Treatment of severe tetanus by intrathecal injections of baclofen without artificial ventilation.

A study was conducted to evaluate repeated intrathecal injections of baclofen, without artificial ventilation, in the treatment of severe tetanus. Ten patients, 5 men and 5 women, with a mean age of 34 +/- 7 years, were included in the study. The dose of baclofen injected was 1000 micrograms between the ages of 16 and 55 years, 800 micrograms over the age of 55 years and 500 micrograms under the age of 16 years. The efficacy was assessed on the basis of the resolution of contractures and paroxysms and the initial dose was reinjected prior to the reappearance of these symptoms. Treatment was discontinued in the case of central nervous system depression or inefficacy. The first injection was effective in 9 cases for 24-48 h. The haemodynamic safety was always good. Five patients developed central depression with coma and respiratory depression, requiring artificial ventilation in 3 cases and reversed by flumazenil in 2 cases. Five patients were treated exclusively with baclofen with 4 cures. Five patients had to be ventilated with only one cure. This study confirms earlier studies concerning the efficacy of intrathecal baclofen in tetanus. However, the frequency of episodes of respiratory depression prevents the recommendation of repeated injections when respiratory intensive care facilities are not available.

Severe malaria in African adults living in a seasonal endemic area.

OBJECTIVE: This study investigates severe malaria in African adults living in a seasonal endemic area. DESIGN: A prospective study of all adults admitted with severe malaria over 2 consecutive seasons: October 1990 till January 1991 and October 1991 till January 1992. SETTING: ICU (15 beds) of Hôpital Principal, Dakar, Sénégal. PATIENTS: 23 patients: 14 men and 9 women with a mean age of 30 +/- 3 years were included in the study; all fulfilled the 1990 WHO criteria for severe malaria. RESULTS: At admission, 12 patients were comatose (Glasgow Coma Scale < 10), 7 had generalized convulsions. Parasitaemia was 135 +/- 52 x 10(9)/l. Biological indications of severity were as follows: hypophosphataemia < 0.8 mmol/l in 14 cases, serum creatine phosphokinase > 500 IU/l in 15 cases; and PaO2 < 70 mmHg in 5 cases. Serum TNF alpha levels, measured in 16 cases, were increased at 298.4 +/- 63.5 pg/ml, serum levels of IL-6 and IL-2SR were also elevated: 609.5 +/- 304.2 pg/ml and 297.6 +/- 35.6 pg/ml respectively. Circulating IgM and IgG antibodies were found in 14 out of 16 patients. Serum levels of TNF alpha, IL-6 and IL-2SR correlated positively with each other. TNF alpha and IL-2SR were also positively correlated to parasitaemia. Intravenous therapy with quinine at loading dose was favorable in 19 patients. Four patients died during the study, 3 from multiple organ failure. CONCLUSIONS: This work demonstrated that severe malaria in a seasonal endemic area displays original clinical features with a high rate of either cerebral malaria or multiple organ failure.

[Severe acute asthma in adults in black Africa]. / Asthme aigu grave de l'adulte en Afrique noire.

A prospective study has been conducted in an intensive care unit of West Africa in order to determine the clinical and laboratory features of severe acute asthma in black Africans. The study concerned 55 episodes of severe acute asthma, with PaCO2 above 45 mmHg, in 42 patients (26 men and 16 women, mean age 35 +/- 3 years). A triggering factor was found in only 36 percent of the cases. None of the patients were using beta-adrenergic stimulants as maintenance therapy. The mean duration of asthmatic attacks prior to hospitalization was 49 +/- 7 hours. Three patients had cardiorespiratory arrest on admission. Mechanical ventilation was necessary on 12 occasions (initially in 4 and secondarily in 8). Four patients died. It would appear from this study that severe acute asthma in black Africans is characterized by a prolonged onset and by a frequent need for mechanical ventilation, suggesting a physiopathological mechanism different from that described in industrialized countries.

[Effects of diazepam on mortality from acute chloroquine poisoning]. / Effets du diazépam sur la mortalité des intoxications aiguës par la chloroquine.

A retrospective study was carried out, over a twelve-year period, of all cases of acute chloroquine poisoning where more than 2 g of chloroquine had been taken. It included 386 patients; of these, 60 who had taken drugs other than chloroquine, and 17 who had ingested less than 1 g of the drug, were excluded. The remaining 309 patients were allocated to two groups: a "control group", consisting of the patients admitted between January 1973 and April 1980 (n = 146), and a "diazepam group", made up of those admitted from May 1980 to December 1989 (n = 163). The patients in the latter group had had the same symptomatic treatment as those in the control group, and had been routinely given a 0.5 mg.kg-1 bolus of diazepam on admission followed by 0.1 mg.kg-1.day-1 for every 100 mg of chloroquine supposed to have been ingested. Both groups were divided into three subgroups, those patients with cardiorespiratory arrest, and those with, and those without, symptoms on admission. No statistically significant difference was found between either the control and diazepam groups or between subgroups, concerning the distribution of age, sex, amount of chloroquine supposed to have been ingested, delay in hospital admission and death rate. However, there was a higher death rate in the asymptomatic subgroup not treated with diazepam than in the diazepam group. Therefore, the routine use of diazepam for the treatment of acute chloroquine poisoning does not seem to be justified in symptomatic cases and in those with inaugural cardiac arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

[Severe malaria in an African seasonal endemic area. Comparison of aspects in adults and children and prognostic value of cytokines]. / Paludisme grave en zone d'endémie saisonnière Africaine. Comparaison des formes de l'adulte et de l'enfant et valeur pronostique des cytokines.

OBJECTIVES: The present study was conducted in West Africa in a region where malaria exists as a seasonal endemic disease. The aim was to compare clinical and biological aspects of adult severe falciparum malaria with those found in children and to appreciate the role of cytokines a prognostic markers. Thirty-one patients fulfilling the WHO criteria of severe malaria were included. METHODS: Fifteen children (8 boys and 7 girls; mean age: 7.9 +/- 3.7 years) were compared with an adult group of 16 patients (9 men and 7 women; mean age: 31.1 +/- 14.5 years). The number of severe criteria and most of the biological features (glycaemia, parasitaemia, haemoglobin levels, platelet count) were similar in both groups. As regards immunological findings, serum levels of IgM and IgG were significantly increased in the adult group. Serum levels of TNF alpha, IL-6 and IL-2SR were similar (255.2 +/- 375.3 versus 298.4 +/- 254.1 pg/ml for TNF alpha, 534.6 +/- 642.7 versus 609.5 +/- 1217.0 pg/ml for IL-6, 253.1 +/- 120.5 versus 297.6 +/- 142.2 pg/ml for IL-2SR). Each of these cytokines correlated with the others and were also correlated to parasitaemia. Three children and two adults died during the course of the study. At admission a significant died during the course of the study. At admission a significant difference was observed between serum levels of TNF alpha (p < 0.01), IL-6 (p < 0.001) and IL-2SR (p < 0.05) in patients who were later survivors or non-survivors. CONCLUSION: This study confirms the prognostic significance of serum levels of TNF alpha, IL-6 and IL-2SR in severe malaria.

[Valium-aspegic association. Its value in a remote medical unit (author's transl)]. / L'association Valium-Aspegic. Intérêt en poste isolé.

An efficient narco-analgesia is given by the association of two drugs: -- diazepam (Valium): a benzodiazepine with an anxiolytic and myoresolutive effect, inducing sleep and giving amnesia; -- lysine acetylsalicylate (Aspegic) giving an analgesia inferior to that of morphinomimetic drugs but not inducing respiratory depression. These two drugs are given in an intravenous catheter. Their effects last about 20 minutes - vomiting is rare. The authors report their experience of 50 cases and think that this technique is recommended in remote medical units for moderately painful and short duration operations.

[Typhoid fever in a resuscitation department. Apropos of 42 cases]. / Les fièvres typhoïdes en service de reanimation. A propos de 42 cas.

A review is given on 42 cases of typhoid fever that were admitted in the "Hôpital Girard et Robic" anesthesia and resuscitation department in Tananarive, Madagascar, from 1979 to 1982. The authors have noticed: 18 digestive hemorrhages. 5 ileo-caecal perforations. 9 encephalitides. 16 myocarditides. 5 enterobacterial superinfections. The encephalitic complications and the enterobacterial superinfections are the cause of the very poor prognosis (5 fatalities). The authors recall the basic treatment of each of these complications. The rules of the antibiotic treatment are reviewed. In Tananarive, no resistance has been found to the following three antibiotics: ampicillin, chloramphenicol and sulfamethoxazole-trimetoprim. Finally, the authors lay emphasis on the necessity of a careful rehydratation and a high-level caloric and proteic artificial alimentation.

[Filarial meningoencephalitis: discussion of a case]. / Méningoencéphalite filarienne: discussion à propos d'un cas.

Loiasis treatment by diethylcarbamazine (DEC) may be complicated by a meningoencephalitis that is often fatal. Following one case, four others have been reviewed in the literature and the therapeutic approach in resuscitation departments discussed. Until the discovery of other less-dangerous microfilaricidal or macrofilaricidal drugs, we raise the question of the opportunity to treat loiasis by DEC, while many authors consider it as a simple nuisance.

[Malaria and surgery: which prophylaxis?]. / Paludisme et chirurgie. Quelle prophylaxie?

The authors report on a study carried out at the Centre Hospitalier universitaire (University Hospital) of Yaounde (Cameroon). Such a study aimed at to check interest of systematic malaria chemoprophylaxis during the peri-operative phase in general surgery. 61 patients were divided in two groups by random allocation with and without quinine chemoprophylaxis. All of them were monitored clinically and parasitologically during the peri-operative phase. Results show that in both groups, only patients already positive before surgical intervention presented clinical malaria signs, biologically confirmed; malaria attack was more frequent and more severe in the group without quinine. No malaria attack was observed in patients of both groups in which thick smear was negative in pre-operative phase. The authors suggest that any patient during the pre-operative phase, be tested to find out Plasmodium falciparum. If the test is positive, so chemoprophylaxis with quinine be prescribed. But such a medication is valuable only in urban endemic zone.

[Heroin-induced acute rhabdomyolysis]. / Rhabdomyolyse aiguë à l'héroïne.

A 24 year ald-man, was admitted in intensive care with coma and shock, 4 hours after intravenous injection of heroin. Awakening was obtained by naloxone. Diagnosis of acute rhabdomyolysis associated with heroin addiction was asserted by association of anury, hyperkalemia, and CPK increase. Recovery was obtained with, however, neurologic after-effects. Pathophysiology of acute rhabdomyolysis associated with heroin addict is obscure. Hypotheses for the cause of the muscle damage include the effects of toxicity (either directly or immunologically mediated) of the drug or an adulterant. However prolonged coma and immobilization in one position with either direct compression of the muscles or occlusions of the regional vascular supply can play a major role.

[Treatment of severe tetanus by repeated intrathecal injections of baclofen]. / Traitement du tétanos sévère par injections intrathécales itératives de baclofène.

A case of tétanos was treated through intrathecal injections of baclofen. This new technique was pioneered in Anglo-saxon countries and has made it possible in the present case to success fully treat a Mollaret's third-stage generalized tetanus, without a tracheotomy or controlled ventilation. Because of its simplicity low cost, this technique could be another way of treating African tetanus.

[Current aspects on cerebral malaria in the non-immune patient in African endemic areas]. / Aspects actuels du neuropaludisme chez le sujet non immun en zone d'endémie africaine.

The current clinical and therapeutic aspects of cerebral malaria in non-immune adult subjects living in endemic areas of Africa were evaluated in 10 men (mean age: 40 + or - 11, 4 years). On admission, 8 patients had fever, 3 were truly comatose with a Glasgow score of 7 or more. All had negative central venous pressure and only one was in a state of hyperkinetic shock. Respiratory symptoms were present in 8 cases, and jaundice was observed in 8 cases. Three patients has a haemoglobin level lower than 8 g/100 ml, and 8 had thrombocytopenia. Blood creatinine levels above 240 umol/l and blood bilirubin levels above 50 umol/l were found in 6 and 8 patients respectively. Plasma creatine phosphokinase was above 500 iu/l in 7 cases, and PaO2 was above 70 mmHg in 7 cases. All patients received quinine, combined with doxycycline in 6 cases. Infectious complications occurred in 5 patients, with 2 septic shocks. Two patients developed acute pulmonary oedema. Five patients died. This study shows that cerebral malaria in non-immune subjects living in endemic areas produces multivisceral deficiency similar to that observed in imported malaria. Its prognosis can be improved by loading doses of quinine and by a better prevention of nosocomial infections.

[Preliminary study on the nutritional status of patients operated on for cancer of the digestive system: reflections apropos of the first 18 cases]. / Etude préliminaire sur l'etat nutrionnel de sujets opérés de cancers digestifs: réflexions à propos des 18 premiers cas.

The authors undertook a preliminary study of two categories of patients to link morbidity and mortality to the nutritional condition of patients before and after surgery: the first group of patients were to be operated on for cancer; the second group was to act as a control group. For both groups, a study was made before and after surgery, of the nutritional condition of the patients and of progress, respectively. The findings revealed signs of de-nutrition in both groups and a distinct correlation between post-operation complications and the degree of de-nutrition. Hence, in the case of cancer, it is recommended some nutritional preparation before the operation.

[Severe malaria in Black Africa]. / Le paludisme grave en Afrique noire.

Severe and complicated malaria is a fatal from a human Plasmodium falciparum infection. In clinical practice cerebral malaria in children, with unrousable coma, hyperthermia, generalized convulsions, frequently hypoglycemia, is different of severe in non immunized adults resulting in multiple organ failure with degree of impaired consciousness less important. Specific treatment requires quinine with loading dose: 16.7 mg/kg then 8.3 mg/kg every 8 hours for 7 days. Symptomatic therapy, artificial ventilation in particular is indispensable. Recovery is usual in children although neurological sequelae are frequent. In adults evolution is often complicated with pulmonary edema, aggravation of coma, nosocomial infection, and sometimes late multiple organ failure.

[Neuromalaria and cytokines]. / Neuropaludisme et cytokines.

Levels of TNF alpha, IL-6-, soluble R IL-2, and fibronectin, were evaluated in fifteen patients with cerebral malaria. Relations between cytokines levels and parasitemia were assessed. Concentration of IL-6, and soluble R IL-2, correlated with parasitic density on admission. It was appeared, that IL-6, would be a prognostic factor, as interesting as TNF alpha.

[Failure of medical treatment with antihypertensive agents in a child with pheochromocytoma. Recovery after surgery]. / Echec du traitement médical antihypertenseur chez un enfant porteur d'un phéochromocytome. Guérison opératoire.

Anaesthesia for removal of pheochromocytomas requires preoperative preparation of patients so as to normalize blood pressure. During operation, hypovolemia linked with the sudden fall of circulating catecholamines as well as hypertension during handling of the tumor are to be managed. A case of a 11 year child with pheochromocytoma is reported. Once the diagnosis had been established, various attempts to normalize blood pressure failed. Despite a precarious condition, the operation could be performed. During surgery, hypertension occurred and three hypotensive drugs failed to correct it. It ceased after removal of the tumor. The postoperative course was uneventful. The authors discuss the role of the type of catecholamines and their concentration in the failure of antihypertensive medication.