[Successful treatment of life-threatening Panton-Valentine leucocidin positive Staphylococcus aureus pneumonia with antibiotics and immunoglobulins targeting the toxin production]. / Pneumopathie nécrosante à Stapholococcus aureus sécréteur de la leucocidine de Panton-Valentine: traitement avec succès par antibiotiques et immunoglobulines à visée anti-toxinique.

We report a patient who presented a severe Panton-Valentine-secreting methicillin-susceptible Staphylococcus aureus pneumonia with threatening multi-organ failure including acute respiratory distress syndrome, cardiac failure, renal failure and disseminated intravascular coagulation. Clinical and biological disease course using empiric therapy with treatment directed against toxin production (linezolid, clindamycin and intravenous immunoglobulins) was found to be quickly effective.

[Antitoxin treatments for necrotizing pneumonia due to Panton-Valentine leukocidin-secreting Staphylococcus aureus]. / Traitements antitoxiniques et pneumopathies nécrosantes àStaphylococcus aureus sécréteurs de leucocidine de Panton-Valentine.

Staphylococcus aureus is responsible for two main clinical presentations in humans: suppurative infections and toxigenic diseases. A small percentage of S. aureus strains secrete Panton-Valentine leukocidin (PVL). This toxin is implicated in skin infections, furunculosis, osteoarticular infections, and particularly, in serious pulmonary infections known as necrotizing pneumonia, which affect immunocompetent patients with no comorbidity. A clear outline of the clinical presentation was described recently. Necrotizing pneumonia caused by PVL-secreting S. aureus strains is characterized by a combination of fever, hemoptysis, multilobar alveolar infiltrations, and leukopenia. The disease usually progresses to toxic shock or refractory hypoxemia. A number of interesting therapies targeting leukocidin have been proposed over the past few years based on in vitro data. This review focuses on the physiopathological basis and on the therapeutic relevance of various drugs.

[Peripheral polyneuropathy after heat stroke]. / Polyneuropathie périphérique après coup de chaleur.

The authors report the case of a woman who developed a peripheral polyneuropathy after heat stroke. All the classical aetiologies of neuropathy were excluded. The final diagnostic was residual peripheral neuropathy provoked by heat stroke. The sequella of heat stroke are dominated by cerebellar compromise, but this case shows that peripheral polyneuropathies exist even if they are rare. They raise the issue of care because of severe neurological sequella.

Superior vena cava gunshot wound: successful management.

Superior vena cava gunshot wounds are rare and usually associated with high mortality before patients reach the hospital. We present an exceptional case with a 16 hour preoperative delay and a final recovery.

MRI and cranial traumas in the acute phase.

The authors have reviewed 12 cases of severe cranial trauma examined by MRI and determine the position of this method in exploration in the acute phase. Since the 1970's, computerized tomography (CT) has completely modified the emergency diagnosis. Intra- and extracerebral blood effusions are readily recognized, but the patient is often in a dangerous situation and little help is obtained from CT which does not detect shearing lesions located in the white matter, the corpus callosum or the brain stem. Early MRI examination performed with gradient-echo sequences provides a better anatomico-clinical correlation, a better prognostic approach and even a new therapeutic approach.

[Methemalbuminnemia after massive hemolysis during blackwater fever]. / Methémmalbuminémie après hémolyse massive au cours d'une fièvre bilieuse hémoglobinurique.

We report a case of blackwater fever with brown plasma due to the presence of methemalbumin. The discovery of plasma with this color is a rare event at the laboratory. This compound appears during intravascular hemolysis or hemorrhagic pancreatitis when the ability of haptoglobin and hemopexin to bind free hemoglobin has been exceeded. In these cases some of heme is oxidized to hematin and taken up by serum albumin to form an albumin-hematin complex called methemalbumin. The major clinical problem is to evoke the diagnosis of methemalbuminemia and not confuse with methemoglobinemia. In our case, methemalbumin was detected and quantified using a scanning spectrophotometer. Its diagnostic and clinicals consequences are discussed.

[Diffuse toxoplasmic encephalitis in a non-immunosuppressed patient]. / Encéphalite toxoplasmique diffuse chez un sujet non immunodéprimé.

Diffuse encephalitic toxoplasmosis is an unusual presentation of toxoplasmosis, in which neuroradiological investigations may not show focal abcesses. Until now it was only reported in immunocompromised patients. In immunocompetent patients, cerebral toxoplasmosis is very unusual, and appears as multiple abcesses, like the classic form in immunocompromised patients. We report the case of an immunocompetent patient who presented a diffuse encephalitic toxoplasmosis; CT and MR examinations showed only nonspecific features of brain swelling and cortical infarct due to vasculitis.

[Rhabdomyolysis and truncular sciatica. 2 cases studied by MRI]. / Rhabdomyolyse et sciatique tronculaire. Deux cas étudiés en IRM.

We report two cases of acute rhabdomyolysis in pelvic girdle muscles with sciatic palsy secondary to compression of the sciatic nerve trunk, with clinical and MRI correlation. The diagnosis of rhabdomyolysis is based on clinical and biological data, but diagnosis of compression complications secondary to swelling of the muscles, especially the compression of nerve trunk, is done by imaging. T2 weighted images give a definite anatomical evaluation. They show enlarged high signal intensity muscles and anatomic relationship with the sciatic nerve from its emergence out of pelvis, giving a good correlation between rhabdomyolysis and the compressed nervous trunk. It helps for planning a possible surgical fasciotomy. However, MRI provides only morphological informations, but not differentiates edema from necrosis in involved muscles.

[Obesity, diabetes mellitus, and gas gangrene: a major therapeutic challenge]. / Gangrène gazeuse sur terrain d'obésité morbide et de diabète.

Soft tissue infections are uncommon but prognosis is severe (20 to 50%). Management consists in surgical debridement, antibiotic therapy against anaerobic and aerobic bacteria, and appropriate intensive care. When available, hyperbaric oxygen therapy is an integral part of the treatment. We report the case of 56-year-old female patient with diabetes (150 kg) was hospitalized in our unit a few days after surgical treatment of a buttocks abscess for clinical signs of peripheral gas gangrene. Surgical exploration showed necrotizing soft tissue infection with fasciitis. Adequate therapy using antibiotics, surgery daily and hyperbaric oxygen was given. Therapy had to be adapted to the patient's obesity. Outcome was good with recovery and few sequelae, allowing transfer to a medical ward.

[Acute neurotoxic organophosphate poisoning: insecticides and chemical weapons]. / Intoxications aiguës par neurotoxiques organophosphorés: insecticides et armes chimiques.

OBJECTIVE: To review clinical and therapeutic bases of an organophosphate poisoning, either with insecticide or nerve agent. DATA SOURCES: References were obtained from computerized bibliographic research (Medline), from personal data (academic memoir, documents under approbation of the National Defense Office), from Internet's data. DATA SYNTHESIS: Generally, organophosphate poisoning occurs during accidental exposure with agricultural insecticide or suicide. The effects of organophosphate compounds are due to the inhibition of the enzyme acetylcholinesterase. The intoxication symptoms can be divided into muscarine-like, nicotine-like effects, effects on the central nervous system and symptoms related to the dysfunction of the neuromuscular junction. The interest of biological acetylcholinesterase's measuring is minimal because it is weakly specific or sensitive. The immediate severity is due to hypoxia. Respiratory failure results from the lack of central drive inflated with excessive bronchial secretions, bronchospasm and respiratory muscles paralysis. The secondary complications are early myopathies whose gravity is correlated with the decrease of acetylcholinesterases, or later neuropathies induced by a different mechanism. Beside the symptomatic measures, atropine is the specific anticholinergic treatment. When promptly used, oximes can regenerate cholinesterases. The attempted effects of the treatment are mouth dryness, pupilar dilatation and flushing of the skin. Nerve agents are lethal toxics which have a short onset time and produce severe neurological pathology. In a terrorist incident, it is as important to identify rapidly the toxic agent and provide emergency decontamination as to manage medical care. An effective response must be multidisciplinary, involving clinicians, toxicologists, Emergency Medical Service and public's health personnel.

[Four hours for a record, or a severe fuminating cellulitis: can Saccharomyces cerevisiae be the causal agent?]. / Quatre heures pour un record, ou une cellulite vraiment foudroyante: Saccharomyces cerevisiae peut-elle en être la cause?

A 31-year-old woman presented with a subcutaneous cellulitis which occurred within four hours following a minor wound of a knee. This very short delay could be explained neither by the health state, nor the mechanism of injury, nor the bacteria usually responsible for such a cellulitis. Considering the clinical characteristics (high gas production) and the professional context (wine cellar employee), Saccharomyces cerevisiae, a yeast used for wine or bread production, may explain this complication.

[Nosocomial Candida albicans septicemia in parenteral alimentation through a peripheral vein]. / Septicémie nosocomiale à Candida albicans au cours d'une alimentation parentérale sur veine périphérique.

Fungal septicaemias during total parenteral nutrition are frequent, but their occurrence during parenteral nutrition via a peripheral vein is uncommon. A case of disseminated candidemia with ocular and renal localizations during parenteral nutrition via a peripheral vein is reported in a 24 year old patient hospitalized for primary cerebellar haemorrhage. The case history showed the importance of early ophthalmologic examination in all septicaemic cases. The diagnosis was confirmed by nine positive blood cultures and immunological tests, but the dosage of soluble antigens remained negative. The part played by a contaminated perfusion bottle out-of-date was suggested, but could not be proved absolutely. The assessment of the immune state could wrongly suggest an acquired immunodeficiency syndrome, for it has been demonstrated that Candida albicans itself had an immunosuppressive activity.

[Paraplegia and the sitting position]. / Paraplégie et position assise.

The sitting position in neurosurgery may lead to complications such as air embolism and neurological complications. We report the case of a 16-year-old male who suffered from post-operation paraplegia after surgery for Arnold Chiari disease. This patient had several risk factors and serious morphological spinal abnormalities. We propose to include monitoring of somatosensory evoked potentials (SSEP) during this surgery in order to detect this type of devastating incident.

[Black oesophagus, a rare event in intensive care unit]. / L'oesophage noir, une complication exceptionnelle du patient de réanimation.

We report a new case of acute necrotizing oesophagitis, diagnosing on a patient hospitalised in intensive care unit. This pathology is still a rare event; the definition excludes patients with a history of recent caustic ingestion. Oesophageal necrosis can be diagnosed at endoscopy by the presence of black necroting appearing oesophagus. Contrary to the caustic oesophagitis whose treatment is often surgical, treatment of the acute necrotizing oesophagitis is primarily medical. The prognosis for patients who develop acute necrotizing oesophagitis is generally poor, even if one can hope for the cure without after-effect of it.

[Anesthesia for the surgery of malignant pheochromocytoma. Hypertensive crisis after the administration of droperidol]. / Anesthésie pour chirurgie d'un phéochromocytome malin. Accès hypertensif après administration de dropéridol.

A case of malignant phaeochromocytoma is reported. Computerized tomography and scintigraphy using metaiodobenzylguanidine localized the tumour and metastases. The anesthetic management included invasive monitoring of pulmonary pressures with a Swan-Ganz catheter and arterial pressure with a radial arterial cannula. Plasma catecholamine concentrations were measured before and during adrenalectomy and resection of a metastatic lesion on the fourth right rib. Induction of anaesthesia was carried out with droperidol, phenoperidine, thiopentone and pancuronium. After intravenous administration of droperidol, blood pressure increased together with the heart rate, vascular resistances and pulmonary pressure, whilst cardiac output decreased. Plasma noradrenaline levels were also greatly increased at the same time. The mechanism of this paradoxic pressor effect of droperidol is discussed.

[Intracranial aneurysm and coronary ectasia]. / Anévrisme intra-crânien et coronaires ectasiques.

BACKGROUND: Coronary aneurysms are uncommon and can exceptionally be associated with other aneurysmal localizations. CASE REPORT: A 34 year-old man with a history of aneurysm of the coronary arteries revealed by myocardial infarction without a wave six months earlier, presented cerebral hemorrhage secondary to an aneurysmal rupture of the anterior communicating artery. DISCUSSION: Other aneurysmal localizations such as the abdominal artery, pulmonary artery, hepatic artery, popliteal artery, coronary venous system or the left ventricle have been associated with coronary artery aneurysm. Only one case of coronary and cerebral aneurysm has been previously reported in the literature in an 8-year-old child with X-linked lymphoproliferative syndrome and EBV-induced infectious mononucleosis. Our case suggests that systemic aneurysmal disease may be a clinical entity and that cerebral angiogram should be discussed in patients with a coronary artery aneurysm.

[Severe pneumococcal meningitis and ceftriaxone allergy]. / Méningite grave à pneumocoque et allergie à la ceftriaxone.

We report the case of a 51-year-old man with an allergy to amoxicillin/acid clavulanique who presented with Streptococcus pneumoniae meningitis. Initial treatment consisted of an association of antibiotics including ceftriaxone. Six days after treatment was initiated the patient developed skin reaction and the diagnosis of allergy to ceftriaxone was established by the dosage of specific IgE. Typically Streptococcus pneumoniae meningitis is treated with vancomycin and a third-generation cephalosporin. This association had to be modified because cross allergy to cephalosporins could have developed in this patient who had previously reacted to penicillins.

[Diagnosis of ventilator-associated pneumonia: a prospective comparison of the telescoping plugged catheter with the endotracheal aspirate]. / Diagnostic non invasif des pneumopathies nosocomiales acquises sous ventilation mécanique: comparaison entre le prélèvement distal protégé et l'aspiration endotrachéale.

OBJECTIVE: Quantitative culture of endotracheal aspirates (EA) is widely accepted for the diagnosis of ventilator-associated pneumonia (VAP). The aim of the study was to compare the diagnostic accuracy of the EA with the blinded plugged telescoping catheter (PTC) in patients suspected of VAP. STUDY DESIGN: Prospective non-randomised observational study. PATIENTS AND METHODS: 31 patients suspected of having VAP underwent 46 bronchial samplings. An EA and a blinded PTC were performed successively in each case; the PTC result was taken as the reference standard. The EA and PTC cultures were defined positive if the result of bacterial cultures yielding were > or = 10(5) cfu.mL-1 and > or = 10(3) cfu.mL-1 respectively. RESULTS: The diagnosis of VAP could be established in 19 cases when PTC was taking as gold test. The overall agreement between the two techniques was 76%. EA had a sensitivity of 89.5%, a specificity of 66.7%, a negative predictive value of 90% and a positive predictive value of 65.4%. CONCLUSION: EA is a good diagnostic test when a non-invasive test has been chosen. The diagnosis of VAP could be excluded in 90% of cases when the EA cultures yielding were < 10(5) cfu.mL-1. His low specificity could drive in an over treatment of bronchopulmonar bacterial colonization. The accuracy of the EA compares well with that of the TPC for the diagnostic of VAP.

[Febrile coma and multiple organ failure: suspected hemoglobinopathy SC]. / Coma fébrile et défaillance multiviscérale: suspicion d'hémoglobinopathie SC.

We report the case of febrile fatal coma in a 51-year-old man from Burkina Faso. Magnetic resonance imaging (MRI) shows cerebral fat embolism. Haemoglobin electrophoresis shows probably haemoglobinopathy SC. A short review of the literature demonstrate the need to consider this complication in patients with neurological or respiratory disorders, in areas where this disease is highly prevalent, irrespective of age. It also emphasizes the diagnostic contribution of MRI and discusses the mechanism, the diagnosis as well as the difficulty of choosing the appropriate therapeutic course.

[Continuous infusion of vancomycin in post-neurosurgical staphylococcal meningitis in adults]. / Vancomycine en perfusion continue dans les méningites à staphylocoques post-neurochirurgicales de l'adulte.

Eight adult patients with post-surgery meningitis caused by methicillin-resistant staphylococci were treated with continuous intravenous infusion of vancomycin in mean doses of 50 mg/kg/day. This treatment, which lasted 3 to 6 weeks, was well tolerated by the kidneys and resulted in cure in all cases; its effect on the ear was not evaluated. Stable concentrations of 4 to 7 mg/l in cerebrospinal fluid were obtained after the 48th hour of treatment.