[Empirical treatment of granulomatous hepatitis of unknown origin: practice investigation in the French National Society of Internal Medicine].
OBJECTIVE
Ten to fifteen percent of granulomatous hepatitis are idiopathic. If symptoms like prolonged fever are present, empirical treatment is discussed. The goal of this study is to describe the empirical treatment proposed in this situation by French specialists of internal medicine.


METHODS
We conducted a practice investigation among the French national society of internal medicine (SNFMI), using an anonymous questionnaire that related a case of idiopathic granulomatous hepatitis. This questionnaire was proposed to all French internists present at the SNFMI congress in June and December 2004. French specialists of internal medicine had to answer if they would prescribe an empirical treatment and if so, to specify this treatment.


RESULTS
Thirty-six French specialists of internal medicine answered to the questionnaire. In the proposed situation, 89% of them initiate an empirical treatment. In 18/36 cases (50%), a first-line anti-tuberculosis empirical treatment is proposed (quadritherapy in 11 cases). In 7 cases (19%), an empirical treatment with prednisone, 0.4 mg/kg/d (N=1) and 1 mg/kg/d (N=6), would be prescribed. Seven internists (19%) would prescribe an empirical treatment with cyclins at the dose of 100 to 400 mg/d. Median duration of the empirical treatment would be 28 days (range: 8-252d). The evaluation parameters mentionned are: fever (69%), weight (59%), seric level of C-reactive protein (59%), and liver biology (53%). In case of failure of first-line empirical treatments, 69% of all questionned internists prescribe a second-line treatments: prednisone at the dose of 0.4 to 2 mg/kg/d (72%), anti-tuberculosis treatments (16%), cyclins 200 mg/d (12%), with a median duration of 28 days. Seven internists (19%) propose to combine two empirical treatments.


CONCLUSIONS
Faced with a problem of idiopathic granulomatous hepatitis, French internists questionned propose four therapeutics options: no treatment, anti-tuberculosis treatment, cyclins or steroids treatment. First-line anti-tuberculosis treatment is a coherent proposition regarding to the high prevalence of tuberculosis. There are only few data available concerning empirical treatment with steroids or cyclins. Specific proposition of such empirical treatments should be defined.


CONCLUSIONS
The management of idiopathic granulomatous hepatitis is difficult. Our study shows that therapeutics practices of French internists are heterogenous. The main proposition consists in a first-line anti-tuberculosis empirical treatment, that has to be evaluated after four weeks, and switched with steroids (prednisone, 1 mg/Kg/d) in case of failure. This study is not an expert proposition but contributes to suggest clinical practice guidelines for a rare, complex, heterogenous, and typically internist situation.
Agard
C
C
Service de Médecine Interne, CHU Hôtel-Dieu, place Alexis-Ricordeau, 44093 Nantes cedex 01, France. christian.agard@chu-nantes.fr
Pottier
P
P
Hamidou
M
M
Papo
T
T
Généreau
T
T
de Faucal
P
P
Boutoille
D
D
Ponge
T
T
Connault
J
J
Brisseau
J-M
JM
Planchon
B
B
Barrier
J-H
JH
D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use; D000328:Adult; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000627:therapeutic use; D001706:Biopsy; D004359:Drug Therapy, Combination; D005602:France; D006099:Granuloma / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology; D006505:Hepatitis / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology; D006529:Hepatomegaly / Q000175:diagnosis / Q000473:pathology; D006801:Humans; D007388:Internal Medicine; D008099:Liver / Q000473:pathology; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011241:Prednisone / Q000008:administration & dosage / Q000627:therapeutic use; D012955:Societies, Medical; D011795:Surveys and Questionnaires; D013997:Time Factors; D014375:Tuberculoma / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology
D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents; D000893:Anti-Inflammatory Agents; D000995:Antitubercular Agents; D011241:Prednisone