Systemic capillary leak syndrome: report on 13 patients with special focus on course and treatment

BACKGROUND

Systemic capillary leak syndrome (SCLS) is a rare condition characterized by unexplained episodic capillary hyperpermeability due to a shift of fluid and protein from the intravascular to the interstitial space. This results in diffuse swelling, weight gain, and renal shut-down. From the first publication in 1960, only 34 cases have been reported.

OBJECTIVE

To collate enough patients to observe the natural history of the disease and evaluate the efficacy of empiric treatments.

DESIGN

Multicentric retrospective study.

RESULTS

Thirteen patients (6 women and 7 men) were collated with a mean follow-up of 6.4 years. Eight patients are still alive after a mean of 5.6 years (range 1 to 15). Three patients out of the 11 who were not lost to follow-up died; 1 during an attack and 2 because of a progression towards multiple myeloma.

CONCLUSIONS

Our series shows an improvement in the prognosis of SCLS due most likely to improved management during attacks. Some patients' disease could evolve into a multiple myeloma. Treatment is still empiric and no prophylactic therapy, including terbutaline associated with aminophylline, has clearly proven its efficacy.

Pregnancy in relapsing polychondritis: twenty-five pregnancies in eleven patients

OBJECTIVE

To determine maternal and fetal outcome in pregnant women with relapsing polychondritis (RP).

METHODS

Retrospective review of 11 records selected from among those of 116 female RP (Michet's criteria) patients.

RESULTS

In these 11 women, 25 pregnancies occurred after or concomitantly with the onset of RP. The mean (+/- SD) age at RP onset was 25 +/- 5 years (range 15-31). Therapeutic abortion was performed in 1 woman because of ongoing cyclophosphamide treatment. Disease flare occurred in 7 of 24 pregnancies, requiring treatment modification in 2 cases. RP was considered stable in 16 and asymptomatic in 1 of the 24. Treatment of RP was with nonsteroidal antiinflammatory drugs (2 of 24), steroids (13 of 24), dapsone (7 of 24), or plasma exchanges (1 of 24); no treatment was given in 8 of the 24 pregnancies. In 14 pregnancies, the course was uneventful. Ten pregnancies were complicated by ectopic nidation (n = 3), spontaneous abortion (n = 3), premature birth (n = 3), and premature rupture of membranes (n = 1). Eighteen normal children were born.

CONCLUSION

Pregnancy does not seem to modify the course of RP. Successful pregnancies may be achieved in women with RP. No RP was observed in the neonates.

Management of the antiphospholipid syndrome. Main trends, unsolved questions, practical and educational aspects

Therapeutic guidelines are progressively emerging in the antiphospholipid syndrome (APS). For primary APS, prevention of recurrent miscarriages is frequently achieved by a combination of heparin plus aspirin. Steroids should not be used in the absence of associated systemic lupus erythematosus. Long term warfarin aimed at an INR of 3-3.5 is effective for the secondary prevention of thrombosis. However, some doubt is raising regarding the pertinence of INR monitoring in patients with a lupus anticoagulant. Education is an important part of the management of patients with APS. Coincident risk factors for thrombosis have to be suppressed or controlled. Psychological aspects also need to be carely considered during the course of this chronic disorder.

[A new cause of prolonged fever of unknown origin: progesterone substitution therapy]

OBJECTIVES

Over the last 3 years, we examined 15 patients on progesterone substitution therapy who presented prolonged fever. Many explanations had been put forward before the diagnosis was suggested. We recall the thermogenic effect of progesterone.

METHODS

Based on a retrospective analysis, we reported the clinical and biological features of 15 patients with prolonged fever due to progesterone substitution therapy and prospectively followed the temperature curves of 9 menopaused women who received substitution therapy for the first time.

RESULTS

The 15 case reports were quite typical. Often onset occurred with an acute infectious episode. Following this episode, the patients continued to take their temperature and discovered persistent fever. The context was often one of anxiety-depression rich in functional symptomatology. Laboratory findings included a normal sedimentation rate in all patients. Several days after treatment withdrawal temperature returned to normal. The prospective study confirmed the thermogenetic effect of almost all progesterone substitution drugs.

CONCLUSION

The thermogenic effect of natural progesterone is well known but it must be recalled that all progesterone agents with 5-beta metabolites have the same effect. Since metabolic clearance is long, the thermogenic effect may persist for several days after withdrawal.

[Pachydermodactyly: report of a case]

This 20 year old white patient complained of progressive thickening of his fingers over a period of four years. The second, third and fifth fingers of each hand indeed appeared podgy. The soft tissue on each side of the first phalanx was swollen, firm without adherence to the bone. The skin of the interdigital space was hyperpigmented and lichenified. This case illustrates the clinical and histologic features of digital fibromatosis which are discussed.

[Antiphospholipid syndrome. 20 cases]

OBJECTIVES

We analyzed the clinical and biological characteristics as well as the clinical course and outcome observed in 20 patients with antiphospholipid antibodies and clinical signs including thrombosis or repeated spontaneous abortion to better identify the recently described antiphospholipid syndrome.

METHODS

We retrospectively studied all patients observed in our unit from 1981 to 1992 who fulfilled the following inclusion criteria: a) at least one episode of arterial or venous thrombosis and/or repeated spontaneous abortions, b) positive for antiphospholipid antibodies.

RESULTS

Twenty patients were included, 3 with systemic lupus erythematosus (according to the American Rheumatism Association criteria). Arterial or venous thrombosis occurred in 9 and 16 respectively, including exceptional cases of cerebral phlebitis and thrombosis of dermal capillaries. High blood pressure was recorded in 8. Only 1 or 2 types of antiphospholipid antibodies were found in most patients. Anticardiolipin, a circulating anticoagulant and a false-positive Bordet-Wassermann reaction were found together in only 3 out of 16. In addition, the antibody level varied independently from the thrombotic events. There was no case with a clinical course from primary antiphospholipid syndrome to systemic erythromatosus lupus. The effect to treatment on occurrence of new thrombotic events was studied. Three patients suffered one or more haemorrhagic events during antivitamin K treatment.

CONCLUSION

It is difficult to establish a differentiation between primary antiphospholipid syndrome, systemic lupus erythematosus and lupus-like syndromes, and precise methods of identifying antiphospholipid antibodies should be further developed.

[Hyperthyroidism and hypersecretion of chorionic gonadotropin in gastric adenocarcinoma]

We report a case of hyperthyroidism complicating and revealing a metastatized adenocarcinoma of the stomach with high circulating levels of human chorionic gonadotropin and its beta component. To our knowledge, this is the first reported case of a non-trophoblastic tumor with hyperthyroidism and secreting quantities of these hormones. High circulating levels of beta component in such patients have been considered to be a sign of malignancy. The mechanisms of thyroid stimulation could be related to the biological activity of certain forms of the human chorionic gonadotropin.