A rare complication of viper envenomation: cardiac failure. A case report.

Viper envenomation is common in North Africa. Cardiac complications are not common features of snakebites, the clinical picture of which is usually dominated by toxin-associated neurological, hematological, and vascular damage. There are rare reports of acute myocardial infarction and/or ischemia caused by snakebites, while myocarditis after envenomation has not yet been reported, to our knowledge. We report the case of a 43-year-old woman admitted to our intensive care unit after viper envenomation complicated by acute heart failure with acute pulmonary edema, in a state of cardiogenic shock, accompanied by multi-organ failure, intravascular disseminated coagulation, and neurological damage. Some of the mechanisms that may be involved in this heart failure are discussed, including the possibility of acute myocarditis.

[Posttraumatic thromboembolic complications: Incidence, risk factors, pathophysiology and prevention]. / Les complications thromboemboliques post-traumatique : incidence, facteurs de risques, physiopathologie et prévention.

Venous thromboembolism (VTE) remains a major challenge in critically ill patients. Subjects admitted in intensive care unit (ICU), in particular trauma patients, are at high-risk for both deep vein thrombosis (DVT) and pulmonary embolism (PE). The rate of symptomatic PE in injured patients has been reported previously ranging from 1 to 6%. The high incidence of posttraumatic venous thromboembolic events is well known. In fact, major trauma is a hypercoagulable state. Several factors placing the individual patient at a higher risk for the development of DVT and PE have been suggested: high ISS score, meningeal hemorrhage and spinal cord injuries have frequently been reported as a significant risk factor for VTEs after trauma. Posttraumatic pulmonary embolism traditionally occurs after a period of at least 5 days from trauma. The prevention can reduce the incidence and mortality associated with the pulmonary embolism if it is effective. There is no consensus is now available about the prevention of venous thromboembolism in trauma patients.

Post-concussive syndrome after mild head trauma: epidemiological features in Tunisia.

BACKGROUND: Minor head injury is one of the major diagnoses requiring management in emergency departments (ED) but its squeals are not well studied in our country. OBJECTIVE: To describe the prevalence of post-concussive syndrome and its impacts on life activities, up to 6 months of follow-up, among patients having a minor head injury and discharged from ED. METHODS: A prospective bi-centric study including adults having a minor head trauma and consenting to be followed up to 6 months after discharge. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was used at baseline, after 15 days, at 1 month, at 3 months and at 6 months post-injury to assess concussive symptoms. We also used the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) to describe impacts of minor head trauma on life activities. RESULTS: There were 130 consenting patients at baseline interview. Proportion of patients describing post-concussive symptoms at baseline was 71/130. At 6 months of follow-up, post-concussive syndrome was diagnosed among 21.4 % of participants. Sustaining symptoms at 6 months post-injury were mainly anger and irritability (12.5 %). Correlations between high RPQ sum rates since 15 days' post-injury call and the sum total rates of RHFUQ were significant. The major significant impact of minor head trauma at 6 months of follow-up was among domestic activities. CONCLUSION: The two most important findings of this study were the huge proportion of patients having minor head injury and discharged from ED without any explanation of possible symptoms after head trauma and the unknown impacts on life activities.

[Up-to-date on the HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets)]. / Actualité sur le syndrome HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets).

HELLP syndrome is an acronym for Hemolysis, Elevated Liver enzymes and Low Platelets. It is generally considered in the literature as a particular clinical form of pre-eclampsia, a severe complication of the second half of pregnancy. However, this syndrome can occur in isolation in the absence of pre-eclampsia symptoms. Its pathophysiology remains still unclear. The clinical picture is often incomplete and fruste at first. To date, its diagnosis and management is still the subject of much controversy. Associated or not with a vascular and renal manifestations, the HELLP syndrome is a high-risk maternal disorder. The objective of this article is to review the pathophysiological and clinical data and current treatment.

[Post-trauma cerebral thrombophlebitis revealed by psychiatric disorders]. / Une thrombophlébite cérébrale post-traumatique révélée par des troubles psychiatriques.

Head injuries are described in the literature as a rare but possible etiology of cerebral venous thrombosis although no pathophysiological link has been identified. Trauma-related venous thrombi occurring in the brain produce a broad spectrum of clinical presentations. A purely psychiatric term is exceptional, leading to misinterpretation and late diagnosis. Positive diagnosis has been greatly improved by advances in magnetic resonance imaging with venous phase angiography, currently the gold standard exploration. We report the case of a patient who presented with post-trauma cerebral venous thrombosis revealed by psychiatric disorders.

[Cardiogenic pulmonary edema following ß2 agonist infusion for acute, severe asthma]. / Œdème aigu du poumon secondaire à l'administration intraveineuse de ß2 mimétiques pour asthme aigu grave.

We report the case of a severe acute pulmonary edema secondary to the administration of salbutamol to a patient admitted for severe asthma. The diagnosis of acute pulmonary edema was suspected on the clinical examination, chest radiography, biological (plasmatic Pro-BNP rate) and echocardiographic findings. Rapid improvement under dobutamine and mechanical ventilation argue in favour of cardiogenic pulmonary edema. The young age of our patient, the absence of history of cardiovascular disease and the chronology of this complication onset regarded to salbutamol infusion could suggest ß2 agonist involvement in this event. The improvement of cardiac function on echocardiography and the normal results obtained with myocardial perfusion scintigraphy performed 35 days later show the left ventricular reversible dysfunction.

[Ischemic stroke: A rare complication of liver hydatid cyst]. / Accident vasculaire cérébral ischémique : une complication rare du kyste hydatique du foie.

Hydatid cyst of the liver (HCL) is a widespread disease in North African countries. We report the case of a 39-year-old patient who was admitted in our intensive care unit because of anaphylactic shock due to a cracked HCL fortuitously discovered. This accident was also complicated by an ischemic stroke witch underline mechanisms are discussed.

[Evaluation of stress among emergency staff: survey in a Tunisian emergency department]. / Évaluation du stress chez le personnel des urgences : enquête dans un service d'urgences tunisien.

OBJECTIVES: The objectives of this work were to make an inventory of the stress level, to detect various stressors and to describe the working conditions as perceived by staff to pinpoint the factors that might be changed. STUDY DESIGN: This survey was conducted from July to August 2012 in all sectors of the emergency department. We used the Karasek model. Collected data were demographic and professional. RESULTS: We included 107 participants, which represent 61.5% of the whole staff. The median age of participants was 30 years with a male predominance (66%). Scores found place our sample in the dial of "job strain". Only 17.8% of participants were found to be active. No significant correlation between gender, marital status, seniority and emergency risk of developing stress state was found. Age under 30 years (P=0.04) and low social support by supervisors (P=0.02) were predictive of developing stress. Job satisfaction was lower among paramedics. In multivariate analysis, they were much more sensitive to psychological demands that the doctors. CONCLUSION: This study could be used to show the importance of preventing this emotional exhaustion in order to improve the quality of health care providers but also the care given in this service.

[Mucormycosis: an unusual cause of unilateral exophthalmia]. / La mucormycose : une cause rare d'exophtalmie unilatérale.

Mucormycosis is an invasive fungal infection associated with high mortality. Orbital involvement was usually reported but was rarely isolated. We report the case of a 57-year-old patient who presented a proptosis associated to an ethmoid sinusitis. Inflammatory symptoms were late which was responsible for delayed diagnosis. Our patient died because of multi-organ failure.

[Rhinocerebral mucormycosis complicated by hemophagocytic lymphohistiocytosis: case report from Tunisia]. / Mucormycose rhinocérébrale compliquée d'un syndrome d'activation macrophagique: une observation Tunisienne.

Mucormycosis is a rare and often fatal fungal infection caused by fungi of the Mucorales order. It is mostly seen in people with weakened immune systems or with uncontrolled diabetes, and can cause extensive soft tissue damage and decay. Hemophagocytic lymphohistiocytosis has been reported only rarely and never described in an intensive care or emergency department setting. The purpose of this report is to describe a fatal case of sinonasal mucormycosis complicated by hemophagocytic lymphohistiocytosis in a diabetic child.

[Haemophagocytic lymphohistiocytosis syndrome: a possible cause of multi-organ failure in severe head trauma?]. / Le syndrome d'activation macrophagique : une cause possible de défaillance multiviscérale chez le traumatisé du crâne ?

We report the case of a 26-year-old patient who was victim of severe head trauma following a trafic road accident. Two days after trauma, she had fever, pancytopenia and multi-organ failure. The haemophagocytic lymphohistiocytosis syndrome was suspected. This diagnosis was confirmed by biologic findings (elevated serum levels of ferritin and triglycerid) and histological findings (examination of bone marrow smears showing histiocytes phagocytosing blood cells). The evolution was unfavorable despite of corticotherapy and symptomatic measures.

High level cephalosporin-resistant Enterobacteriaceae ventilator-associated pneumonia: prognostic factors based on a cohort study.

The impact of high level cephalosporin resistance due to Enterobacteriaceae harbouring a type I-inducible chromosomal ß-lactamase on the outcome of ventilator-associated pneumonia (VAP) remains unknown. A retrospective cohort study was conducted in two intensive care units (ICUs) over a four-year period to identify factors prognostic of VAP caused by high level AmpC (HL-AmpC)-producing Enterobacteriaceae. The study included 75 patients, who developed VAP due to Enterobacteriaceae harbouring a type I-inducible chromosomal ß-lactamase. One-third of these VAP episodes were due to HL-AmpC-producing Enterobacteriaceae. Demographic and clinical characteristics at ICU admission were similar for patients, regardless of Enterobacteriaceae susceptibility, but those who developed VAP due to HL-AmpC-producing Enterobacteriaceae received antibiotics more frequently before its onset and had higher disease severity and organ dysfunction scores. Enterobacter spp. were the major HL-AmpC-producing micro-organisms responsible for VAP. VAP due to HL-AmpC-producing Enterobacteriaceae is rare. High level cephalosporin resistance was not associated with higher day 28 mortality, despite its association with more severe disease at VAP onset.

[An unusual mode of snake poisoning in Tunisia]. / Un mode insolite d'envenimation vipérine en Tunisie.

Snake poisoning constitutes a real public health problem in the North African countries. In Tunisia, snake poisonings are particularly frequent in the sub-Saharan regions (southern areas) with high mortality and possible debilitation in survivors. The most common mode of snake poisoning is biting, particularly on the extremities. The purpose of this report is to describe a case involving a patient who presented authentic systemic signs of a snake poisoning after ingesting a whole raw viper of the Cerastes cerastes species. Local signs as well as coagulation abnormalities often associated with bites by this kind of viper were not observed. The outcome was favorable after three days of hospitalization. Treatment consisted of symptomatic measures and administration of antivenom therapy.

[Neurological and heart failure following an accidental intoxication by hydrogen sulphide: a case report]. / Défaillance cardiaque et neurologique secondaire à une intoxication accidentelle par l'hydrogène sulfuré : à propos d'un cas.

We report the case of a patient who was victim of a hydrogen sulphide poisoning. This poisoning took place following a fall in sewers. The initial clinical presentation was dominated by an acute respiratory failure caused by an acute pulmonary oedema. In this context, non cardiogenic pulmonary oedema is usually evoked in the literature. Our observation supports a left ventricular systolic dysfunction as a possible cause of this cardiorespiratory complication. The initial presentation was also marked by a coma which is often associated with severe poisonings by hydrogen sulphide. Evolution was favourable under symptomatic treatment. We discuss the mechanism of heart and neurological failure.

[Acute renal failure and rhabdomyolysis secondary to prolonged hunger strike. A case report]. / Grève de la faim prolongée compliquée d'une rhabdomyolyse et d'une insuffisance rénale aiguë. A propos d'un cas.

Acute renal failure following hunger strike has been rarely reported. We report a 47-year-old man, prisoner, who developed an acute renal failure secondary to hypovolemia and major rhabdomyolysis. Failure of hydration with persistence of oliguria and secondary pulmonary edema required hemodialysis with eventually a favorable outcome.

[Peripartum cardiomyopathy: incidence, pathogenesis, diagnosis, treatment and prognosis]. / Myocardiopathie du péripartum : incidence, physiopathologie, manifestations cliniques, prise en charge thérapeutique et pronostic.

INTRODUCTION: Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease of unknown aetiology. The primary objective of this review was to analysed aetiopathogeneses, clinical presentation and diagnosis, as well as pharmacological, perioperative and intensive care management and prognosis of this pathology. METHODS: We undertook a systematic review of the literature using Medline, Google Scholar and PubMed searches. RESULTS: Unlike other parts of the world in which cardiomyopathy are rare, dilated cardiomyopathy is a major cause of heart failure throughout Africa. Its aetiopathogenesis is still poorly understood, but recent evidence supports inflammation, viral infection and autoimmunity as the leading causative hypotheses. This diagnosis should be limited to previously healthy women who present with congestive heart failure (CHF) and decreased left ventricular systolic function in the last month of pregnancy or within 5 months after delivery. Recently, introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Conventional treatment consists of diuretics, vasodilators, and sometimes digoxin and anticoagulants, usually in combination. Patients who fail to recover may require inotropic therapy. In resistant cases, newer therapeutic modalities such as immunomodulation, immunoglobulin and immunosuppression may be considered. Prognosis is highly related to reversal of ventricular dysfunction. Compared to historically higher mortality rates, recent reports describe better outcome, probably because of advances in medical care. Based on current information, future pregnancy is usually not recommended in patients who fail to recover normal heart function. CONCLUSION: PPCM is a rare but serious form of cardiac failure affecting women in the last months of pregnancy or early puerperium. Its aetiopathogenesis is still poorly understood. Introduction of echocardiography has made diagnosis of PPCM easier and more accurate. Prognosis is highly related to reversal of ventricular dysfunction.

[Thrombotic microangiopathies. Incidence, pathogenesis, diagnosis, treatment and prognosis]. / Les microangiopathies thrombotiques. Incidence, physiopathologie, tableau clinique, prise en charge thérapeutique et pronostic.

INTRODUCTION: The objective of this work was to review current data about the pathophysiology, clinical features, and treatment of thrombotic microangiopathies. CURRENT KNOWLEDGE: Thrombotic microangiopathies are microvascular occlusive disorders characterized by systemic or intrarenal aggregation of platelets, thrombocytopenia, and mechanical injury to erythrocytes. In thrombotic thrombocytopenic purpura, systemic microvascular aggregation of platelets causes ischemia in the brain and other organs. In the hemolytic-uremic syndrome, platelet-fibrin thrombi occlude predominantly the renal circulation. Thrombotic microangiopathy is a rare disorder whose varied clinical manifestations result from the formation of platelet-rich thrombi within the microvasculature and consequent tissue ischemia. The clinical features are acute renal failure, microangiopathic hemolytic anemia and thrombocytopenia. This diagnosis is of considerable importance because of the possible fulminant clinical course. Some atypical forms may be unrecognized. Plasma exchange is the current reference treatment of thrombotic thrombocytopenic purpura. However, in the light of recent publications, either infusions of concentrates of purified enzyme or more intensive immunosuppressive therapy would be more specific.

Safety and efficacy of colistin compared with imipenem in the treatment of ventilator-associated pneumonia: a matched case-control study.

OBJECTIVE: Our study aimed to determine the efficacy and safety of colistin in the treatment of ventilator-associated pneumonia (VAP) caused by pan-drug-resistant Pseudomonas aeruginosa or Acinetobacter baumanii. DESIGN: Pairwise, retrospective exposed-unexposed study. SETTING: Combined medical and surgical intensive care unit of Habib Bourguiba University Hospital (Sfax, Tunisia). PATIENTS: Sixty patients with VAP caused by pan-drug-resistant A. baumanii or P. aeruginosa matched to 60 controls with VAP caused by A. baumanii or P. aeruginosa susceptible to imipenem. All patients had normal renal function at the onset of antibiotic therapy. INTERVENTIONS: Case patients were treated by colistin intravenously and control patients were treated by imipenem intravenously. MEASUREMENTS AND RESULTS: Baseline characteristics were similar between the colistin and imipenem groups. The mean duration of antibiotic therapy for VAP was 9.5+/-3.8 days (range 5-22 days) with colistin and 8.9+/-2.8 days (range 5-20 days) with imipenem (p=0.32). A favorable clinical response to antibiotic therapy for VAP occurred in 45 patients (75%) in the colistin group and in 43 patients (71.7%) in the imipenem group (p=0.68). The time to resolution of infectious parameters after the initiation of antibiotic therapy was not statistically different between the two groups. During the antibiotic course, none of the patients in either group developed renal failure. CONCLUSIONS: We conclude that colistin can be a safe and effective option in the treatments of VAP caused by pan-drug-resistant P. aeruginosa or A. baumanii.

[Acute fatty liver of pregnancy. About 22 cases]. / Stéatose hépatique aiguë gravidique. A propos de 22 cas.

OBJECTIVE: To report the clinical experience, biochemical findings, complications and maternal outcome in patients with acute fatty liver of pregnancy (AFLP). PATIENTS AND METHODS: Retrospective study over a period of 11 years (1993-2003). The diagnosis of AFLP was confirmed by liver biopsy in 15 women. However, in 7 women a medical committee that took into account clinical symptoms, and laboratory findings assessed the diagnosis. RESULTS: Were included in this study, 22 women with a mean age of 30+/-5.4 years. Only 22.7% of cases were primigravid. The mean gestational age was 36+/-2.76 weeks (range 31-41 weeks). The fetus was a male infant in 75% of cases. Ten women were admitted in the hospital without jaundice. However 15 women had developed an icterus since their hospital admission or during ICU stay. The mean SAPS II on the ICU admission was of 24.86+/-11.2 points. Biological disturbances observed were mainly: liver cytolysis in 91% of cases, a trend to hypoglycaemia in 86%, a hypoprotidemia in 66.7% and CIVD in 32%. During their ICU stay, 19 women (86.4%) developed one or several organ failures associated to the hepatic failure and 18 women required blood transfusion. After an average stay of 7.5 days, evolution was marked by the death of seven patients (31.8%). Factors correlated with a poor prognosis were: the delay of medical consultation, the development of jaundice, the development of encephalopathy, respiratory or a circulatory failure. DISCUSSION AND CONCLUSION: AFLP is a rare but life-threatening complication. Furthermore AFLP shares features with other more common and less perilous illnesses. An early diagnosis and appropriate therapy of this pathology should improve the poor prognosis in our country.