La Revue de medecine interne最新文献

Metabolic steatotic diseases affect 16.7% of the French population, i.e. approximately 8 million individuals. Approximately 60% of type 2 diabetes patients have hepatic steatosis, 30% of whom also have fibrosis. The progression of fibrosis, linked to systemic inflammation, is associated with a significant increase in cardiovascular and cancer mortality (particularly hepatocellular carcinoma and colorectal adenocarcinoma). In 2023, an international reform of the nomenclature led to the replacement of the old terminology "non-alcoholic fatty liver disease (NAFLD)" and "non-alcoholic steatohepatitis (NASH)" in order to better reflect the metabolic causes. The following terms were defined: "steatotic liver disease (SLD)", which refers to all forms of steatosis, "metabolic dysfunction-associated steatotic liver disease (MASLD)", which explicitly includes metabolic factors, and "metabolic dysfunction-associated steatohepatitis (MASH)", which emphasizes histologically confirmed metabolic steatohepatitis. A new entity, "metabolic alcohol-related liver disease (MetALD)," refers to MASLD with moderate but regular alcohol consumption. The definition of "alcohol-related liver disease (ALD)" remains unchanged (alcohol consumption greater than 50-60g/day). "Cryptogenic steatosis" includes cases with no known cause. This new classification allows for the continued use of previous data and aims to improve patient stratification for personalized treatments.

Introduction: Hepatic encephalopathy is a neuropsychologic disorder due to hyperammonaemia, related to liver failure and/or portosystemic shunts for instance. We herein describe the case of a 74-year-old woman who developed hepatic encephalopathy in the context of portal hypertension secondary to chronic stenosis of the left common femoral vein.

Case report: A 74-year-old woman presented with confusion and major hyperammonemia (>100μmol/L). She had a past medical history of angioma of the left leg treated with radiotherapy. Post radiotherapy stenosis of the left common femoral vein occurred, then bypass paths leading to large pelvic varicose veins draining into the inferior mesenteric vein. There was no evidence for liver failure and common causes of confusion were excluded. The liver biopsy was refused by the patient. In the absence of another etiology, the retained diagnosis was an hepatic encephalopathy secondary to portal hypertension, related to inferior mesenteric vein hyper flow draining into the splenic vein, then into the portal vein. Treatment by lactulose and rifaximine allowed clinical improvement and hyperammonemia reduction.

Conclusion: An hepatic encephalopathy may occur without any evidence of hepatopathy, in the context of venous malformations responsible for portal venous hyper flow, as illustrated by this unusual case report.

Subcutaneous (SC) infusion, or hypodermoclysis, is a route of administration involving the injection of fluids or medications into the hypodermis. Historically used and subsequently abandoned due to complications arising from poor technique, it has regained interest since the 1990s, particularly in geriatrics and palliative care. Compared with the intravenous (IV) route, it is less invasive, better tolerated, easier to implement in outpatient settings, and carries a lower risk of serious complications. The pharmacokinetics of the SC route show slightly slower absorption than IV administration, with bioavailability often exceeding 80% for hydrosoluble compounds. Main indications include the preventive or therapeutic management of moderate dehydration, palliative care (analgesics, anxiolytics, antipyretics, antisecretory agents), and some antibiotics (such as ceftriaxone, as well as ertapenem and teicoplanin, with a good level of supporting evidence). In internal medicine departments, the SC route can also be used for furosemide, levetiracetam, and vitamin B12 when no alternative is available. Some vaccines may be administered subcutaneously in patients with contraindications to the intramuscular route. Local adverse events may occur but are generally mild (pain, edema), transient, and infections are rare. Although often used off-label, hypodermoclysis is a safe and practical alternative, particularly suited to elderly or frail patients, and meets current healthcare challenges related to outpatient medicine and hospital overcrowding. Its wider adoption relies on healthcare professional training, standardized protocols, and robust comparative data.

Systemic autoinflammatory diseases (SAIDs) are associated with a dysregulation of innate immunity leading to recurrent or chronic inflammation. There are both well-characterized monogenic forms, such as familial Mediterranean fever, cryopyrinopathies and VEXAS syndrome, and multifactorial forms defined by classification criteria, such as Still's disease, Schnitzler syndrome and SITRAME. However, a significant proportion of patients, estimated at up to 73% in some series, present with an autoinflammatory phenotype without any identified pathogenic variant or established diagnosis based on classification criteria. These situations are grouped under the term undifferentiated systemic autoinflammatory diseases (USAID). In adults, the most common manifestations are recurrent fever, fatigue, myalgia, arthralgia, cutaneomucous and digestive features, ENT or ocular involvement. Clinical heterogeneity contributes to delayed diagnosis, which can take several years. Diagnosis is based on repeated documentation of a biological inflammatory syndrome, the progression of symptoms over at least six months, the exclusion of common differential diagnoses (infections, cancers, haematological disorders or autoimmune diseases) and the absence of criteria allowing to classify the patient to a defined entity. Investigations include repeated biological tests, screening for immune deficiencies or autoantibodies, and sometimes genetic testing to detect monogenic diseases with either germinal or somatic variants. In the absence of specific criteria, response to treatments targeting innate immunity, such as colchicine or cytokine inhibitors (IL-1, IL-6, TNF, JAK), may confirm the diagnosis. USAID in adults is an emerging entity, on the borderline between monogenic and multifactorial diseases, the recognition of which is essential to reduce diagnostic uncertainty and adapt management.

Introduction: Tapia's syndrome is a rare condition characterized by simultaneous unilateral paralysis of the hypoglossal and recurrent laryngeal nerves, first described in the early 20th century.

Case report: We report a 51-year-old patient admitted in our internal medicine department for post-resuscitation care following a cardiorespiratory arrest, requiring orotracheal intubation and prolonged mechanical ventilation. Following extubation, the patient developed dysphagia associated with left vocal cord paralysis and tongue deviation with atrophy Tapia's syndrome was diagnosed, likely secondary to prolonged intubation. Tailored speech therapy intervention led to symptom resolution.

Conclusion: This report highlights an underrecognized complication of prolonged or traumatic intubation, whose clinical consequences require prompt, individualized, and multidisciplinary management.

Rituximab, a chimeric monoclonal antibody targeting the CD20, is a key therapy for treating haematological malignancies and numerous autoimmune diseases. However, its use may be complicated by the occurrence of anti-drug antibodies (ADA), which reflect its immunogenicity. This immunogenicity varies depending on the clinical context: it remains rare in oncology, but is more common in autoimmune diseases. These ADAs may be neutralising or non-neutralising and may influence pharmacokinetics, B-cell depletion, clinical efficacy and the risk of hypersensitivity reactions. Their occurrence is influenced by multiple factors: drug characteristics, administration methods, treatment regimen, but also patient-specific parameters. To limit immunogenicity, several approaches are being studied, such as optimising treatment regimens, combining with immunosuppressants, or using alternative humanised or fully human antibodies. This review provides an updated summary of anti-rituximab antibodies and highlights the importance of a personalised monitoring strategy to optimise the management of patients treated with rituximab.

Introduction: Prolonged fever of unknown origin (FUO) is a complex diagnostic entity, most commonly caused by infectious, neoplastic, or inflammatory conditions. Hepatic hemangiomas, although frequent and benign, are rarely implicated.

Case report: A 53-year-old woman was hospitalized for FUO. Imaging revealed a giant hepatic hemangioma with areas of necrosis and hemorrhage. In the absence of infectious, neoplastic, or autoimmune etiology, the hemangioma was considered the most likely cause of fever. Arterial embolization using lipiodol and bleomycin led to complete resolution of the fever, normalization of inflammatory markers, and significant tumor volume reduction.

Conclusion: Hemangiomas as a cause of FUO are extremely rare, typically associated with giant lesions and necrotic or hemorrhagic complications. While surgical resection is the standard treatment, our case suggests that embolization may offer an effective and less invasive alternative.