Therapeutic plasma exchange in the treatment of COVID-19 induced cytokine storm: the first Moroccan experience.

INTRODUCTION: COVID-19 induced cytokine storm is a well-documented phenomena that contributes significantly in the disease's evolution and prognosis. Therefore, therapies such as therapeutic plasma exchange, constitute a mainstay of therapeutic management especially for critically-ill patients. METHODS: We conducted a monocentric retrospective cohort study in the Resuscitation Department of the Mohammed VI University Hospital of Oujda-Morocco, to evaluate the efficiency of therapeutic plasma exchange on critically-ill COVID-19 patients over a 6 months period. We divided our patients into two groups: patients who received TPE (Therapeutic Plasma Exchange) sessions (TPE group) and patients who only benefited from the standard protocol treatment (non TPE group). RESULTS: Our study included a total of 165 patients, 34.5% of which benefited from TPE sessions. We observed an improvement of oxygenation parameters (SpO2 and PaO2/FiO2 ratio) and a progressive respiratory weaning, as well as a significant decrease of biomarkers indicative of inflammation (lymphocyte count, CRP (C Reactive Protein), IL-6, Ferritin) and coagulopathy (d-dimers, fibrinogen) in the TPE group after 5 consecutive TPE sessions. In comparison with the non-TPE group, The TPE-group patients had a shorter ICU (Intensive Care Unit) length of stay, required less frequently mechanical ventilation, and we more likely to be extubated. Furthermore, the TPE group had a lower mortality rate. DISCUSSION: Multiple studies have reported the safety and efficiency of therapeutic plasma exchange in the COVID-19 induced cytokine storm. Given the urgent character of the pandemic at the time, each center followed its own protocol in implementing plasma exchange. CONCLUSION: Similar to the results reported in the literature, our study reports positive results after using TPE specifically in terms of respiratory weaning and an improvement of the cytokine storm biomarkers, and more importantly a lower mortality rate.

Severe Sepsis Secondary to Toxic Megacolon Revealing an Inflammatory Bowel Disease.

Patients with inflammatory bowel disease can present with numerous infectious complications, including intra-abdominal abscess, perforations of the intestine, fistula formation, and the occurrence of septicemia. Toxic megacolon (TM) is a potentially fatal complication of inflammatory bowel disease (IBD) and is associated with high morbidity and mortality. In this case report, we report a 49-year-old male patient who was admitted to the intensive care unit for the management of severe sepsis that was secondary to an inaugural toxic megacolon complicating a silent inflammatory bowel disease, with a Lichtiger score of 11. Nonresponse to anti-bacterial therapy, noradrenaline, and intravenous corticosteroid therapy required an emergency total colectomy. After surgery, the patient died because of his unresolved septic shock. Correct management of this condition requires an accurate assessment of the patient's history, a correct physical examination, abdominal radiographs, and sigmoid coloscopy, and frequently requires surgery. The indications for surgery in cases of toxic megacolon, massive hemorrhage, perforation, peritonitis, or non-response to medical therapy are the most important ones. Patients with a history of inflammatory bowel disease are particularly prone to infectious complications since therapy for these inflammatory diseases is based on the use of immunosuppressive drugs and frequent abdominal surgeries.

Acute neurogenic stunned myocardium in a patient with Guillain-Barré syndrome: case report.

Autonomic dysfunction is a prevalent symptom of Guillain-Barré syndrome (GBS); cardiovascular involvement in this scenario has been mentioned infrequently in the literature. Case Presentation: A 65-year-old man with GBS presented with reversible left ventricular systolic failure. On first presentation, our patient had no history or indications of heart malfunction. During the clinical manifestation of his autonomic dysfunction, he had electrocardiographic alterations, modestly increased cardiac enzymes, significant left ventricular systolic dysfunction, and segmental wall motion irregularity. Once the initial episode was over, these anomalies and his symptoms resolved quickly. Discussion: We believe the reversible left ventricular dysfunction was caused by the toxic impact of elevated catecholamines as well as transiently injured sympathetic nerve endings in the myocardium, which was apparently caused by GBS. We recommend that echocardiography be performed in patients who exhibit clinical signs of autonomic dysfunction, particularly if they are associated with abnormal electrocardiographic findings, cardiac enzyme elevation, or hemodynamic instability, so that appropriate medical therapy can be instituted as soon as possible. Conclusion: GBS is a not a very rare situation in our context. Thus, doctors are supposed to know the life-threatening complications such as neurogenic stunned myocardium and be prepared to dodge it.

Pneumorachis and pneumocephalus: Case report of a rare blunt chest trauma complication.

INTRODUCTION: Pneumorachis, air in the spinal canal, is very rare and its association with pneumocephalus following blunt thoracic trauma remains exceptionally uncommon. CASE PRESENTATION: We present the case of a 65-year-old patient, a pedestrian hit by a car driving at very high speed. The lesion assessment on admission showed a bilateral hemothorax of moderate abundance, a right pneumothorax of low abundance and a left pneumothorax of moderate abundance, subcutaneous cervico-dorsal emphysema, pneumocephalus and significant pneumorachis at the cervico-dorsal level without fracture of the base of the skull, sinuses or the spine. DISCUSSION: We discuss the different etiologies of pneumorachis, the main hypotheses of the constitution of this air effusion and the principles of management. CONCLUSION: Pneumorachis associated with pneumocephalus in a traumatic context without bone lesions is an extremely rare entity, its discovery should lead to further investigations to look for any spinal or basilar skull fracturethat could expose to an infectious risk or require a surgical procedure.

Plasmapherisis in Covid-19 patient under ECMO: A Moroccan case report experience.

INTRODUCTION: Sars-CoV-2 induces an intense cytokine response called cytokine storm at the origin of acute respiratory distress syndrome, multiple organ dysfunction syndrome and death. In this context, several treatments have been proposed; and plasmapheresis appears as a promising treatment. CASE PRESENTATION: We report the case of a 57-year-old patient admitted for Sars-CoV-2 infection, who requiried the use of mechanical ventilation, assistance by veno-venous extracorporeal membrane oxygenation ECMO and treated by plasmapheresis plugged on the ECMO circuit. DISCUSSION: We discuss the mechanisms responsible for the Sars-CoV-2 induced cytokine storm leading to an acute respiratory distress syndrome and the main therapeutic alternatives with emphasis on plasmapheresis. CONCLUSION: Reduction of cytokines by plasmapheresis may be very useful in the management of Covid-19 infection if it is undertaken early even on an ECMO circuit.

Cerebral thrombophlebitis revealing SARS-CoV-2 infection: About one case.

INTRODUCTION: SARS-CoV-2 infection is a pandemic that continues to ravage the world, the list of its complications continues to grow longer every day. CASE PRESENTATION: We report the case of a patient admitted to intensive care for cerebral thrombophlebitis revealing a SARS-CoV-2 infection. DISCUSSION: The inflammatory nature of SARS-CoV-2 infection exposes an increased risk of thrombosis.In this article, we will discuss its mechanism and the anticoagulant treatment modalities. CONCLUSION: Besides the typical clinical signs, SARS-CoV-2 infection can manifest as thromboembolic complications such as pulmonary embolism, deep vein thrombosis, and less frequently cerebral thrombophlebitis.

Cardiogenic shock revealing myocarditis after mRNA vaccination against covid-19: Case report and brief review for the first case in Morocco.

INTRODUCTION: and importance: After its unexpected effectiveness in the clinical trials, the anti-COVID-19 vaccine type mRNA was launched on December 11, 2020, but a few months later, several reports of post-mRNA vaccination myocarditis were published, but without any proven causal link. CASE PRESENTATION: We report the case of a 14-year-old teenager admitted to the emergency department for a cardiogenic shock, the patient mentioned that he had an anti-COVID 19 vaccination 10 days before his admission. First, the vasoactive drugs had stabilized the patient; the troponins came back highly favorable but later confirmed myocarditis by magnetic resonance imaging. In this sense an etiological analysis was made and it came back without any particularities, leaving us relating the myocarditis to the vaccination. CLINICAL DISCUSSION: Post-vaccination myocarditis is a rare event, with very few reports in the literature. After the introduction of COVID vaccination, several reports were published, mostly after the mRNA vaccine. Until now, no causal link has been proven, so we need to have more reports in this sense to have a better knowledge of this phenomenon. CONCLUSION: Until we obtain a more precise explanation of the mechanism of myocarditis after vaccination with the anti-COVID-19 vaccine, all symptoms suggesting myocarditis should be systematically monitored during the first 7 days after vaccination.

Bilateral spontaneous pneumothorax in critically-ill COVID-19 infants: About two cases.

INTRODUCTION: COVID-19 is an emerging infection, it is the first large-scale pandemic of the 21st century. Several complications have been described during this infection but spontaneous pneumothorax remains an uncommon complication, even more so in infants. CLINICAL PRESENTATION: We report two cases of a 9-month-old and 18-month-old males admitted to our department for the management of an acute respiratory distress due to a COVID-19 infection associated to a spontaneous pneumothorax successfully drained.While one patient had a favorable outcome, the other was readmitted to our department for the management of a septic shock secondary to a urinary tract infection with a deadly outcome. DISCUSSION: In this paragraph we describe known causes behind spontaneous pneumothorax, before detailing the different pathogenesis hypotheses linking pneumothorax to COVID-19, all while comparing data to the literature related to the adult population. CONCLUSION: Spontaneous pneumothorax is a serious complication associated with severe COVID-19 that can occur in infants and must be considered in the event of a respiratory aggravation or a persistent hypoxia.

C-Reactive Protein (CRP): A poor prognostic biomarker in COVID-19.

Introduction: The COVID-19 pandemic continues to be rampant with considerable morbidity and mortality worldwide since its emergence in December 2019. Several studies have focused on identifying different predictive factors of poor prognosis, including biological markers, such as C Reactive Protein among others. The objective of our work was to determine whether the CRP levels on admission to the intensive care unit are predictive of an unfavorable evolution of patients with COVID-19 through the experience of the Anesthesia and Intensive Care Unit of the University Hospital of Oujda and to compare our results with those reported in the literature. Methods: We conducted a retrospective, monocentric, descriptive and analytical study in the Department of Anesthesia and Intensive Care of the Mohammed VI University Hospital of Oujda, Morocco, between March 2020 and October 2021, including all critically ill patients admitted to the department during this period and meeting the inclusion criteria. The baseline admission CRP value was arbitrarily set at 100mg/d, thus conditioning the division of our patients into two groups (group 1: CRP < 100mg/L, group 2: CRP ≥ 100mg/L). Results: Among our 1035 included patients, 291 patients with had a CRP<100mlg/L (group 1) and 744 presented a CRP level equal or superior to 100mg/L (group 2). Lung parenchymal involvement was more severe or even critical (CT involvement > 75%) in group 2 (60.8%) compared to group 1 (39.2%). In group 2, 79.8% of patients were mechanically ventilated, compared to 20.2% of patients in group 1. Finally, the mortality rate in patients with a CRP ≥ 100mg/l was 77.4%, compared with 22.6% for patients with a CRP < 100mg/l. These findings are all statistically highly significant (p<0.001). Conclusion: Given the high contagiousness of the virus and the emergence of several variants, the management of the COVID-19 pandemic has focused more on prevention through vaccination against the virus, but also on an early identification of patients likely to evolve unfavorably for a personalized management.

Post-traumatic compressive pneumopericardium with spontaneous ventilation: Case report.

Pneumopericardium is a rare complication of a blunt thoracic trauma. It is defined as the presence of air in the pericardial sac. There are just a few cases described in the literature. This article brings pneumopericardium to light, reinforcing the importance of considering it within the blunt chest trauma and remarking its management with a careful monitoring for the patients whose stable or even asymptomatic with spontaneous ventilation because of the risk of tension pneumopericardium and cardiac arrest. Diagnosis is often difficult, and it can be life-threatening by the occurrence of gas tamponade. We report the case of a 48 years old patient victim of a severe traumatism with pneumothorax and pneumopericardium; he was stable with spontaneous ventilation.

Posterior Reversible Encephalopathy Syndrome Induced by an Acute Postinfectious Glomerulonephritis.

Posterior reversible encephalopathy (PRES) is a rare but a serious disease that affects the central nervous system. PRES is responsible for various but nonspecific neurological symptoms, including confusion, coma, and seizures as well as visual disturbances. Diagnosis is made using cerebral MRI which typically shows at the early stage, bilateral symmetrical parietooccipital hyperintensities on T2 and fluid-attenuated inversion recovery (FLAIR) sequences. Case study. In this article, we base our research on a case study that includes, as a population sample, a 9-year-old boy who suffers from an acute postinfectious glomerulonephritis and arterial hypertension. Two days before diagnosis, he developed confusion with generalized tonic-clonic attacks. His blood pressure was 180/80 mmHg. A cerebral computed tomography made in emergency showed cerebral edema. It was supplemented by magnetic resonance imaging which revealed cortical and posterior cortical lesions which appear as hypointense on T1 and hyperintense on T2 and Flair. An MRI control was performed 40 days later which shows a clear improvement of the occipital lesions. PRES is a radioclinical syndrome characterized by the association of variable neurological signs which reversibility is conditioned by the early diagnosis and the correction of the contributing factors.

Severe hepatic impairment after sevoflurane anesthesia in a 10-month-old child: Case report.

INTRODUCTION: Like other halogenated agents, sevoflurane can potentially cause a toxic reaction including severe hepatic failure which can lead to the death of the patient. However, Halogen immuno-allergic hepatitis is a very rare complication of anesthesia. We reported a 10 months' child who presented a severe hepatic injury after sevoflurane exposure. CASE MANAGEMENT: A 10-month-old child was scheduled for acute intussusception anesthesia, induction was done with sevoflurane and propofol while maintenance of anesthesia was provided by sevoflurane alone. Three days after the operation, he was developed jaundice and altered general condition. A dramatic increase in liver enzymes was observed. The evolution was marked by an alteration of his consciousness and his hemodynamic state, he was intubated. Without improvement, the patient died on the 4th postoperative day. The autopsy was refused by the family. CONCLUSION: These results underscore the need findings for a global and comprehensive understanding of the potential hepatotoxicity of exposure to volatile anesthetics including sevoflurane in infants and its long-term side effects which can be fatal.

Caesarean section under continuous spinal anaesthesia in a parturient with pulmonary hypertension: A case report.

INTRODUCTION: Women with pulmonary hypertension have high morbidity and mortality during pregnancy. The inability to increase cardiac output can lead to heart failure, while hypercoagulability and reduced systemic vascular resistance also lead to other risks. CASE MANAGEMENT: This paper report the case of a parturient admitted for caesarean section under continuous spinal anaesthesia scheduled at 34 weeks of amenorrhea following severe pulmonary arterial hypertension. She had a history of significant mitral insufficiency. The procedure was performed without incident. The catheter was removed immediately postoperatively. The baby was female and in good health. She was transferred to the resuscitation service with restoration of oral nutrition. CONCLUSION: Loco-regional anaesthesia is to be preferred in pulmonary hypertension associated to pregnancy. In order to reduce the risk of mortality due to general anaesthesia for this type of patient, it is possible to practice the continuous spinal anaesthesia for caesarean section without having hemodynamic consequences.