory results revealed a normal C-reactive protein, elevated liver enzymes: ALAT (alanin-aminotransferase) 119,ASAT (aspartat-aminotransferase) 66, Gamma-GT 203 and undetectable cryoglobulins. Anti-CCP was 21 IU/ml (negative < 20 IU/ml), antinuclear antibodies were positive 1280 (negative<160), rheumatoid factor was 192 (normal < 30 IU/ml).

A diagnosis of rheumatoid arthritis (RA) was made on the basis of clinical and ultra-sonographic evidence as well as Rheumatoid Factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody positivity. Moreover, an autoimmune thyroiditis was found that evolved into hypothyroidism treated with thyroxine.

Results:

The patient developed a sustained virological response as evidenced by persistent undetectable HCV RNA and normal aminotransferase activities. Upon completion of a 12-week course of antiviral therapy, The rheumatoid syndrome disappeared after cessation of IFN therapy. By that time, antinuclear antibodies were in a titre of 1 /180, rheumatoid factor and Anti-CCP were negative.

Conclusion:

The present case suggests that biological agents, affecting the cytokine network, may work as triggering factors for the development of RA in previously predisposed individuals. Screening for RF and anti-CCP may be considered before treating with IFN. In addition, a close surveillance for the occurrence of autoimmune phenomena during and after treatment should be worthy, for early diagnosis and adequate clinical management.

References:

[1]DARICE YANG,DANIEL ARKFELDandTSE-LING FONG TreatmentforChronic Hepatitis C Infection.DevelopmentofAnti-CCP-positive Rheumatoid Arthritis Following Pegylated Interferon-alpha. J Rheumatol 2010;37;1777Volume 37, no. 8. 2a

[2]Okanoue T, Sakamoto S, Itoh Y, Minami M, Yasui K, Sakamoto M, et al. Side effects of high-dose interferon therapy for chronic hepatitis C. J Hepatol 1996;25:283-91.

Disclosure of Interests:

None declared

AB0320 BDMARDS SURVIVAL: THE TUNISIAN DATA

Background:

The advent of biotherapies in the late 90s radically changed the face of inflammatory diseases including rheumatoid arthritis. The survival of these innovative therapies is an indicator, in clinical practice, of their long-term efficacy and safety.

Objectives:

The objective of this study was to assess their use in Tunisia through their survival during rheumatoid arthritis as well as to determine the factors that may influence their therapeutic maintenance in real life.

Methods:

This is a retrospective study including RA patients (ACR/EULAR 2010 criteria) and putted on biotherapy between 01-01-2014 and 12-31-2016. They were followed until 12-31-2018. The therapeutic maintenance rate at 12, 24, 36 and 48 months as well as the survival curves of biotherapies were analyzed using the Kaplan-Meier survival curves and compared by the Log-rank test. Reasons for interruption and patterns of biological change have been reported. Finally, an analysis of factors influencing survival was performed using Cox regression.

A p<0.05 was considered statistically significant.

Results:

Three hundred seventy-four patients were included in the study; sex ratio was 0,147. The baseline age was 55 ± 12.5 years [20 – 90] and the average disease duration was 11.7 ± 6.7 years [2 – 41]. Rheumatoid factor and ACPA were positive respectively in 79% and 71% cases. After failure of cDMARD, the first biotherapy prescribed was etanercept in 54% of cases, adalimumab in 14% of cases, certolizumab pegol 13%, infliximab 6%, tocilizumab 6% and rituximab in 7% of cases, with an average DAS28 at baseline 6.01 ± 0.89 [5,37 – 6,50]. Association with methotrexate was observed in 59,6% case and with corticosteroid in 57.2% case. Drug persistency rate at 12 months was 85.8%; at 24 months, 69.9%; at 36 months, 60.6% and at 48 months, 55.9%. Survival was on average 41.7 months with 95% CI (39.47 - 43.91). The presence of rheumatoid factors, the co-prescription of methotrexate as well as good initial therapeutic response were predictor of a better survival of biologicals at a statistically significant level p<0.01 (Hazard Ratios for pursuit of biotherapy were respectively 1.79, 1.91 and 2,3). The use of glucocorticoids was a negative predictor of retention (Hazard Ratio for therapy pursuit was 0.47 p < 0.001). This first biotherapy was stopped in 39% of cases and ineffectiveness was the major reason of interruption (52.7%). The anti-TNFα cycling was the most adopted therapeutic strategy with 64.6% of cases. The survival rates of the second biotherapy at 12, 24 and 36 months were 91%, 76.4% and 72.1%, respectively.

Conclusion:

Our study provides information about biotherapy prescription practices in Tunisia and their effectiveness in “real life”. It informs us about the use of these new therapies in our country and has shown an efficacy and a tolerance profile close to those reported in international registers.

Disclosure of Interests:

None declared

THU0605 AN ATYPICAL CASE OF PONCET DISEASE

Background:

Poncet disease (PD) is defined as an inflammatory rheumatism associated with visceral tuberculosis without direct bacteriological involvement of the joints [1]. It is classified as a parainfectious rather than a reactive arthritis [2].

Objectives:

Here by a first case of PD who presented with sterile arthritis and tuberculous spondylodiscitis.

Methods:

We report a case of a 40-year-old women who presented with polyarthritis in 2014. On physical examination, she had synovitis in both wrists, the metacarpophalangeal joints and the fifth proximal interphalangeal joint of the right hand. Her serum was negative for Rheumatoid Factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody. Her C-reactive protein (CRP) was 24,5mg/l. Ultrasound revealed tenosynovitis of the superficial and deep flexor tendons on both hands with Doppler signal. The Magnetic resonance imaging (MRI) of the hands showed active synovitis in the wrists mainly in the distal radioulnar joint, erosions in the ulnar styloid as well as edematous infiltration of the soft tissue of the hands. Since she fulfilled the new ACR/EULAR 2010 criteria for RA, a diagnosis of rheumatoid arthritis (RA) was made and the patient was put on Methotrexate (MTX) 15 mg/week/po in January 2015. Eight months later, the patient developed high temperature 38°c and lumbar stiffness. A chest CT performed as part of the etiologic investigation didn’t show pulmonary manifestations but revealed a lytic vertebrae lesion. Lumbar spine MRI showed prevertebral edema and soft tissue enhancement with abnormal marrow signal in L2 and L3 which was concerning for infectious etiology. MTX was stopped. A CT-guided core needle biopsy concluded to a tuberculous spondylodiscitis. The patient was initiated on an antituberculous-therapy (ATT) for 15 months. The course was marked by the reoccurrence of low back pain. MRI of the spine was then performed and revealed persistence of spondylodiscitis and multiple abscesses at the levels of L2-L3. The ATT was resumed.

Results:

The patient received four drugs for 4 months, followed by isoniazid and rifampicin for 1 year. At follow up, the patient responded well to treatment with complete resolution of symptoms without sequelae. She did not present neither polyarthritis nor synovitis. Moreover, she sustained a negative CRP (2mg/dl). Ultrasound control of the wrists did not show synovitis or tenosynovitis Doppler signal. Similarly, a disappearance of effusion as well as synovitis was noted on the MRI at follow up.

Conclusion:

We report a unique case of Poncet disease with tubercular spondylodiscitis. It is important to recognize PD in a patient presenting with polyarthritis in order to avoid unnecessary long-term disease-modifying antirheumatic treatment. Future research is indicated to understand the etiopathogenesis of Poncet’s disease and to educate clinicians as to the importance of maintaining a high index of suspicion about this rare, yet potentially easily treatable disease.

References:

[1]Sood R, Wali JP, Handa R. Poncet’s disease in a north Indian hospital. Trop Doctor. 1999; 29: 33-6.

[2]Bloxham CA, Addy DP. Poncet’s disease: parainfective tuberculous polyarthropathy. Br Med J. 1978; 1: 1590.

Disclosure of Interests:

None declared

AB0287 HEMATOLOGICAL SIDE EFFECTS OF BIOLOGICAL THERAPY IN RHEUMATOLOGY: DATA FROM THE TUNISIAN REGISTER

Background:

During the last decade, the treatment of chronic inflammatory rheumatism (CIR) has been greatly improved with the advent of biotherapy.However, the use of biological treatment can lead to a number of side effects including abnormalities in the blood count.

Objectives:

The aim of this study was to assess the different hematological side effects of biological treatment in patients with rheumatoid arthritis (RA) and spondyloarthitis (SA).

Methods:

This study included patients with RA (ACR/EULAR 2010) and SA (ASAS 2009) registred with the Tunisian Biologic National Registry (BINAR).Patients were followed and treated with biologics for 2 years of less. Clinical data relative to biological treatment, including haematological side effects, have been collected.

Results:

Two hundred and ninety-eight patients (178 women and 111 men) were included in the study.

The mean age was 49.2 ± 14.1 years. The male/female ratio was 0.6. The mean diseases durations for RA and SA were respectively 6.7 ± 3.5 years and 6.5 ±3.6 years.

Anti-TNFα agents were prescribed in 87.9% of patients (n = 263) with respectively: Infliximab (20.4%) Etanercept (23.1%), Adalimumab (24.6%) and Certolizumab (26.5%).

Tocilizumab and Rituximab were prescribed in 10.4% and 5% of the patients, respectively.

Blood count abnormalities were noted in 15.4 % of patients (n=46).

Neutropenia was the most frequently anomaly met on the hemogram (9.1%) followed by anemia (3.4%) and thrombocytopenia (3%). Pancytopenia was found in 11.4% of patients (n=34).

The median time between biological therapy initiation and the onset of hematologic manifestations was 4.8 months [1-12]. Biological treatment was interrupted in two patients.

In the other cases, the biological treatment was maintained with close monitoring of blood cell count. No case of death related to these hematological disturbances has been reported.

Conclusion:

In our registry, hematological side effects of biological treatment were found in 15.4% of cases and were noted with a median delay of 4.8 [1-12] months after the treatment initiation. Further studies are needed to confirm our preliminary results.

Disclosure of Interests:

None declared

FRI0618-HPR EFFECTS OF MUSIC THERAPY ON PAIN, ANXIETY, AND VITAL SIGNS IN CHRONIC INFLAMMATORY RHEUMATIC DISEASES PATIENTS DURING BIOLOGICAL DRUGS INFUSION

Background:

Music therapy is based on ancient cross-cultural beliefs that music can have a “healing” effect on mind and body. Research determined that listening to music can increase comfort and relaxation, relieve pain, lower distress, reduce anxiety, improve positive emotions and mood, and decrease psychological symptoms. Music therapy has been used greatly in various medical procedures to reduce associated anxiety and pain. Patients have a high level of anxiety when they are in the hospital, this is the case of patients with rheumatic diseases who consult regularly to have intravenous infusion of biological therapies.

Objectives:

The purpose of this study was to examine the effectiveness of music therapy on pain, anxiety, and vital signs among patients with chronic inflammatory rheumatic diseases during intravenous infusion of biological drugs.

Methods:

Fifty patients were divided into two groups: The experimental group G1 (n=25) received drug infusion while lestening to soft music (30 minutes); and the control group G2 (n=25) received only drug infusion. Measures include pain, anxiety, vital signs (blood pressure, heart rate and respiratory rate). The pain was measured using visual analogic scale (VAS). The state-trait anxiety inventory (STAI) was used for measuring anxiety, low anxiety ranges from 20 to 39, the moderate anxiety ranges from 40 to 59, and high anxiety ranges from 60 to 80. Vital signs (systolic blood pressure [SBP], diastolic blood pressure [DBP], heart rate [HR], and respiratory rate [RR]) were measured before, during and immediately after the infusion.

Statistical package for social sciences (SPSS) was used for analysis.

Results:

The mean age in G1 was 44.45 years (26-72) with a sex ratio (M/F) of 0.8. Including the 25 patients, 12 had rheumatoid arthritis, 10 had ankylosing spondylitis and 3 had psoriatic arthritis. The mean disease duration was 8 years. In G2, the mean age was 46 years (25-70) with a sex ratio (M/F) of 0.75, 12 had rheumatoid arthritis, 11 had ankylosing spondylitis and 2 had psoriatic arthritis. The mean disease duration was 7.5 years. The biological drugs used were: Infliximab in 30 cases, Tocilizumab in 12 cases and Rituximab in 8 cases.

Before the infusion, the patients of experimental group had a mean VAS of 5/10±3, a mean STAI of 50.62±6.01, a mean SBP of 13.6 cmHg±1.4, a mean DBP of 8.6 cmHg±1, a mean HR of 85±10 and a mean RR of 18±3. While in control group the mean VAS was 5.5±2, the mean STAI was 50.89±5.5, the mean SBP was 13.4±1.2, the mean DBP was 8.8±1.1, the mean HR was 82±8 and the mean RR was 19±2.

During the infusion and after music intervention in G1, the mean STAI became 38.35±5 in G1 versus 46.7±5.2 in G2 (p value=0.022), the mean SBP became 12.1±0.5 in G1 versus 13±1 in G2 (p=0.035), the mean DBP became 8.1±0.8 in G1 versus 8.4±0.9 in G2 (p=0.4), the mean HR became 76±9 in G1 versus 78±7 in G2 (p=0.04) and the mean RR became 17.3±2.1 in G1 versus 18.2±1.7 in G2 (p=0.39).

This study found a statistically significant decrease in anxiety, systolic blood pressure and heart rate in patients receiving music interventions during biological therapies infusion, but no significant difference were identified in diastolic blood pressure and respiratory rate.

Conclusion:

The findings provide further evidence to support the use of music therapy to reduce anxiety, and lower systolic blood pressure and heart rate in patients with rheumatic disease during biological therapies infusion.

References:

[1] Lin, C., Hwang, S., Jiang, P., & Hsiung, N. (2019).Effect of Music Therapy on Pain After Orthopedic Surgery -A Systematic review and Meta-Analysis. Pain Practice.

Disclosure of Interests:

None declared

[Intracoronary adenosine induced-atrial fibrillation during fractional flow reserve evaluation]

Fractional flow reserve (FFR) measurement for functional evaluation of haemodynamic relevance of coronary artery stenoses is a well established and straightforward method applied on daily basis in cardiac catheterization laboratory; it is known to be reliable, reproducible and secure associated with a low rate of adverse events. We report the case of a 68-year-old man with no history of arrhythmias in whom intracoronary injection of adenosine for FFR assessment immediately induced atrial fibrillation mandating hospitalization for pharmacological cardioversion.

[Cocaine-induced acute myocarditis]

Cocaine is a potent sympathomimetic drug usually associated with cardiotoxicity, including ventricular arrhythmia, systemic hypertension and acute myocardial infarction. It constitutes the most frequent cause of drug-related death reported by medical examiners in the US, and these events are most often related to the cardiovascular manifestations of the drug. However; to the best of our knowledge; cocaine induced acute myocarditis has very rarely been reported. We describe the case of a 19 year-old male regular user of marijuana and cocaine who was admitted for a suspicion on an acute lateral-wall myocardial infarction and in whom the final diagnosis of acute cocaine myocarditis has been made. We report diagnosis modalities and evolution.

[Adipose epicardial tissue association with subclinical systolic dysfunction detected by longitudinal strain in diabetic patients with poor glycemic control]

OBJECTIVE

The aim of this study is to assess the association between epicardial adipose tissue (EAT) and infraclinical myocardial dysfunction detected by strain imaging in diabetic patients (T2DM) with poor glycemic control.

METHODS

22 patients with T2DM and 22 healthy control subjects of similar age and sex were prospectively recruited. Echocardiographic parameters were investigated.

RESULTS

In comparison to controls, diabetic patients had significantly higher body mass index (27.7 vs. 24.6; P<0.01), waist perimeter (103 vs. 84; P<0.001) and usCRP level (5.4 vs. 1.5; P<0.01). On echocardiography; no differences were found in terms of ejection fraction or ventricular mass; however, patients with T2DM had significantly thicker EAT (8.7±0.7 vs. 3.0±1.0; P<0.001) and altered systolic longitudinal strain (-18.8±3.2 vs. 22.3±1.6; P<0.001). On multivariate analysis, EAT was identified as an independent contributor (β=0,46, P=0.001) to systolic longitudinal strain.

CONCLUSION

In patients with T2DM and poor glycemic control; EAT was associated with infraclinical systolic dysfunction evaluated by global longitudinal strain despite normal at rest ejection fraction and no coronary artery disease.

Functional repercussion of polyarthrosis of the elderly in tunisia

INTRODUCTION

Osteoarthritis (OA) is the most common degenerative joint disease in the elderly. The often multifocal location at this age can be a source of pain, limitation of everyday activities, thus affecting their quality of life.

AIM

To evaluate functional status of aged people with generalized OA in Tunisia, and to detect the main factors associated with a poor function in order to optimize their medical care.

METHODS

A cross-sectional, descriptive study done between January and March 2017. Fifty patients were included, aged 65 years and over followed for generalized osteoarthritis. The functional repercussions of polyarthrosis was assessed by functional independence measure (FIM), the Lequesne Algofunctional Index, the Womac index for hip and knee OA, and the Oswestry questionnaire for low back pain.

RESULTS

The mean age of patients was 71.94 ± 0.8 years with a sex ratio of 0.42.The functional status of patients with polyarthrosis were altered to varying degrees. The most impaired dimensions of FIM were self-care, transfers and locomotion. Activities of daily living of the Lequesne index was the most impaired section with an average of 5.28. The three dimensions of the Womac index were affected, particularly the pain section with an average of 49.18/100. The Oswestry index was altered with an average of 18.89 / 40. Factors associated with poor functional status were: Female gender (p<0,05), age of development (p<0,05), spinal arthrosis (p<0,05) and history of falls(p<0,05).

CONCLUSION

Polyarthrosis is accompanied by functional impairment in the elderly. Factors associated with functional impairment should be considered in the Patient Management Program.

[Stress dobutamine echocardiography or resting strain rate imaging to unveil an early symptomatic diabetic cardiomyopathy?]

Diabetes mellitus has been associated with changes in the structure and function of the myocardium manifesting in the early stages of the disease as subtle systolic and diastolic dysfunction; myocardial strain imaging has recently been favored over dobutamine stress echocardiography for early detection of diabetic cardiomyopathy. We report a case of an elderly diabetic patient presenting with pulmonary edema in whom at rest echocardiographic parameters including strain rate were all within normal range, while dobutamine stress echocardiography induced a deep systolic deterioration unmasking an early-stage diabetic cardiomyopathy.

[Lead-related infective endocarditis with massive vegetation causing severe functionnal tricuspid stenosis]

Lead-related infective endocarditis with negative hemocultures constitutes a severe condition potentially associated with a pejorative prognosis. It may induce a functional tricuspid stenosis caused by an important obstructive vegetation. We report the case of an 82 year-old woman in whom the lead-related endocarditis produced massive vegetation causing a severe functional tricuspid stenosis. We describe the medical history, diagnosis and treatment.

[Impressive extension into the right heart cavities and the inferior vena cava of renal carcinoma]

Renal carcinoma is an aggressive cancer with a high metastatic tendency. It may invade the renal vein, inferior vena cava and potentially extend in some cases to the right heart cavities. We report a case of a 71-year-old male presenting with an impressive polylobular tissular mass inside the right atrium and the right ventricle revealing an aggressive renal carcinoma extending through the inferior vena cava.

[Massive intraatrial mass?]

Posterior mediastinal hematoma in a rare and potentially lethal disease and is frequently consecutive to a traumatism. We report the original case of a 88-year-old male admitted to our department for lipothymia and syncope related to a severe compression of the left atrium by an important mediastinal hematoma mimicking in transthoracic echocardiography an obstructive intraatrial mass.

[Atypical form of cor triatrium in a 59-year-old man]

Cor triatrium is a rare congenital heart disease typically diagnosed amongst very young patients. Delayed diagnosis in the elderly is much more unusual. We report the case of a 59-year-old male with unremarkable medical history in whom we have discovered, on an echocardiography performed for an exploration of transient ischemic accident with atrial fibrillation, a particular form of an isolated cor triatrium dextrum investigated with multimodality imaging.

[Prethrombus acute constitution during dobutamine stress echocardiography]

Although generally regarded as a safe stress modality, dobutamine stress echocardiography (DSE) has been associated with several well described complications. However, to our knowledge, acute constitution of thrombi during the stress test has never been described. In this report, we present the case of a 64 year-old man with a history of ischemic heart disease who underwent a preoperative DSE; during the test, we witnessed a striking acute constitution of an intense prethrombotic state with almost a formation of a highly mobile massive thrombus adjacent to the infero-apical segment spontaneously resolving few minutes after the end of the test.

[Dobutamine-related coronary spasm among patients with false positive dobutamine stress echocardiography: Prevalence and predictors]

BACKGROUND AND OBJECTIVE

Dobutamine stress echocardiography (DSE) is being consistently used as an exercise-independent stress modality aimed at the detection of coronary artery disease (CAD) and the evaluation of myocardial ischemia. It may though occasionally induce coronary vasospasm. In this study, we aimed to evaluate the prevalence and predictors of dobutamine-related coronary spasm in patients without known CAD and false positive DSE (positive DSE but no significant coronary lesions on angiogram).

METHODS

Three thousand nine hundred and fifty-two patients referred to our echocardiography laboratory for DSE between January 2010 and May 2012 were prospectively investigated. Those with positive DSE underwent coronary angiograms with systematic methylergometrine intracoronary injection in case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients with spontaneous occlusive coronary spasm or positive methylergometrine test but no significant stenoses were enrolled and compared with those with positive DSE but no coronary lesions nor spontaneous or induced spasm ("true" false positive DSE).

RESULTS

Twenty-nine patients with DSE-related vasospasm (19.4% of positive DES without known CAD) were compared with 56 patients with no lesions and no spasm ("true" false positive DSE). They were more frequently smokers (72.4% vs 37.5%; P=0.003); they had more frequently dyslipidemia (79.3% vs 43%; P=0.001); they also had a larger ischemic area at peak DSE (3.4 segments vs 2.7 segments; P=0.05). On multivariate analysis, dyslipidemia (HR=10.7; 95% CI=[2.7-42.1]; P=0.001) and active smoking (HR=6.1; 95% CI=[1.7-21.1]; P=0.004) were found to be independent predictors of spasm-related DSE rather than "true" false positive DSE.

CONCLUSION

DSE-related coronary spasm is present in a significant proportion of patients with erroneously labelled "false" positive DSE and should systematically be ruled out. Dyslipidemia and active smoking were independent predictors of spasm rather than "true" false positive DSE.

[Biphasic reaction to dobutamine stress echocardiography as a predictor of coronary artery spasm: Apropos of 3 cases]

Dobutamine-related coronary spasm is a possible complication of dobutamine stress echocardiography potentially explaining a part of some erroneously labeled "false positive tests". Presently, there are no established echographic predictors of coronary spasm. We report 3 clinical cases in which dobutamine-induced spasm was strongly suspected on the basis of a biphasic reaction including an initial deterioration rapidly followed by a spontaneous recovery in well-defined echocardiographic territory. In all three cases, we were able to confirm spasm of angiography. The biphasic reaction may constitute a potential predictor of spasm in patients with positive dobutamine stress tests.

[Partial anomalous pulmonary venous return in a 64-year-old woman]

Partial anomalous pulmonary venous return (PAPVR) represents 3 % of the congenital cardiopathies. Diagnosis in adults is challenging as clinical symptomatology is non-specific and echocardiographic signs are discrete and misleading potentially confusing with idiopathic pulmonary hypertension. We report the case of a 64-year-old woman in whom we diagnosed PAPVR associated with sinus venosus atrial septal defect. We describe medical history, clinical signs, investigations and postoperative evolution.

[High pressure trap]

Pheochromocytoma is a rare tumor potentially life-threatening and associated with non specific and diverse symptomatology. Cardiac symptoms may mislead diagnosis; they could manifest as myocardial sideration concomitant to a hypertensive peak or supraventricular arythmia. We report a case of pheochromocytoma associated with hypokaliemia revealed by a myocardial ischemia with acute cardiac failure and severe left ventricular depression and complete reversal after surgery.

[Instent rupture of a saphenous vein graft during percutaneous intervention successfully treated with a covered stent]

Percutaneous coronary interventions of saphenous vein grafts are associated with an increased risk of periprocedural complications; among these, the rupture of the vein graft is probably the less common and the most dangerous; it is even more exceptional when it occurs on a stented portion of the graft. We report the case of a 75-year-old man who presented during a balloon angioplasty of intent restenosis of a saphenous vein graft a spectacular graft rupture at the level of the previously stented site and who was ultimately successfully treated with a covered stent.

[Large aneurysm of the left sinus of Valsalva in a 54-year-old man successfully treated with surgery]

Sinus of Valsalva aneurysms are very rare and are often asymptomatic. Clinical manifestations depend on associated complications, most commonly rupture or dissection. We describe the case of a 54-year-old male presenting with exercise-related angina and dyspnea and in whom we found a large unruptured aneurysm of the left sinus of Valsalva. On angiography, he also had a severe stenosis of the left artery descending and the diagonal. He underwent a successful surgical intervention with bypass and closure of the aneurysm.

[Uselessness of high-sensitivity cardiac troponins to improve diagnostic accuracy of dobutamine stress echocardiography in high-risk diabetic patients]

BACKGROUND AND AIM

Dobutamine stress echocardiography (DSE) is a well-established noninvasive stress modality for the detection and evaluation of coronary artery disease in diabetic patients. High-sensitivity cardiac troponin T recently emerged as a highly sensitive dosage for the detection of ischemia. The aim of the study was to examine whether high-sensitivity cardiac troponin T may improve the diagnostic accuracy of silent ischemia by DSE in high-risk diabetic patients.

METHODS AND RESULTS

Twenty-one patients with long-standing (>10years) and/or complicated type II DM but no established CAD were included. In addition to DSE, venous blood samples for measurement of hs-cTnT were collected prior to DSE, 6hours and 24hours after the test. Troponins were deemed positive if>1.5 upper limit for normality. Patients with positive troponins underwent coronary angiography or CT scan regardless of the result of DSE. Among the 21 patients, 7 had positive troponins measured 6hours after stress, (mean peak troponin=44.5). DSE were negative in all of them. Mean age was 64years significantly higher than patients with negative troponins. No differences were noted between the groups in terms of epidemiological, clinical or echocardiographic characteristics. Patients with positive cardiac troponins were evaluated for the presence of coronary lesions but none of them had significant disease. After an 18-month mean follow-up, no adverse cardiac events were noted in either group.

CONCLUSION

In high-risk diabetic patients, the measurement of hs-cTnT during DSE does not improve the sensitivity at least in those with negative DSE tests.

[Totally asymptomatic coronary left main artery critical stenosis: when non-invasive tests are falsely reassuring]

Left main coronary artery severe stenosis is frequently very symptomatic and is considered as a classical contraindication for non-invasive ischemia testing. When performed, those tests usually yield a large area of ischemia associated with a rich symptomatology. We report the case of a 69-year-old completely asymptomatic man in whom both treadmill effort testing and dobutamine stress echocardiography were falsely reassuring as they eliminated significant ischemia despite the presence of a critical stenosis of distal left main artery ultimately confirmed by angiography. Dobutamine 2D strain performed afterwards was pathological and could have corrected the initially reassuring diagnosis.