[HIV-lipodystrophy syndrome]

CLINICAL FINDINGS

The HIV-associated lipodystrophy syndrome is reported with an increasing incidence predominantly in HIV-seropositive patients on antiretroviral therapy. The core of the lipodystrophy syndrome consists of fat loss in face, extremities and buttocks with or without a visceral fat accumulation, hyperlipidemia and a disturbed glucose metabolism are considered essential parts of the syndrome too. Additional metabolic abnormalities are regarded as syndrome related.

PATHOGENESIS

Currently identified risk factors associated with the development of lipodystrophy are antiretroviral treatment (duration, number and kind of drugs), low CD4 cell count, higher age and metabolic abnormalities. The currently favored hypotheses to explain the lipodystrophy syndrome are essentially based on the assumption that antiretroviral treatment is the cause of the disorder.

TREATMENT

The short-term benefit of antiretroviral treatment is greater than the disadvantages of the lipodystrophy syndrome, in the long term, however, the cardiovascular risk associated with the metabolic disturbances may result in an increased mortality on its own. The current approach to treatment includes modification of antiretroviral therapy and specific treatment of symptoms.

L-Carnitine in the treatment of HIV-associated lipodystrophy syndrome

The objective of this pilot study was to assess the effect of L-carnitine on the course of the HIV-associated lipodystrophy syndrome. Twelve patients presenting with combined atrophic and hypertrophic changes of body fat were treated with L-carnitine 1000 mg bid for 3 months. No marked improvement of the body changes was observed. However a reduction in serum cholesterol levels, but not triglycerides, was noted. These preliminary data do not support the use of L-carnitine for the rapid reversal of advanced fat tissue alterations due to HIV-associated lipodystrophy.

Liver adenomatosis: reappraisal, diagnosis, and surgical management: eight new cases and review of the literature

OBJECTIVE

Liver adenomatosis (LA) is a rare disease originally defined by Flejou et al in 1985 from a series of 13 cases. In 1998, 38 cases were available for analysis, including eight personal cases. The aim of this study was to review and reappraise the characteristics of this rare liver disease and to discuss diagnosis and therapeutic options.

BACKGROUND

LA was defined as the presence of >10 adenomas in an otherwise normal parenchyma. Neither female predominance nor a relation with estrogen/progesterone intake has been noted. Natural progression is poorly known.

METHODS

The clinical presentation, evolution, histologic characteristics, and therapeutic options and results were analyzed based on a personal series of eight new cases and an updated review of the literature.

RESULTS

From a diagnostic standpoint, two forms of liver adenomatosis with different presentations and evolution can be defined: a massive form and a multifocal form. The role of estrogen and progesterone is reevaluated. The risks of hemorrhage and malignant transformation are of major concern. In the authors' series, liver transplantation was indicated in two young women with the massive, aggressive form, and good results were obtained.

CONCLUSION

Liver adenomatosis is a rare disease, more common in women, where outcome and evolution vary and are exacerbated by estrogen intake. Most often, conservative surgery is indicated. Liver transplantation is indicated only in highly symptomatic and aggressive forms of the disease.

[Intra-parotid neurogenic tumors of the facial nerve. Value of MRI]

Facial nerve intraparotid neuromas are rare. We report two cases with no facial paralysis. In the first case, the clinical protocol for the evaluation of a parotid mass did not suggest the intramastoid tumor extension. This extension was shown by CT and MRI and confirmed by gross and microscopic appearance. In the second case, no intrapretrous extension was observed with MRI. The diagnosis of neuroma was made during surgery. With a literature review, we discuss the diagnostic difficulties encountered in the investigation of parotid facial nerve tumors, emphasizing on the usefulness of CT and MRI in its diagnosis.

[The effect of a low-dose hydrochlorothiazide therapy on the bone mineral content of the axial and peripheral skeleton]

An increase in bone mineral content (BMC) as well as a decrease in the incidence of fracture of the proximal femur have been described in patients on thiazide diuretic treatment. A study was undertaken to assess, by means of dual X-ray absorptiometry, the effect of chronic low-dosage antihypertensive treatment with hydrochlorothiazide (HCT; < or = 25 mg daily) on lumbar vertebrae (representing the axial skeleton) and the nondominant radius (peripheral skeleton). Measurements were made on 27 women (mean age 63.8 +/- 8.2 years) and 23 men (65.9 +/- 9.5 years) and compared with a control group of 19 women (62 +/- 8.7 years) and 20 men (65.9 +/- 9.5 years) with minor surgical or dermatological lesions who had never taken HCT or other drugs with potential effects on mineral bone metabolism. In men who had been on HCT for more than 5 years, BMC of the lumbar vertebrae was higher by 10.3% and of the radius by 3.8% than among the controls (differences not significant). In women who had been on HCT for more than 5 years, the corresponding increases were 19.6% (P < 0.05) and 5.4% (not significant). Among those patients who had been on HCT for less than 5 years there were no significant differences compared with the control group. There were no significant differences between the groups relating as regards the proximal radius which, in contrast to the ultradistal radius, consists predominantly of cortical bone. -These data indicate that, while HCT has only a slight influence on BMC, it can be considered to have a desirable associated effect in the antihypertensive treatment of elderly patients.

[Radiologic double-contrast aspects of small esophageal cancers. 38 cases]

Double contrast radiological features of thirty eight small esophageal carcinoma are described. Double contrast study is essential in the detection of small esophageal carcinomas: localized thickening of the folds (29%), localized wall stiffness (23.6%), superficial ulcers (13%), discrete superficial nodule (42%), nodularity (15.7%), and ulcerated nodule (15.7%). In our series, six carcinomas arising from reflux esophagitis have the nodular appearance. As in the majority of the cases, small esophageal carcinomas are asymptomatic, when radiologic study of esophagus is performed in patients over 40 years with heavy alcohol and tobacco use, it is imperative to use the double contrast method and to carefully search for minor mucosal abnormalities.

[Abdominal echography in colonic diseases]

In the past few years, several studies have assessed the visualization of digestive diseases by ultrasound, but its clinical accuracy has been rarely defined. Thus we evaluated the contribution of sonographic examination as an initial diagnostic mean in the detection of colonic lesion. During a period of thirty six months (June 85-June 88) when we performed a standard sonographic abdominal examination, we utilized ultrasound to look for thickening or other modifications of the large bowel wall, if the clinical findings suggested a colonic disease. In these conditions we performed 453 US examinations. In our study, 363 cases were considered to be negative and the controls demonstrated colonic wall lesions in 24 cases. Thus the sensitivity was one of 77%. The sonographic examination was positive in 90 cases with 6 false positives. Thus our specificity reached 98.2% and the accuracy achieved was 93.3%. Thus sonographic examination appears to be a rapid, non invasive, mobile, mean of examining the abdominal cavity and also the large bowel in all patients. If this examination is negative, a colonic disease is possible since sensitivity is 77%. On the other hand, if the examination is positive, a colonic disease is very probable, since specificity reached 98.2%. The accuracy of US Colonic examination is 93.3% and with using abdominal plain film, theses percentages may be improved.

[Enteroclysis in malabsorption syndrome in adults. Apropos of 73 cases]

We retrospectively analyzed the small bowel radiographies, performed by enteroclysis in 73 patients presenting a malabsorption disease. The etiology are: celiac disease (44 cases), abetalipoprotidemia (2 cases), Whipple's disease (7 cases), mastocytosis (1 case), amyloidosis (1 case), ischemia enteritis (4 cases), radiation injury (4 cases), lymphangiectasia (4 cases), Crohn's disease (4 cases) and NH lymphoma (2 cases). With enteroclysis, the radiological diagnosis of malabsorption disease is improved and it is able to differentiate malabsorption diseases based on radiological features: increased or decreased number of folds (celiac disease, mastocytosis, abetalipoprotidemia), nodularity of folds (Whipple's disease) and wall thickness (amyloidosis, lymphangiectasia, ischemic enteritis and radiation injury). It is no possible to differentiate NH lymphoma from Crohn's disease.

[What is the contribution of echography in Crohn disease?]

The alimentary tract often contains some gas which may obstruct the passage of the ultrasonic beam. However, when a pathological process involves the intestinal wall, a "target" pattern or a "pseudo-kidney" pattern may be visualized by ultrasound. It is also possible to visualize by US examination some complications of Crohn's disease: intestinal obstructive lesion with distended loops, fistula, abscesses and renal or biliary lithiasis. Because sonography is non-invasive and simple to perform without radiation exposure, it should often be used in Crohn's disease as the initial diagnosis and as the following-up test.

[Hepatitis secondary to current non-steroidal anti-inflammatory agents]

The authors report 83 cases of acute hepatitis secondary to non steroid anti-inflammatory drugs (NSAID), published in the literature. The NSAID in question are: niflumic acid, tolfenamic acid, diclofenac, fenoprofen, ibuprofen, indomethacin, naproxen, piroxicam, pirprofen and sulindac. Six deaths are directly ascribed to NSAID: although rare, these forms of hepatitis deserve therefore to be reported. They are usually mixed immuno-allergic forms of hepatitis (cytolytic as well as cholestatic). They often affect elderly women taking multiple medications. Monitoring of the liver function tests is necessary, during prolonged treatment with NSAID, especially during the first six months.

[Enteroclysis in chronic radioenteritis. Study of 43 cases]

Enteroclysis were practiced for 43 patients with radiation induced injuries of the small bowel. The radiological data revealed mucosal lesions in 23 cases, submucosa lesions in 21 cases, parietal thickening in 20 cases, mesenteric involvement in 32 cases. Narrowings and stenosis were present in 24 cases and dilated loops in 15 cases. Fistula formation existed in two cases. Twenty four patients were operated and the diagnosis of radiation enteritis was confirmed. In 12 cases, the enteroclysis succeed to a per os technique. The authors showed the superiority of the enteroclysis.

[Primary malignant melanoma of the digestive tract: esophagus and rectum. Apropos of 2 cases]

The authors report two cases of primary malignant melanoma. These primary neoplasms are exceptional on the GI tract. The diagnostical problems are discussed. The radiological features are a nodular lesion like an under-mucosa tumor.

[Abetalipoproteinemia. Apropos of 2 cases]

The cases of two sisters with abetalipoproteinemia are reported. Both presented the complete clinical and biological features of the disease: ataxia, retinitis pigmentosa, lack of apolipoprotein B, chylomicrons, LDL and VLDL, reduced titers of serum cholesterol and triglycerides, acanthocytosis, very low levels of serum vitamin A and E. Abetalipoproteinemia is a rare autosomal inherited disease. It is usually revealed during early childhood by steatorrhea and failure to thrive; ataxia and retinitis pigmentosa appear later. The originality of these two cases stems from: 1) their late and fortuitous diagnosis: the first sister was investigated at the age of 42 after the discovery of a vitamin K induced coagulation disorder. The other sister was 39 when she was routinely examined as a family member; 2) the presence of constipation without any other suggestive digestive complaint. However, white discoloration of the duodenal mucosa seen at endoscopy and lipid droplets within the intestinal absorptive cells at biopsy were characteristic. Barium studies showed diffuse involvement of the small bowel which was displaced by an enlarged sigmoid. Treatment consists of administration of vitamin A and vitamin E which prevent or delay ocular and neurologic symptoms. Vitamin K is associated whenever necessary.

[Rectocolic tuberculosis. Radiological aspects apropos of 14 cases]

During 11 years, 14 cases of tuberculosis of the colon are radiographied. The clinical findings are not specific and the association with evolutive pulmonary tuberculosis is infrequent (28%). The radiological features are described: ulcerations (4 cases), ulcerations and hypertrophic features (3 cases) and hypertrophic features (7 cases). The involving sites are caecum and ileocecum in 6 cases, ascending colon in 3 cases, transverse colon in 2 cases, descending colon in 2 cases and recto-sigmoid in 2 cases. The differential diagnosis are segmental Crohn colitis and colonic carcinoma. Endoscopic examination with biopsy is a help to the diagnosis, but in 5 cases, it will be deficient. The diagnosis of colonic tuberculosis is setting only by surgical resections in 6 cases (43%) and 4 patients have been treated by medical treatment with success. No relapse appears in operated patients.

[Cystic lymphangioma of the mediastinum. Radiologic data apropos of 7 cases]

Cystic mediastinal lymphangiomas are rare benign uncommon slow-growing tumors. Seven cases of cystic mediastinal lymphangioma in adults are presented. In both cases a mediastinal opacity is evident on plain chest radiographs. Roentgen findings are not specific. The mass is noted to be non-pulsatile, and well circumscribed smooth-surfaced. There are no evidence of invasion to the neighboring structures and no calcification are seen within the lesions. In two patients, sonography examination confirmed the cystic nature of the mass. Four patients underwent computed tomography (CT) scan. Ct can offer considerable additional information: CT will show well circumscribed and uniform low density lesions without invasive characteristics. Attenuation values in CT scan cannot be considered conclusive for diagnosis in all cases, on the non contrast scan, attenuation varied between -49 to +27 UH, there was no contrast enhancement.

[Value of small intestine transit by enteroclysis in obstructive syndromes of the small intestine. Apropos of 212 examinations]

During seven years, 212 small bowel examinations are made on patients with suspected small bowel obstruction by barium infusion. We find all the main small bowel pathology: Crohn's disease (16.5%), carcinomatosis (14.6%), neoplasia (10.3%), vascular disease (17.8%), actinic enteritis (9.5%) and miscellanous (18%). The small bowel infusion is normal in 15%. Surgery is avoided in 51% of the cases. There is non complications associated with the examination but in 12% of the cases, the examination is unsuccessful.

[Echographic aspects of Crohn's disease. Apropos of 42 studies]

Thirty two patients with confirmed Crohn's disease were examined from october 1983 to may 1985 by ultrasound (42 examinations) and by Conventional Contrast Radiology (Barium Contrast Studies). The well-know "target" pattern is the most frequent feature (88%) which is characteristic of the thickening bowel wall. The thickening is more important for the small bowel wall than the large bowel wall. But the "target" pattern is not the single pattern of inflammation involving the bowel. We also find a "rosette" pattern. This third ring is hypo or hyperechogenic or more complex. Other infrequent features are noted: solid abdominal masses, distended loops, luminal narrowing, fistula and stiffness. Because sonography is noninvasive and simple to perform without radiation exposure, it must often be used as the initial diagnostic tool and as the follow-up test for young people.

[Granulomatous colitis presenting as ischemic colitis]

The authors describe a case of granulomatous colitis mimicking a non gangrenous ischemic colitis. The radiological features are thumbprinting, ulcerations, then stenosis and sacculation. The resected specimen reveal some granuloma without necrosa.

[Granular cell tumors of the esophagus. Apropos of a case associated with bronchial carcinoma and treated by endoscopic excision]

The case of a granular cell tumor of the lower esophagus associated with a bronchial carcinoma is reported. The esophageal tumor was discovered by radiological and endoscopic examination for symptoms of gastroesophageal reflux and caused dysphagia after 6 1/2 years. An associated bronchial carcinoma led to the endoscopic removal of the esophageal tumor immediately prior to the thoracotomy. Eight days after operation the patient presented an hematemesis probably related to the endoscopic polypectomy. The course can be considered favorable after 17 months concerning the esophageal as well as the pulmonary situation. Histologically the esophageal tumor was a typical granular cell tumor and the bronchial tumor a squamous cell carcinoma. Seventy-nine cases of granular cell tumors of the esophagus have been published; 10 p. 100 of the cases are associated with bronchial, digestive or otorhinolaryngeal carcinoma. The onset of the carcinoma is usually subsequent to the esophageal tumor, justifying prolonged surveillance. This is the third case of a granular cell tumor of the esophagus treated by endoscopic polypectomy; this type of treatment requires close short-term follow-up because of the risk of hemorrhage as well as long-term follow-up because of the possibility of a second esophageal localization.