Spectacular Improvement of Paradoxical Reaction in Tuberculosis after Tumor Necrosis Factor-Alpha Antagonist Therapy.

We report the case of a 42-year-old immunocompetent Indian patient presenting with miliary tuberculosis complicated by respiratory failure requiring intubation. Conventional quadritherapy was initiated for wild-type Mycobacterium tuberculosis. On day 29 of antibiotic treatment, persistent fever and neurological deterioration prompted the diagnosis of multiple brain and medullary tuberculomas, some surrounded by edema. Laboratory investigations ruled out meningitis and subtherapeutic drug concentrations. To enhance cerebrospinal fluid penetration, ethambutol was replaced with levofloxacin on day 30, and rifampicin doses were increased to 30 mg/kg. Dexamethasone was introduced on day 30 to address the paradoxical response to antituberculosis therapy, but neurological deterioration persisted, leading to hemiparesis and coma, with concurrent development of acute respiratory distress syndrome. As salvage therapy, an anti-tumor necrosis factor agent, infliximab (IFX), was administered on day 40. Rapid clinical improvement was observed, marked by awakening and subsequent weaning from respiratory ventilation just eight days after the first IFX infusion. The patient was discharged from the intensive care unit 10 days post-IFX initiation, with steroids discontinued one month after IFX introduction. Both antituberculosis treatment and IFX infusions (seven in total) were maintained for one year. Clinical and radiological evaluation at one year demonstrated complete clinical and radiological recovery.

Cerebrovascular complications and outcomes of critically ill adult patients with infective endocarditis.

BACKGROUND: Neurological complications are associated with poor outcome in patients with infective endocarditis (IE). Although guidelines recommend systematic brain imaging in the evaluation of IE patients, the association between early brain imaging findings and outcomes has never been evaluated in critically ill patients. We aimed to assess the association of CT-defined neurological complications with functional outcomes of critically ill IE patients. METHODS: This retrospective cohort study included consecutive patients with severe, left-sided IE hospitalized in the medical ICU of a tertiary care hospital. Patients with no baseline brain CT were excluded. Baseline CT-scans were classified in five mutually exclusive categories (normal, moderate-to-severe ischemic stroke, minor ischemic stroke, intracranial hemorrhage, other abnormal CT). The primary endpoint was 1-year favorable outcome, defined by a modified Rankin Scale score of 0-3. RESULTS: Between 06/01/2011 and 07/31/2018, 156 patients were included. Among them, 87/156 (56%) had a CT-defined neurological complication, including moderate-to-severe ischemic stroke (n = 33/156, 21%), intracranial hemorrhage (n = 24/156, 15%), minor ischemic stroke (n = 29/156, 19%), other (n = 3/156, 2%). At one year, 69 (45%) patients had a favorable outcome. Factors negatively associated with favorable outcome in multivariable analysis were moderate-to-severe ischemic stroke (OR 0.37, 95%CI 0.14 - 0.95) and age (OR 0.94, 95%CI 0.91-0.97). By contrast, the score on the Glasgow Coma Scale was positively associated with favorable outcome (per 1-point increment, OR 1.23, 95%CI 1.08-1.42). Sensitivity analyses conducted in operated patients revealed similar findings. Compared to normal CT, only moderate-to-severe ischemic stroke was associated with more frequent post-operative neurological complications (n = 8/23 (35%) vs n = 1/46 (2%), p < 0.01). CONCLUSION: Moderate-to-severe ischemic stroke had an independent negative impact on 1-year functional outcome in critically ill IE patients; whereas other complications, including intracranial hemorrhage, had no such impact.

Augmented renal clearance in the ICU: estimation, incidence, risk factors and consequences-a retrospective observational study.

BACKGROUND: Augmented renal clearance (ARC) remains poorly evaluated in ICU. The objective of this study is to provide a full description of ARC in ICU including prevalence, evolution profile, risk factors and outcomes. METHODS: This was a retrospective, single-center, observational study. All the patients older than 18 years admitted for the first time in Medical ICU, Bichat, University Hospital, APHP, France, between January 1, 2017, and November 31, 2020 and included into the Outcomerea database with an ICU length of stay longer than 72 h were included. Patients with chronic kidney disease were excluded. Glomerular filtration rate was estimated each day during ICU stay using the measured creatinine renal clearance (CrCl). Augmented renal clearance (ARC) was defined as a 24 h CrCl greater than 130 ml/min/m2. RESULTS: 312 patients were included, with a median age of 62.7 years [51.4; 71.8], 106(31.9%) had chronic cardiovascular disease. The main reason for admission was acute respiratory failure (184(59%)) and 196(62.8%) patients had SARS-COV2. The median value for SAPS II score was 32[24; 42.5]; 146(44%) and 154(46.4%) patients were under vasopressors and invasive mechanical ventilation, respectively. The overall prevalence of ARC was 24.6% with a peak prevalence on Day 5 of ICU stay. The risk factors for the occurrence of ARC were young age and absence of cardiovascular comorbidities. The persistence of ARC during more than 10% of the time spent in ICU was significantly associated with a lower risk of death at Day 30. CONCLUSION: ARC is a frequent phenomenon in the ICU with an increased incidence during the first week of ICU stay. Further studies are needed to assess its impact on patient prognosis.

Removal of Remdesivir's Metabolite GS-441524 by Hemodialysis in a Double Lung Transplant Recipient with COVID-19.

Remdesivir has reported efficacy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro and in vivo Drug-drug interactions limit therapeutic options in transplant patients. Remdesivir and its metabolite GS-441524 are excreted principally in urine. In intensive care unit (ICU) settings, in which multiple-organ dysfunctions can occur rapidly, hemodialysis may be a viable option for maintaining remdesivir treatment, while improving tolerance, by removing both remdesivir's metabolite (GS-441524) and sulfobutylether ß-cyclodextrin sodium (SEBCD). Additional studies may prove informative, particularly in the evaluations of therapeutic options for coronavirus disease 2019 (COVID-19).

Giant hemosiderotic dermatofibroma: a case report and review of the literature.

Dermatofibroma is a common benign fibrohistiocytic lesion that usually appears as a slow-growing, firm dermal nodule with a predilection for the legs of middle-aged women. They are usually smaller than 2 cm in diameter. Many histological variants have been described. Generally, the clinical and histological diagnosis is straightforward, but differentiating it from other cutaneous tumors can be difficult in atypical cases and rare variants. Giant dermatofibroma is a rare clinical variant of dermatofibroma and less than 25 cases have been reported. It is characterized essentially by its unusually large size, which often mimics malignant tumors clinically. We first present the case of a giant hemosiderotic dermatofibroma in a 54-year-old patient, who presented with a large ulcerated mass of the left foot which was excised, and then review the literature briefly.