[Rheumatologic aspects of toxocariasis (visceral Larva migrans). Apropos of 2 cases]

Visceral Larva migrans is a human infection by the larvae of dog ascarids or, more rarely, ascarids of other animal species. It is endemic in France. Two cases which respectively manifested as acute oligoarthritis and inflammatory myalgia with increased muscle enzyme levels are reported. Manifestations of the minor forms of this infestation are reviewed.

[For which hypertensive patient should angiotensin-converting enzyme inhibitor be prescribed or forbidden?]

Angiotensin-converting enzyme (ACE) inhibitors act by lowering the level of angiotensin II. The therapeutic benefits of these drugs and their potential side-effects therefore result from suppression of the physiological effects of angiotensin II. It is rational to prescribe an ACE inhibitor when the renin-angiotensin system is activated, as in renin-dependent essential hypertension, malignant hypertension and hypertension associated with heart failure. The beneficial effects of ACE inhibitor must be weighed against the special risks of renovascular hypertension: risk of renal artery thrombosis in case of unilateral stenosis and risk of renal failure if the stenosis is bilateral or affects a solitary kidney. In some situations the renin-angiotensin system is not directly involved in hypertension but may play a local haemodynamic role, as in some cases of primary or diabetic nephropathy. In such case the ACE inhibitors are thought to exert a protective effect. ACE inhibitors were reputed to be less effective in the elderly than in younger patients, but we now know that they can be prescribed with equal success in both instances to reduce peripheral resistance and improve regional blood flow as well as arterial compliance. Finally, ACE inhibitors can be prescribed, albeit with limited effectiveness, when the renin-angiotensin system is not activated, as in low renin hypertension and idiopathic hyperaldosteronism due to adrenal hyperplasia. They are ineffective in case of Conn's adenoma and contra-indicated in pregnant women.

[Value of nocturnal blood pressure in treated non-insulin-dependent hypertensive patients]

The purpose of the study was to evaluate the loss of nocturnal (N) decline in blood pressure (BP) in type II treated hypertensive diabetics. The study concerned 36 hypertensive diabetics 59 +/- 10 years old, 20 men and 16 women, with poor metabolic control (HbA1C: 9.6 +/- 3%), without dysautonomia; 14 had macroproteinuria and/or microalbuminuria (mu alb) (< 30 micrograms/min). An ambulatory BP monitoring (Spacelabs 90207) was performed in all patients. Left ventricular mass index (LVMI) and E/A were determined by Doppler-echocardiography. Two groups (G) were individualized: G1 (n = 17), with a normal circadian rhythm (diurnal and N.BP significantly different); G2 (n = 19) with a loss of N decline in systolic (S) and diastolic (D) BP or both; and compared to non diabetic treated hypertensive controls (G3). There was no difference neither in LVMI (125 +/- 43 g/m2), E/A (0.7), 24 h-mean (M) BP in the three groups, nor in HbA1C levels and mu alb occurrence in G1 and G2. Mean N.SBP and mean N.DBP were more closely related to LVMI in G2 than in G1 and G3. [table: see text] Half of these hypertensive diabetics, with bad metabolic control, have an altered circadian BP pattern; the prognostic value of nocturnal BP, related to LVMI despite the antihypertensive treatment, is suggested.

Ambulatory blood pressure in patients with Parkinson's disease without and with orthostatic hypotension

Non-invasive ambulatory recordings of blood pressure and heart rate were performed using a Spacelabs device during day and night periods in patients with Parkinson's disease with (n = 19) or without orthostatic hypotension (n = 19). In patients with orthostatic hypotension, the average systolic and diastolic blood pressure during the night (137 +/- 5/80 +/- 3 mmHg) was higher (p less than 0.05) than during the day period (121 +/- 3/76 +/- 2 mmHg). In patients without orthostatic hypotension, a decrease in blood pressure was recorded during the nocturnal period. In patients with orthostatic hypotension, the blood pressure variability was higher (p less than 0.05) during the day (systolic: 14.6 +/- 1.3%; diastolic: 16.5 +/- 1.0%) than during the night (systolic: 9.1 +/- 0.8%; diastolic: 10.8 +/- 1.1%). The blood pressure load (percentage of values above 140/90 mmHg) during the night was significantly higher than during the day for both systolic (41.2 +/- 8.1 vs. 19.6 +/- 4.7%) and diastolic blood pressure (24.9 +/- 6.9 vs. 16.3 +/- 4.9%). There was a decrease in heart rate in both groups during the night. A fall of 25 mmHg or more in systolic blood pressure after meals occurred in ten patients with orthostatic hypotension and in one patient without orthostatic hypotension. These results indicate that orthostatic hypotension in Parkinson's disease is associated with specific modifications of ambulatory blood pressure including loss of circadian rhythm of blood pressure, increased diurnal blood pressure variability and post-prandial hypotension.

[Value of the study of electrocardiographic P wave in pheochromocytoma]

The diagnostic value of electrocardiographic P wave analysis in the frontal plane was assessed with respect to previously reported abnormalities: right atrial hypertrophy-dilatation; an enlarged, crenalleted summit without criteria of right atrial hypertrophy. Two observers studied the ECG recordings of 20 hypertensive patients with pheochromocytomas: 10 men and 10 women, aged 45.5 +/- 16 years, and in 30 patients with essential hypertension, 15 men and 15 women, aged 48.9 +/- 9 years (NS). The duration of hypertension was 2.6 +/- 2 years versus 4.7 +/- 4 years (p = 0.02). Right atrial hypertrophy-dilatation was observed in 5 patients in the pheochromocytoma group and in none of the essential hypertensive patients: an isolated abnormality of the summit of the P wave was observed in 5 other cases of pheochromocytoma and by 1 observer in 1 of the essential hypertension. These abnormalities disappeared after ablation of the tumour. These changes were not recorded in 3 patients who had predominant noradrenaline hypersecretion; nevertheless, comparison of the urinary adrenaline, noradrenaline, normeta- and metanephrine levels were inconclusive. No relationship was established between these concentrations, global urinary catecholamines and meta block, the duration of hypertension, the frequency and level of hypertensive crises, or the presence of "ischaemic" ST-T wave changes. P wave changes are thought to be related to high plasma catecholamine levels irrespective of the clinical impact; the sensitivity of these changes is modest (10/20) but the specificity is better within a group of hypertensive patients. An experienced observer can orient the diagnostic investigations to the search for a pheochromocytoma or to a secondary recurrence of the tumour from the surface ECG. The role of marker of a very high noradrenaline or adrenaline secretion cannot be confirmed from a series limited in separated plasma concentration measurements.

[Results of the evaluation of platelet sodium-proton exchange in the young hypertensive subject]

In order to assess the relationships between increased cellular sodium-proton (Na+/H+) exchange and cardiovascular abnormalities in essential hypertension (EH), 21 young subjects as part of an ongoing longitudinal study were tested for the platelets Na+/H+ exchange using the amiloride sensitive sodium dependent component of platelet volume change under cytoplasmic acidification induced by a sodium propionate medium; cell volumes were determined by electronic cell sizing (Livne et al., Lancet 1987; i: 533-6). 24 normal subjects with normotension and without familial history of hypertension were taken as controls. Data of ambulatory blood pressure recording (ABPR) defined 2 groups according to the presence of normotension (group I, n = 10), or of hypertension (group II, n = 11): established (n = 2) or borderline (n = 9) hypertension. Hypertensive subjects (group II) had increased values of Na+/H+ exchange (k coefficient, mean (SEM): 0.287 (0.07) vs 0.228 (0.05) in control group (p less than 0.01). Na+/H+ rates were significantly related to ABPR data (r = 0.46, p less than 0.02 with diastolic charge during ABPR), but not to left ventricular mass index in g/m2 by echocardiography. Increased rates of platelets Na+/H+ exchange which were related to diastolic blood pressure levels by ABPR, and perhaps to the level of peripheric vascular resistances, may play a significant role in the development of EH in the early stages.

[Should arterial hypertension in sleep apnea syndrome be stressed?]

The frequent association of sleep apnea syndrome and essential hypertension led to think of sleep apnea as an etiology of hypertension, especially as a good correlation has been found between the severity of both diseases. Moreover, treating the apnea syndrome results in a decrease of blood pressure. The aim of our study is to depict the outlines of a severe hypertensive individual with sleep apnea by comparing 9 men primarily referred to the hypertension clinic with refractory hypertension and finally found to have sleep apnea (study group) to 23 men whose diagnosis of sleep apnea was made in the pulmonary unit (controls). Fifteen of these were hypertensives. Mean age of the study group was 47 +/- 7 years vs 60 +/- 11. Controls were less overweighted: BMI = 33 +/- 6 kg/m3 vs 39 +/- 5. Mean blood pressure was 171 +/- 16/107 +/- 4 mmHg in the study group vs 157 +/- 19/92 +/- 12 mmHg in controls. Prevalence of glucose metabolism disorders was significantly greater in the study group: 6 patients with maturity onset diabetes and 3 with proven glucose intolerance, vs respectively 4 and 6 controls. Triglycerides were elevated in both groups whereas mean cholesterol was slightly above normal values. Six patients of the study group could have an echocardiogram which showed left ventricular hypertrophy (mean left ventricular mass index = 206 +/- 31 g/m2 after the Penn convention).(ABSTRACT TRUNCATED AT 250 WORDS)

[Outcome of "white coat reaction" induced by nurse and physician in patients with hypertension treated with a beta blockader (bisoprolol)]

The aim of the study was to assess the evolution of Alerting reaction (AR) under beta blocker treatment and to discuss its incidence on the management of arterial hypertension (AH). In 28 patients (pts), 19 men, 9 females, 46 +/- 12 years old, suffering from a mild to moderate AH, blood pressure (BP) was measured, according to a ritual circuit by a nurse (N), then a 12-minutes recorded monitoring, then a physician (Ph) using a mercury sphygmomanometer in upright, then in supine position at the end of the visit (165 +/- 18/108 +/- 13 mmHg, 161 +/- 14/100 +/- 9 mmHg). Pts received a cardioselective beta blocker, bisoprolol (B), 10 mg once daily and BP was evaluated after 1 and 2 months (D30; D60) under identical conditions. When compared to monitoring BP, there was a significant increase in systolic (S) and diastolic (D) BP, taken by the nurse and the physician, attributed to AR (delta SBP; delta DBP). Under B, AR remained unchanged, even increased regarding upright DBP at D30, D60 in spite of its efficacy: (formula; see text) The study demonstrates that there is no incidence of beta blocker on alerting reaction and that AR must be considered to evaluate the treatment and avoid an unnecessary or overtreatment. In case of discrepancies, it is suggested to perform an ambulatory BP monitoring.

[Ambulatory blood pressure in hypertension with dysautonomia]

The purpose of the study was to evaluate the interest of ambulatory blood pressure (BP) recording (ABPR) in the management of arterial hypertension (AH) with dysautonomia. The study concerned 8 hypertensive patients (pts), 5 men, 3 females 52 +/- 10 years old, with orthostatic hypotension (OH): BP was 162 +/- 19/87 +/- 16 mmHg and 129 +/- 15/76 +/- 8 mmHg in lying and standing position respectively. In two cases AH was associated with a central degenerative disorder whereas the six other pts had a diabetic dysautonomia: bad metabolic control (HBA1c 14.4 +/- 2.7%), and incipient or over nephropathy (4 pts). ABPR was performed in all pts during 24 hours (space-labs system). In these hypertensive pts with OH, the mean 24 hour-BP was surprisingly normal at 128 +/- 11/76 +/- 6 mmHg. ABPR demonstrated the loss of nocturnal decline in BP: diurnal and nocturnal BP were respectively 125 +/- 13/74 +/- 6 mmHg and 133 +/- 16/78 +/- 10 mmHg (NS). 6 of 8 pts had an increase in BP at night resulting for the population (n = 8) in a nocturnal increase (%) of + 5.6%, this pattern widely differs from controls--13%. The decrease in heart rate during sleep was blunted but significant from 89 +/- 9 b/min to 81 +/- 9 b/min (p 0.01). Diurnal and nocturnal BP variability (V), assessed by variation coefficient were not significantly different: SBP-V was 10.3 +/- 6.4% day and 12.3 +/- 4.2% night, DBP-V 7.5 +/- 6.3% day and 12.5 +/- 3.1% night.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of a calcium inhibitor, nicardipine, on aldosterone secretion in primary hyperaldosteronism]

The purpose of the study was to evaluate the effects of a dihydropyridine calcium antagonist, nicardipine (N), on blood pressure (BP) and aldosterone secretion in hypertensive patients (pt) with primary aldosteronism. The study concerned 8 pts, mean age 55.6 +/- 7.7 years, 1 pt with aldosterone-producing adenoma (APA) and 7 pts with idiopathic aldosteronism: plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were respectively 0.30 +/- 0.2 ng/ml/h) and 314 +/- 109 pg/ml. Acute administration of 12 mg of nicardipine during 90 mn (three periods of N infusion during 30 mn: 0.4 mg/mn-5 mn; then 0.08 mg/mn-25 mn) significantly decreased BP, with an increase in heart rate (HR); the levels of PAC were significantly reduced with a slight but not significant increase in PRA, 60 mn after N: (table; see text) N decreased also PAC in the pt with APA [600 to 410 pg/ml] but did not improve hypokalemia (3.1 vs 3.3 mmol/l, n = 8 N.S.). In contrast, PAC levels were not modified 2 hours after acute oral administration of captopril (1 mg/kg): 302 +/- 164 pg/ml vs 332 +/- 191 pg/ml (NS). This study demonstrated the antihypertensive efficacy of acute infusion of nicardipine in primary aldosteronism; the decrease of PAC under this calcium antagonist suggested its potential interest in the management of idiopathic aldosteronism.

[Neurogenic arterial hypertension in humans]

The purpose of this study was to investigate baroreflex activity in hypertensive patients with orthostatic hypotension (OH) due to sinoaortic baroreceptor denervation. The study concerned 3 patients (pts), 58-63 years, mean age 60.6 +/- 2 with both arterial hypertension (paroxysms recorded at 250/130 mmHg) and OH. They received radiation therapy to the entire cervical area for neoplasm, 9.6 +/- 2.8 years ago and had a carotid murmur without significant stenosis. Every pt had a severe and symptomatic OH: blood pressure (BP) and heart rate (HR) were respectively 163 +/- 17/105 +/- 7, 82 +/- 5 b/mn in lying position and 82 +/- 16/53 +/- 9 mmHg, 99 +/- 1 b/mm in standing position. The standing-induced increase in HR was lower (delta HR = + 17.3 b/mn) than expected; atropine (0.02 mg/kg) infusion and cold pressor test were ineffective; the massage of sinocarotid receptors induced a slight decrease in HR (delta HR = - 8 b/mn) and BP was not modified by Valsalva's maneuver. Infusion of norepinephrine (0.016 mg/mn) performed in one pt, increased BP without effect on HR. Platelet alpha 2-adrenoreceptors (alpha 2AR) evaluated by (3H) Yohimbine binding showed a significant increase in alpha 2AR number (Bmax), without any significant change in affinity (KD) when compared with normotensive and essential hypertensive pts: (table; see text) This study described an unusual etiology of a paroxysmal hypertension with orthostatic hypotension, demonstrated the impairment of baroreflex activity and suggested the potential interest of platelet alpha 2 adrenoceptors measurement to evaluate sympathetic tone in these patients.

[Renal insufficiency and treatment of persistent cardiac insufficiency with converting enzyme inhibitor]

The purpose of this retrospective study was to consider impaired renal function in patients with severe congestive heart failure after converting enzyme inhibition and to emphasize the characteristics of this population. The study concerned 26 patients (pts), 72.5 +/- 8.1 years old, with a severe congestive heart failure (NYHA Class IV). Before treatment serum creatinine was slightly increased and the introduction of angiotensin converting enzyme inhibitor (ACEI) - Captopril 58.9 +/- 17.3 mg/j or enalapril 9.2 +/- 4.4 mg - impaired renal function from 132.0 +/- 50.7 mumol/l to 183.5 +/- 139.3 mumol/l (n = 26; p less than 0.05). Patients were separated in 3 groups: in group I; 15 pts, serum creatinine remained unchanged under ACEI in despite of the significant decrease of blood pressure (BP); from 140.7 +/- 24.0/82.5 +/- 13.4 to 120.3 +/- 12.8/71.8 +/- 8.7 mmHg (p less than 0.01). The cause of heart failure was an ischemic heart disease (IHD) in 15 patients (chi 2 test, p less than 0.05), a dilated cardiomyopathy in 4 pts and an aortic or mitral valvular regurgitation in 2 pts. In contrast renal function was significantly impaired in group II; serum creatinine increased from 120.8 +/- 25.2 to 189.0 +/- 80.7 mumol/l under ACEI. BP remained unchanged 136.9 +/- 29.0/78.1 +/- 4.9 and 118.7 +/- 13.6/75.6 +/- 7.6 mmHg respectively before and after treatment. There was 4 pts with dilated cardiomyopathy, 4 pts with mitral or aortic valvular regurgitation and only one with IHD. The introduction of an ACEI in two pts--group III--with severe tricuspid regurgitation induced an acute and reversal renal failure (serum creatinine at 600 mumol/l).

Platelet alpha 2- and leucocyte beta 2-adrenoceptors in phaeochromocytoma: effect of tumour removal

Platelet alpha 2- and leucocyte beta 2-adrenoceptors (as well as noradrenaline and adrenaline plasma levels) were studied in five patients with confirmed phaeochromocytoma using tritiated yohimbine and iodated cyanopindolol, respectively, before and after tumour removal. Patients with phaeochromocytoma had a lower leucocyte iodated cyanopindolol binding than control subjects, but no change in platelet tritiated yohimbine binding. Plasma catecholamine levels were higher than controls. Tumour removal induced a return to normal values of leucocyte iodated cyanopindolol binding and a decrease in plasma catecholamine levels. These results underline the potential interest of leucocyte beta-adrenoceptor quantification in the diagnosis and the follow-up of phaeochromocytoma. Pharmacologically, they show that down-regulation occurs in vivo for leucocyte beta 2-adrenoceptors but not for platelet alpha 2-adrenoceptors.

[Value of the study of circulating adrenergic receptors in the diagnosis and surveillance after surgery of pheochromocytoma]

The purpose of the study was to investigate leukocyte beta adrenoceptors and platelet alpha 2 adrenoceptors in pheochromocytoma. The study concerned nine hypertensive patients, five men and four women (aged 42 +/- 8 years) with a pheochromocytoma demonstrated by high levels of urinary catecholamines and radiological data. Catecholamine plasma levels, assayed by HPLC were wide-ranging: 10.7 to 172.8 nM for noradrenaline and 0.7 to 3.9 nM for adrenaline. In each case the number of leukocyte beta adrenoceptors sites (measured with 125 I-cyanopindolol) significantly decreased: Bmax was 20.6 +/- 2.8 versus 48.5 +/- 1.5 fmol/mg protein in controls (p less than 0.05). In contrast, the number of platelet alpha 2 adrenoceptors sites (measured with 3H-yohimbine) was not modified: 206 +/- 22.6 versus 186.0 +/- 12.1 fmole/mg protein in controls. There was no change in affinity constant (Kd), neither for beta nor alpha2 adrenoceptors. After tumor removal, there was a significant increase in beta adrenoceptor number. We conclude that down regulation occurs in vivo for beta adrenoceptors but not for alpha2 adrenoceptors and that the decrease in leukocyte beta adrenoceptor number is an interesting and suitable index in the management of pheochromocytoma.

[Influence of angiotensin on the secretion of aldosterone in idiopathic hyperaldosteronism]

The purpose of study was to investigate the role of angiotensin II in idiopathic primary aldosteronism (IPA) and to evaluate the interest of angiotensin converting enzyme inhibitors (ACEI) in its management. The study concerned 10 hypertensive patients, mean 49 +/- 11 years with idiopathic primary aldosteronism due to bilateral adrenal hyperplasia: plasma renin activity (PRA) less than 1.5 ng/ml/h and plasma aldosterone (PA) greater than 25 ng/100 ml. Adrenal venography and adrenal vein aldosterone levels demonstrated bilateral hyperplasia. PRA and PA were evaluated in recumbent position, then after 4 hours in upright posture. The next day, a "captopril screening test" was performed with PA assays before and three hours after a single oral administration of captopril (1 mg/kg). Upright PRA and PA were slightly increased and acute administration of captopril reduced significantly PA levels in all patients. Blood pressure (BP was unmodified under captopril. These hormonal results demonstrated that adrenal glomerulosa remained sensitive to low concentrations of angiotensin II, and underlined the potential interest of ACEI in the management of IPA. Brown R. demonstrated already an increase of adrenal sensitivity to angiotensin II infusions, and isolated an aldosterone-stimulating factor (ASF). Plasma aldosterone levels were related to increased ASF concentrations but there was no link between PRA and ASF. Carey R. suggested that ASF acts through an increase of the sensitivity of aldosterone production to angiotensin II.(ABSTRACT TRUNCATED AT 250 WORDS)