Risk Factors of AKI in Acute Respiratory Distress Syndrome: A Time-Dependent Competing Risk Analysis on Severe COVID-19 Patients.

Introduction: Acute kidney injury (AKI) is frequently observed in patients with COVID-19 admitted to intensive care units (ICUs). Observational studies suggest that cardiovascular comorbidities and mechanical ventilation (MV) are the most important risk factors for AKI. However, no studies have investigated the renal impact of longitudinal covariates such as drug treatments, biological variations, and/or MV parameters. Methods: We performed a monocentric, prospective, longitudinal analysis to identify the dynamic risk factors for AKI in ICU patients with severe COVID-19. Results: Seventy-seven patients were included in our study (median age: 63 [interquartile range, IQR: 53-73] years; 58 (75%) men). Acute kidney injury was detected in 28 (36.3%) patients and occurred at a median time of 3 [IQR: 2-6] days after ICU admission. Multivariate Cox cause-specific time-dependent analysis identified a history of hypertension (cause-specific hazard (CSH) = 2.46 [95% confidence interval, CI: 1.04-5.84]; P = .04), a high hemodynamic Sequential Organ Failure Assessment score (CSH = 1.63 [95% CI: 1.23-2.16]; P < .001), and elevated Paco2 (CSH = 1.2 [95%CI: 1.04-1.39] per 5 mm Hg increase in Pco2; P = .02) as independent risk factors for AKI. Concerning the MV parameters, positive end-expiratory pressure (CSH = 1.11 [95% CI: 1.01-1.23] per 1 cm H2O increase; P = .04) and the use of neuromuscular blockade (CSH = 2.96 [95% CI: 1.22-7.18]; P = .02) were associated with renal outcome only in univariate analysis but not after adjustment. Conclusion: Acute kidney injury is frequent in patients with severe COVID-19 and is associated with a history of hypertension, the presence of hemodynamic failure, and increased Pco2. Further studies are necessary to evaluate the impact of hypercapnia on increasing the effects of ischemia, particularly in the most at-risk vascular situations.

Introduction: L'insuffisance rénale aiguë (IRA) est fréquemment observée chez les patients atteints de COVID-19 admis dans les unités de soins intensifs (USI). Des études observationnelles suggèrent que les comorbidités cardiovasculaires et la ventilation mécanique (VM) seraient les plus importants facteurs de risque de l'IRA. Aucune étude n'a cependant examiné l'impact sur la fonction rénale de covariables longitudinales telles que les traitements médicamenteux, les variations biologiques et/ou les paramètres de la VM. Méthodologie: Nous avons procédé à une analyse prospective et longitudinale dans un seul centre hospitalier afin d'identifier les facteurs de risque dynamiques de l'IRA chez les patients hospitalisés aux USI en raison d'une forme grave de la COVID-19. Résultats: Soixante-dix-sept patients ont été inclus dans notre étude (75 % d'hommes [n=58]; âge médian: 63 ans [ÉIQ: 53-73]). L'IRA a été détectée chez 28 patients (36,3 %) et est survenue dans un délai médian de 3 jours (ÉIQ: 2-6 jours) après l'admission à l'USI. Une analyse de Cox multivariée, spécifique à la cause et tenant compte du temps, a permis de dégager les éléments suivants comme étant des facteurs de risque indépendants pour l'IRA: des antécédents d'hypertension (probabilité par cause [PPC]=2,46 [IC 95 %: 1,04-5,84]; p=0,04), un score SOFA hémodynamique élevé (PPC=1,63 [IC 95 %: 1,23-2,16]; p<0,001) et une concentration élevée de PaCO2 (PPC=1,2 [IC 95 %: 1,04-1,39] pour chaque augmentation de 5 mmHg de pCO2; p = 0,02). En ce qui concerne les paramètres de la VM, une pression expiratoire positive (PPC=1,11 [IC 95 %: 1,01-1,23] pour chaque augmentation de 1 cm H2O; p = 0,04) et l'utilisation d'un bloc neuromusculaire (PPC=2,96 [IC 95 %: 1,22-7,18]; p=0,02) ont été associés à l'IRA dans l'analyse univariée seulement, et non après ajustement. Conclusion: L'IRA est fréquente chez les patients atteints d'une forme grave de COVID-19 et elle est associé à des antécédents d'hypertension, à la présence d'une instabilité hémodynamique et à une augmentation de la pCO2. D'autres études sont nécessaires pour évaluer l'impact de l'hypercapnie sur l'augmentation des effets de l'ischémie, en particulier dans les situations vasculaires les plus à risque.

13q31.1 microdeletion: A prenatal case report with macrocephaly and macroglossia.

We report on a female fetus with macrocephaly and macroglossia harbouring 13q31.1 microdeletion encompassing three genes: SPRY2, NDFIP2 and RBM26. NDFIP2 protein is involved in ubiquitination and in Ras/mitogen-activated protein kinase (MAPK) signaling pathways. SPRY2 protein is part of Sprout protein family and inhibits the Ras/MAPK pathways. Ras/MAPK pathway plays important role in complex cellular programs including cell differentiation and proliferation. Germline mutations in genes encoding protein involved in the MAPK cascade is responsible for a wide family of developmental disorders known as RASopathies. Some RASopathies, such as Costello syndrome, present a phenotype with (relative) macrocephaly as perinatal features. However, prenatal-onset macroglossia are generally absent in this syndrome but rather suggestive of the Beckwith-Wiedemann syndrome for which molecular testing were negative. Phenotype-genotype correlation with patients from DECIPHER defines NDFIP2 and SPRY2 as a possible candidate genes for a RASopathy potentially responsible for the clinical features in the fetus. Finally, this original case of 13q31.1 microdeletion underlines the importance of array-CGH in prenatal diagnosis with sonographic signs such as macroglossia and/or macrocephaly. In this case, genetic investigation should be not limited to the search of well-known genetic causes and other genomic microdeletions should be considered as alternative diagnoses for macroglossia.

Filamentous fungi recovered from the water distribution system of a Belgian university hospital.

A study was carried out over a 4-month winter period in order to assess the presence of filamentous fungi in the water distribution system of the University Hospital of Liège. A total of 197 hot and cold water samples were collected from the main water supply lines and from the taps at three different hospital sites. Overall, filamentous fungi were recovered from 55% and 50% of the main water distribution system and tap water samples, respectively, with a mean of 3.5 ± 1.5 colony forming units per 500 ml water. Nine different genera were identified, all belonging to the Hyphomycetes class. Aspergillus spp. were recovered from 6% of the samples of the water distribution system and A. fumigatus was the most frequently recovered species (66.6%). However, this species was not isolated from water taps. Fusarium spp. was predominant at one site, where it was found in 28% of tap water samples. No Aspergillus spp. but some Fusarium spp. isolates were identified in samples collected from high-risk units. Filters were introduced at the point-of-use in the haematology unit after completion of the study. The findings of the present study confirm the need for further documented studies to evaluate the safety of the hospital water system and to define new preventive measures.

Pulmonary superinfection by trichomonads in the course of acute respiratory distress syndrome.

The finding of trichomonads in bronchoalveolar lavage fluid (BALF) samples from an acute respiratory distress syndrome (ARDS) patient, never previously reported, incited us to search for these parasites retrospectively in the BALF of patients with ARDS or related pathologies. Eighty-four consecutive BALF samples have been reviewed. Results were compared with data from clinical files of patients included in this study. Detection and identification of trichomonads were based on cytologic characteristics. Subsequently, immunocytochemistry and in situ hybridization were performed in the last case of the series. Our results were as follows: (1) Trichomonads were detected in 25/84 BALFs (20/77 patients). Among the patients testing positive, 17 suffered from ARDS, about 30% of the ARDS patients included in the study. (2) Trichomonads were detected more frequently at a late ARDS stage. (3) No correlation was found between trichomonad detection and other data. (4) Within the group of trichomonad-infected ARDS patients, density of infection correlated with higher mortality. The late detection of these microorganisms in the course of ARDS suggested that trichomonad development is a secondary event. As BALFs obtained early in the course of ARDS were also included in the study, trichomonad incidence could be underestimated. The significance of trichomonad lung colonization in ARDS and its potential pathogenic role are unclear. Nevertheless, the question of an active role of trichomonads in the extension of alveolar lesions or in the limitation of recovery is clearly raised.

Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients.

OBJECTIVE: To evaluate the extent to which respiratory changes in inferior vena cava (IVC) diameter can be used to predict fluid responsiveness. DESIGN: Prospective clinical study. SETTING: Hospital intensive care unit. PATIENTS: Twenty-three patients with acute circulatory failure related to sepsis and mechanically ventilated because of an acute lung injury. MEASUREMENTS: Inferior vena cava diameter (D) at end-expiration (Dmin) and at end-inspiration (Dmax) was measured by echocardiography using a subcostal approach. The distensibility index of the IVC (dIVC) was calculated as the ratio of Dmax - Dmin / Dmin, and expressed as a percentage. The Doppler technique was applied in the pulmonary artery trunk to determine cardiac index (CI). Measurements were performed at baseline and after a 7 ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in CI > or =15%) and non-responders (increase in CI <15%). RESULTS: Using a threshold dIVC of 18%, responders and non-responders were discriminated with 90% sensitivity and 90% specificity. A strong relation (r = 0.9) was observed between dIVC at baseline and the CI increase following blood volume expansion. Baseline central venous pressure did not accurately predict fluid responsiveness. CONCLUSION: Our study suggests that respiratory change in IVC diameter is an accurate predictor of fluid responsiveness in septic patients.

High-dose intravenous immunoglobulin treatment in two patients with acquired factor V inhibitors.

We report two patients who developed acquired factor V (FV) inhibitors not related to exposure to bovine thrombin. Associated conditions were found in one patient (surgery, antibiotic administration) but none in the other one. Bleeding complications occurred only in the patient with idiopathic FV inhibitor, leading to packed red cell infusion. Laboratory findings showed the presence of specific FV inhibitors with titers of 5.5 and 5 Bethesda units, respectively. These two patients received high-dose intravenous immunoglobulin and FV levels normalized within a few days with a concomitant disappearance of FV inhibitors.

Fatal acute cellulitis due to Neisseria meningitidis.

We describe the first fatal evolution of cellulitis due to Neisseria meningitidis serogroup Y involving an 85-year-old woman. She presented with an extensive cellulitis of the left side of the face, neck, and thorax and septic shock. In spite of active antibiotic therapy, evolution was rapidly fatal.