Cancers digestifs et thromboses: Quelles nouvelles recommandations ?

National audienceVenous thromboembolism (VTE) is an important cause of morbidity and mortality among patients with cancer. Update recommendations on this topic have been proposed in 2019. For VTE prophylaxis, hospitalized patients who have active malignancy and acute medical illness or reduced mobility should be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications. Moreover, all patients with malignant disease undergoing major surgical intervention should be offered pharmacologic thromboprophylaxis that should be continued up to 4 weeks post-operatively for patients undergoing major open or laparoscopic abdominal or pelvic surgery in the absence of high bleeding risk or other contraindications. For treatment of patients with cancer with established VTE, long-term anticoagulation may involve low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). VKAs are inferior but may be used if LMWH or DOACs are not accessible. There is an increase in major bleeding risk with DOACs, particularly in GI malignancies. LMWH should be use for cancer patients with acute diagnosis of VTE and high risk of bleeding, including patients with gastrointestinal cancers. DOACs are acceptable alternatives if there are no drug-drug interactions, no severe renal impairment, incorporating patient preferences.La maladie thromboembolique veineuse est une cause importante de morbi-mortalité chez les patients suivis pour un cancer et a fait l’objet de nouvelles recommandations en 2019.En prévention primaire, chez les patients suivis pour une néoplasie évolutive et hospitalisés pour un problème médical aigu et/ou avec une réduction de leur mobilité, il est recommandé de débuter une prophylaxie anti-thrombotique en l’absence de saignement ou d’autres contre-indications. De plus, il est recommandé de mettre en place un traitement prophylactique anti-thrombotique prolongé pendant quatre semaines pour tous les patients en péri-opératoire d’une chirurgie abdominale ou pelvienne en l’absence de contre-indication ou de risque élevé de saignement.En prévention secondaire, l’anticoagulation au long cours peut se faire par héparine de bas poids moléculaire (HBPM), anticoagulant oral direct (AOD) ou anti-vitamine K (AVK). Un traitement par HBPM réduit significativement le nombre de récidive thromboembolique par comparaison aux AVK sans différence en termes de complications hémorragiques. Les AOD augmentent le risque de saignement par rapport à un traitement par HBPM, en particulier au cours de cancers gastro-intestinaux et génito-urinaires. Ainsi, il convient de rester prudent quant à l’utilisation des AOD au cours du traitement des thromboses chez les patients suivis pour un cancer gastro-intestinal. Il est proposé d’utiliser les HBPM en première intention chez les patients à haut risque de saignement, incluant les patients avec une tumeur gastro-intestinale. Les AOD restent une alternative acceptable en l’absence d’interaction médicamenteuse, d’insuffisance rénale sévère et en accord avec le patient

Association of pulmonary alveolar proteinosis and fibrosis: Patient with GATA2 deficiency

International audience[No abstract available

Une endocardite de Libman-Sacks survenant sous apixaban chez une patiente atteinte de SAPL veineux de profil à haut risque

National audienceINTRODUCTION: Libman-Sacks endocarditis is a rare complication of antiphospholipid syndrome. Anti-vitamin K therapy is the standard treatment, although valvular replacement surgery may be required in some severe cases. In the latest EULAR recommendations, it is advised not to use direct oral anticoagulants in the management of antiphospholipid syndrome, especially of high-risk profile. CASE REPORT: We present a case of a mitral Libman-Sacks endocarditis complicated with multiple strokes occurring in the setting of an antiphospholipid syndrome with triple positive antibody profile in a 63-year-old woman with multiple sclerosis. She was previously treated with apixaban for two years. Tinzaparin followed by prolonged warfarine treatment and two months of hydroxychloroquine resulted in valvular improvement. CONCLUSION: To our knowledge, this is the first case of Libman-Sacks endocarditis occurring during apixaban therapy in a patient with antiphospholipid syndrome. This severe case highlights the inefficiency of direct oral anticoagulants to prevent thrombotic events in the antiphospholipid syndrome

IMPACT OF JAK INHIBITORS ON MACROPHAGE POLARISATION: PERSPECTIVES FOR SYSTEMIC SCLEROSIS

International audienc

Affections non-directement attribuables à la sclérodermie systémique (ANDAS) diagnostiquées au cours du suivi dans un centre de compétence: à propos d'une cohorte de 200 patients

National audienceIntroduction - Our work aimed to investigate the illnesses unrelated to systemic sclerosis (IUSS), diagnosed among patients with systemic sclerosis (SSc) throughout their follow-up in a referral tertiary care center. Methods - All the patients with SSc followed in the Internal Medicine Department of the University Hospital between October, 2014 and December, 2015, were included. We specifically reviewed the medical records of the patients who exhibited IUSS, defined as an illness that could not be considered as a typical clinical manifestation or as a usual complication of the disease. Results - Two hundred patients were included, and 38 IUSS were diagnosed among 31 SSc patients, over a 4 years median follow-up period. These diagnoses included vascular diseases (26%), heart diseases (21%), neoplasia (8%), infectious diseases (6%), autoimmune diseases (5%), endocrinopathies (5%), and others (24%). The median follow-up time before IUSS diagnosis was two years. Seventeen (45%) of these diagnoses were considered in patients showing suggestive clinical signs. A specific therapy was delivered in 25 cases (66%). Group comparisons revealed that dyslipidemia was more frequent in patients with IUSS (OR = 2.6 [1.1-1.5]; p = 0.014), while no differences were found for the other characteristics. Especially, no association between auto-antibodies specificity and the occurrence of IUSS was found. Conclusion - This study focused on IUSS in SSc patients and highlights the need for a polyvalent clinical approach all along the follow up of SSc patients

Characteristics and outcome of varicella-zoster virus central nervous system infections in adults

International audienceWe conducted an observational retrospective study of all adults hospitalized for documented varicella-zoster virus (VZV) meningitis or encephalitis during years 2000-2015 in one referral centre. Thirty-six patients (21 males, 15 females) were included, with meningitis (n = 21), or meningoencephalitis (n = 15). Median age was 51 years [interquartile range, 35-76], and 6 patients (17%) were immunocompromised. Aciclovir was started in 32 patients (89%), with a median dose of 11 mg/kg/8 h [10-15]. No patient died, but 12 (33%) had neurological sequelae at discharge. Age was the only variable associated with adverse outcome (OR 1.98 [1.17-3.35] per 10-year increment, P = 0.011)