[Reservoirs and transmission of Pseudomonas aeruginosa in intensive care unit]. / Réservoirs et transmission de Pseudomonas aeruginosa en réanimation médicale.

OBJECTIVE: The authors had for aim to study reservoirs and transmission of Pseudomonas aeruginosa in an intensive care unit. DESIGN: A 6-month prospective descriptive study was made on water samples, samples from hands of health care workers, and clinical samples. P. aeruginosa strains were compared by pulsed-field gel electrophoresis. RESULTS: Among the 211 patients hospitalized during the study, 14 (6.6%) were infected by P. aeruginosa. Out of 494 water samples, 80 were contaminated by P. aeruginosa. The regularly disinfected water taps were more rarely contaminated than the others (P<10(-5)). Out of 140 hand samples, one showed contamination from an infected patient. CONCLUSIONS: aeruginosa cross transmission was observed during this study. We should follow strict hygienic precautions such as wearing gloves and performing thorough alcoholic rub disinfection. Water taps are often contaminated and require regular disinfection.

[Endocarditis due to Pasteurella sp. Two cases]. / Endocardites à Pasteurella sp. Deux cas.

Human pasteurellosis is, in general, a locoregional infection due to contact with an animal. Systemic infections are rare and endocarditis is exceptionally described. The authors report two new cases of endocarditis due to Pasteurella spp, they then review 29 other published cases. Pasteurella spp. endocarditis presents as an acute form in 64% of cases and affects the aortic as often as the mitral valves. Contact with an animal is documented in 65% of cases. Pasteurella multocida is the most frequent species in this infection. The total death rate is 40% and can reach 57% of cases in case of immunodepression. The bad prognosis of this infection, justifies an early diagnosis and a rapid and adapted but not yet consensual medicosurgical treatment.

[Leptospirosis and thrombocytopenia]. / Leptospirose et thrombopénie.

INTRODUCTION: Leptospirosis is a worldwide zoonosis caused by the spirochete Leptospira interrogans. The spectrum of symptoms reported in leptospirosis is extremely broad. Thrombocytopenia is common during the acute phase of leptospirosis but its pathophysiological mechanism remains not well defined. CASE REPORT: We report a 56-year-old man hospitalized for severe sepsis with acute kidney injury and liver failure. Because of the recent flood of his house, we suspected leptospirosis. The diagnosis was rapidly confirmed. Blood tests revealed thrombocytopenia at 9 G/L associated with hyperferritinemia and hypertriglyceridemia. Cytological examination of bone marrow showed abundance of megakaryocytes and hemophagocytosis which confirmed the diagnosis of hemophagocytic syndrome. Clinical symptoms resolved and blood tests returned to normal values in the same time. CONCLUSION: We suggest that hemophogocytosis is a possible mechanism of thrombocytopenia in leptospirosis and that examination of bone marrow should be performed to confirm the diagnosis.

Prognostic score of short-term survival in HIV-infected patients admitted to medical intensive care units.

A retrospective cohort was set up to identify prognostic factors associated with in-hospital survival in HIV-infected patients admitted to medical intensive care units (MICUs), from 1991 to 1994. Survival from MICU admission to hospital discharge (or in-hospital fatal issue) was estimated and a prognostic score at MICU admission was developed. One hundred and thirty patients were recruited of whom 20% were AIDS-free prior to admission. In-hospital mortality rate was 65%. Median survival was 20 days. The following variables were predictive of mortality: Simplified Acute Physioloy Score II (SAPS II): (hazard ratio [HR]=1.5 for 10 points higher, P<10(-3)), time between HIV diagnosis and admission >5 years (HR=2.7, P<10(-4)), hypoalbuminaemia (HR=1.2 per 5 g/l lower, P=0.03). The prognostic score developed was: SAPS II+25 (if time between HIV diagnosis and MICU admission >5 years) albuminaemia (g/l). A new prognostic score including SAPS II, prior HIV history and albuminaemia better reflected the in-hospital mortality than SAPS II alone. Our findings may still be useful to better evaluate the immediate prognosis of current HIV-infected patients admitted to MICU, particularly those naive to antiretroviral therapy or in treatment failure.

[Acute cardiac insufficiency and toxoplasmosis]. / Insuffisance cardiaque aiguë et toxoplasmose.

The authors report the case of a 21-year old, non-immunocompromised girl who presented with severe acute heart failure associated with Toxoplasma infection. The outcome was favourable: cure without sequelae was obtained in a few months with a symptomatic and specific treatment consisting of spiramycin and methylprednisolone. This case is interesting for several reasons. The occurrence of such an acute heart disease is extremely rare in patients with toxoplasmic myocarditis, and so is the presence of a septal focus suspected on the basis of a predominantly septal hypokinesia at echocardiography and of enzymatic changes. The development of an acute heart failure should suggest a diagnosis of toxoplasmic myocarditis, which is rare but important since a specific treatment is available.

[Arrhythmia in relation to acute alcoholic intoxication in the absence of obvious cardiopathy]. / Arythmies en relation avec une intoxication alcoolique aiguë en l'absence de cardiopathie évidente.

Following acute intoxication with alcohol, 8 patients developed 16 episodes of arrhythmia, including 15 supraventricular tachycardias and one torsade de pointe. Seven of the 8 patients were chronically abusing of alcoholic drinks. None of the patients had clinically obvious cardiac pathology nor echocardiographic evidence of myocardiopathy. In 7 of them, however, baseline electrocardiograms disclosed disorders of intra-atrial conduction. The role of the different factors which might determine the occurrence of arrhythmia (notably alcohol, the autonomic nervous system, associated metabolic abnormalities and absorption of medicines) is discussed.

[Plasma Neutrophil Gelatinase-Associated Lipocalin (NGAL) predicts acute kidney injury in septic shock at ICU admission]. / Le dosage plasmatique de Neutrophil Gelatinase-Associated Lipocalin (NGAL) prédit la défaillance rénale au cours du choc septique dès l'admission en réanimation.

PURPOSE: To validate plasma Neutrophil Gelatinase-Associated Lipocalin (pNGAL) as an early biomarker in intensive care unit (ICU) for acute kidney injury (AKI) in critically ill adult with septic shock. PATIENTS AND METHOD: Fifty consecutive patients with septic shock were included in this observational cohort study. AKI was defined if patients met any RIFLE or AKIN criteria. The main objective was to evaluate diagnosis value of pNGAL measured with a point-of-care device at admission (D0), at 24hours (D1) and at 48hours (D2). RESULTS: Among the 50 patients enrolled, 86% had AKI, 48% had persistent renal AKI and 30% required renal replacement therapy (RRT) during their ICU stay. At D0, pNGAL concentration was significantly higher in patients with AKI compared to patients without AKI (471ng/mL versus 134ng/mL, P<0.001). This level remained significantly higher in the AKI population at D1 and D2 and pNGAL concentration at D0 among AKI patients increased with kidney failure level. At D1, pNGAL was significantly higher for persistent renal AKI rather than transient prerenal (570ng/mL versus 337ng/mL, P=0.027). pNGAL concentration below 348ng/mL at D1 was never seen in patients with RRT. CONCLUSION: Plasma NGAL is a useful, sensitive and early biomarker to predict persistent AKI in septic shock at ICU admission and help to discuss RRT.

[One hundred and fifteen cases of imported falciparum malaria admitted at the Bordeaux teaching hospital Emergency Unit]. / Cent quinze cas de paludisme d'importation àPlasmodium falciparum admis en service d'urgence au CHU de Bordeaux.

OBJECTIVES: The authors had for objective to evaluate the management of a Plasmodium falciparum malaria in a Bordeaux teaching hospital EU. METHODS: One hundred and fifteen patients with falciparum malaria admitted between January 2004 and October 2006 were retrospectively studied and those with ambulatory treatment were questioned by phone. RESULTS: Fifty per cent of patients had consulted a community physician prior to admission, and a parasitic test was made for 50 % of these. In seven (27 %) cases the test was wrong. Twenty-seven (87 %) of ambulatory patients were contacted by phone. Eleven (41 %) of these said they were not aware of the potential disease severity. Patients initially treated in ambulatory care and later hospitalized because of their evolution have either insisted to go back home or have been sent home because there was not enough room in the hospital. Hospitalization for at least 24 hours had been indicated for 83 patients (72 %). Twelve patients (10 %) have presented with symptoms of severe malaria. Atovaquone-proguanil was the main therapeutic regimen for inpatients and outpatients (n=93, 81 %). Twelve (10 %) patients did not undergo follow-up parasitological assessment, 10 ambulatory patients (32 %) and two hospitalized patients (2 %). CONCLUSION: An efficient hospital-community network and recent protocols are the best tools to rapidly refer patients to an adapted structure with available trained staff and referent specialist.

Left ventricular function in chronic obstructive pulmonary disease.

Left ventricular function was studied at rest and during post-extrasystolic potentiation (PESP) in 18 patients with chronic obstructive lung disease. The contractility indices were obtained from pressures recorded in the osovolumetric period and from volume variations during ejection. All patients were hypoxic; six of them had cor pulmonale (group B); the remaining 12 patients constituted group A. Left ventricular function was similar in both groups; it is concluded that right heart failure in cor pulmonale is not secondary to left ventricular failure. Left ventricle was hypertrophied and pump function altered, but left ventricular kinetics was normal or increased. Isovolumetric phase contractility indices were decreased; they may increase during PESP. Left ventricular compliance was altered due to left and right ventricular hypertrophy and to paradoxical movement of interventricular septum which impeded diastolic expansion of left ventricle. The impairment of left ventricular function seems to be related to both intrinsic (hypoxia, hypercapnia, hypertrophy) and extrinsic factors (right ventricular hypertrophy with deviation of interventricular septum, lowering of left ventricular preload).

Effects of nitric oxide inhalation on pulmonary serial vascular resistances in ARDS.

The pulmonary vasculature site of action of nitric oxide (NO) in patients with acute respiratory distress syndrome (ARDS) is still unknown. Seven patients were studied during the early stage of ARDS. The bedside pulmonary artery single-occlusion technique, which allows estimation of the pulmonary capillary pressure (Pcap) and segmental pulmonary vascular resistance, was used without NO or with increasing inhaled NO concentrations (15 and 25 parts per million [ppm]). Systemic circulatory parameters remained unaltered during 15 ppm NO inhalation, whereas 25 ppm NO inhalation slightly decreased mean systemic arterial pressure from 76.7 +/- 5.1 (mean +/- SEM) to 69 +/- 5.2 mm Hg (p < 0.01). Mean pulmonary arterial pressure (Ppam) and mean pulmonary capillary pressure (Pcapm) fell during 25 ppm NO inhalation from 27.4 +/- 3.5 to 21 +/- 2.2 mm Hg (p < 0.001) and from 14.8 +/- 1.5 to 10.7 +/- 1.4 mm Hg (p < 0.001) respectively, the total pulmonary resistance decreased by 28% (p < 0.01). The resistance of the capillary-venous compartment fell during 25 ppm NO inhalation from 100 +/- 16 to 47 +/- 16 dyn x s x m(2) x cm(-5) (p < 0.01), whereas the pulmonary arterial resistance was unchanged. In these patients NO inhalation during the early stage of ARDS reduces selectively Ppam and Pcapm by decreasing the pulmonary capillary-venous resistance. This latter effect may reduce the filtration through the capillary bed and hence alveolar edema during ARDS.

[Left ventricular function in chronic obstructive lung disease (author's transl)]. / La fonction ventriculaire gauche au cours des bronchopneumopathies chroniques obstructives.

Left ventricular function was studied at rest and during post-extrasystolic potentiation in 18 patients with chronic obstructive lung disease. The contractility indices used were obtained from pressures recorded in the isovolumetric period (left ventricular end-diastolic pressure, Vmax., VECmax., dP/dtmax.) and from volume variations during ejection (end-diastolic volume, ejection fraction, VCF). Left ventricular diastolic compliance was also evaluated. All patients were hypoxic (PaO2 = 58 +/- 7 torr); six of them had cor pulmonale (group B); the remaining 12 patients constituted group A. Left ventricular function of groups A and B was similar; we conclude that right cardiac failure, in cor pulmonale, is not secondary to left ventricular failure. However, left ventricular dysfunction exists; the left ventricle is hypertrophied (probably resulting from chronic hypoxia). Pump function is altered (abnormal ventricular function points are found), but left ventricular kinetics is normal or exaggerated (ejection fraction and VCF are increased). Isovolumetric phase contractility indices are diminished; however, they may increase normally during post-extrasystolic potentiation. Left ventricular compliance is abnormal due to left and right ventricular hypertrophy and to paradoxical movement of the interventricular septum which impedes diastolic expansion of the left ventricle. These changes are responsible for decreased left ventricular output. There seems to exist an impairment of left ventricular function related to both intrinsic (secondary to hypoxia, hypercapnia, left ventricular hypertrophy) and extrinsic factors (right ventricula hypertrophy deviating interventricular septum, lowering of left ventricular preload).