[Refractory thrombotic thrombocytopenic purpura revealing an epiglotis neoplasia]. / Purpura thrombotique thrombocytopénique réfractaire révélant un cancer de l'épiglotte.

Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy with neurological disorder which incidence is relatively rare. Since the discovery of the ADAMTS 13 in 1996 and the changes in the treatment (plasma exchanges and rituximab), the prognosis of the TTP has considerably improved. We report the case of a 60-year-old man with a refractory TTP. The subsequent discovery of an epiglottis neoplasia and its treatment saved the patient.

[Disseminated strongyloidiasis with parasitemia in a patient under corticosteroid-treatment]. / Anguillulose disséminée avec parasitémie chez un patient sous corticothérapie.

We report a case of disseminated strongyloidiasis with parasitemia in a 53-year-old man under corticosteroid therapy. It occurred more than 16years after contamination and led to severe sepsis and acute respiratory failure with P. aeruginosa pneumonia. The patient recovered after specific treatment (thiabendazole followed by albendazole) and antibacterial drugs.

[A mixed acid-base disorder revealing a cystic dystrophy of aberrant pancreatic tissue]. / Un trouble métabolique complexe révélateur d'une dystrophie kystique sur pancréas aberrant.

We report about a patient presenting with a mixed acid-base disorder. His blood gas analysis showed a metabolic acidosis caused by renal failure and lactic acidosis combined with a hypochloraemic alkalosis. The underlying pathology was a cystic dystrophy of aberrant pancreatic tissue leading to excessive vomiting, extracellular dehydration with a renal failure and hypochloraemia.

Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. The Association of Non-University Affiliated Intensive Care Specialist Physicians of France.

Low molecular weight heparins are as effective as unfractionated heparin in deep-vein thrombosis (DVT) prophylaxis for major surgery. However, there is no evidence nor consensus for prophylaxis in medical patients. We compared the efficacy and safety of nadroparin calcium (nadroparin) with placebo in medical patients at high risk of DVT. A total of 223 patients mechanically ventilated for acute, decompensated chronic obstructive pulmonary disease, were randomized to treatment with subcutaneous nadroparin adjusted for body weight (0.4 ml, i.e., 3,800 AXa IU, or 0.6 ml, i.e., 5,700 AXa IU) or placebo. The average duration of treatment was 11 d. The incidence of DVT in patients receiving nadroparin was significantly lower than that in patients receiving placebo (15.5 versus 28.2%; p = 0.045). Although the incidence of adverse events was high in both groups, there were no significant differences between nadroparin and placebo for total adverse events (46.3 versus 39.8%; p = 0.33), serious adverse events (25.0 versus 19.5%; p = 0.32), or those resulting in early permanent discontinuation of treatment (12.0 versus 8.8%; p = 0.44). The most common adverse event was hemorrhage. There was the same number of deaths in both treatment groups. Subcutaneous nadroparin resulted in 45% decrease in incidence of DVT compared with placebo.

[Intracranial hypertension in severe diabetic ketoacidosis with coma. Two cases]. / Hypertension intracrânienne au cours de l'acidocétose diabétique grave avec coma. Deux observations.

We observed two cases of severe diabetic ketoacidosis with coma and shock. In one case, coma was present at admission and in the second occurred within 15 hours. In both cases, intracranial hypertension was confirmed with an extradural captor. These findings are in agreement with observations of brain oedema in diabetic ketoacidosis with coma. Clinical data suggest that brain oedema may occur after a latency period but that clinical expression is much more rare, perhaps favoured by treatment (excessive rehydratation, alkalinization, too sharp drop in blood glucose level). In our cases, despite major fluid infusion, shock persisted requiring norepinephrine. This shock could have been the expression of the severe ketoacidosis or have resulted from an underlying infection. In case of sudden onset coma, a regularly encountered manifestation of brain oedema, respiratory assistance and mannitol infusion must be instituted rapidly. With this type of management, it should be possible to improve the severe prognosis of brain oedema in diabetic ketoacidosis.

[Candidal bezoar of the urinary tract during Candida albicans septicemia]. / Bézoard candidosique des voies urinaires au cours d'une septicémie à candida albicans.

We report a case of an obstructing fungus ball of the urinary tract. Typical predisposing factors were present, i.e. bladder catheter, vesico-ureteral reflux, urinary infection, parenteral nutrition, prolonged antibiotherapy, hyperglycemia. Candida albicans septicemia was noted. Diagnosis was made by percutaneous nephrostomy under echographic control allowing urinary sampling (C. albicans) and anterograde pyelography showing an ureteral stenosis. Urinary drainage and local and general administration of amphotericin lead to a complete resolution of the fungus ball and the systemic candidiasis.

[Non-cardiogenic pulmonary edema after transfusion of plasma containing an anti-HLA-B21 antibody]. / Oedème pulmonaire non cardiogénique après transfusion de plasma contenant un anticorps anti-HLA-B21.

A patient with a von Willebrand factor deficiency received three units of fresh frozen plasma during a postoperative period. During the last unit transfusion she developed a severe respiratory distress and non cardiac pulmonary edema was diagnosed based upon the clinical, radiological and hemodynamic findings. Reintubation and mechanical ventilation with end-expiratory pressure were instituted leading to a complete and rapid recovery within 48 h. The serum from the last plasma donor contains an anti-HLA-B21 lymphocytotoxic antibody that did agglutinate neutrophils from HLA-B21 positive individuals. The patient's HLA type was B21. The concerned donor was a IVpar Igeste female. Two problems are evoked by this observation with regard to transfusion: first, fresh-frozen plasma was used as an inappropriate treatment for a coagulating factor deficiency, second, exclusion of this donor from a classical blood donation is needed.

[Pseudomonas cepacia septicemias: therapeutic difficulties]. / Septicémies à Pseudomonas cepacia: difficultés thérapeutiques.

From Summer 1983 to Summer 1986, 34 cases of septicemia due to Pseudomonas cepacia could be detected in several intensive care units in the university hospital in Clermont-Ferrand (France). Intravascular catheters can be involved in the inoculation of this bacterial agent: a previous respiratory tract infection or a drained abscess can be the portal of entry of the bacteremia. Three patients died from the septicemia and the overall prognosis of the intensive care patients looks significatively worsened. The removing of the catheters and drains, the opening of an infected collection were useful but not sufficient to overcome. The choice of a good antibiotic was not easy; only ceftazidime, minocycline and cotrimoxazole have a fair activity in vitro. We only assessed the good results of ceftazidime. Pseudomonas cepacia is also resistant for many antiseptics. The large use of disinfecting procedures in intensive care units promotes the diffusion of this bacteria.

[Diagnosis of amniotic embolism by bronchoalveolar lavage]. / Diagnostic de l'embolie amniotique par lavage broncho-alvéolaire.

A broncho-alveolar lavage performed in a patient who developed pulmonary oedema a few hours after a caesarian section, produced foetal squamae which led to the diagnosis of amniotic fluid embolism.

[A simplified severity index in resuscitation. Validation by a prospective study (280 cases)]. / Un indice de gravité simplifié en réanimation. Validation par une étude prospective (280 cas).

The index studied (simplified acute physiology score, or SAPS) is calculated from 14 measurable clinical and laboratory data obtained during the first 24 hours from admission. It was tested in a prospective study involving 280 consecutive patients treated in a 16-bed intensive care unit. Good correlations were found between SAPS and mortality rate and between SAPS and the two most widely used scoring systems: the Knaus index or APS (acute physiology score) and the Cullen index or TISS (therapeutic intervention scoring system), both evaluating therapeutic effectiveness. SAPS data being easy to collect, the simplified index could be used in many intensive care units or even applied to old case-records. Its main value lies in comparisons between two groups of patients with the same death probability and in evaluations of activities in intensive care units.

[Fatal poisoning by alcohol-free aniseed aperitif]. / Intoxication mortelle par le pastis sans alcool.

A case of chronic poisoning with alcohol-free "pastis" leading to the death of a 32 year old alcoholic patient is reported. The mean daily amount of ingested glycyrrhizinic acid was 0.35 g. "Torsades de pointes" secondary to severe hypokalemia were observed and prolonged cardiac arrest occurred. There was evidence of chronic hypokalemic myopathy and of rhabdomyolysis with acute renal failure. Furthermore, the origin of an associated cardiomyopathy is discussed.

[Diagnosis of trismus, excluding tetanus and local causes]. / Diagnostic des trismus à l'exclusion du tétanos et des causes locales.

The most frequent causes of trismus are tetanus and local lesions. This report discusses other etiologies. Trismus is usually only a secondary sign of a rich clinical picture, but may be of diagnostic value in some cases. Emphasis is placed on the frequency of involvement of neuroleptic intoxication, the early onset of trismus in the malignant hyperthermia syndrome, and on the useful role of trismus in the localization of neurological lesions.