Solitary hypothalamopituitary toxoplasmosis abscess in a patient with AIDS.

Toxoplasmosis is a disease caused by an obligate intracellular protozoal parasite, Toxoplasma gondii. It is the most common cause of focal brain lesions in patients with AIDS. The imaging features and endocrine disorders of CNS toxoplasmosis in patients with AIDS are reviewed.

[Disseminated tuberculosis with severe multi- organ failure in a patient with AIDS]. / Tuberculose disséminée avec défaillance multiviscérale foudroyante au cours d'un sida.

INTRODUCTION: Tuberculosis is the most common infectious complication in HIV infected patients. The incidence of tuberculosis and the proportion of disseminated disease increase with more severe immuno-suppression. Septic shock and multiple organ failure are uncommon but are of markedly bad prognostic significance. CASE REPORT: A forty-four year old HIV seropositive man was admitted to the intensive care unit (ICU) with acute respiratory distress. The patient had been febrile for the previous two weeks. His thoracic radiograph showed a discrete interstitial infiltrate and at bronchoscopy small whitish granulations were observed in the main bronchi. All bacteriological investigations remained negative at the time of ICU admission. The patient died sixteen hours later due to multiple organ failure. Mycobacteria were identified after patient's death on the smear from BAL, from blood cultures, and in a postmortem liver biopsy. CONCLUSIONS: Septic shock is an infrequent complication of disseminated tuberculosis. Mortality is very high. Treatment should be started early in cases with a high diagnostic suspicion.

Emergence of nosocomial Pseudomonas aeruginosa colonization/infection in pregnant women with preterm premature rupture of membranes and in their neonates.

The epidemiology, risk factors, maternal and neonatal outcomes of nosocomial Pseudomonas aeruginosa acquisition in preterm premature rupture of membranes were analysed. Of 63 women receiving antibiotic prophylaxis with co-amoxiclav, 11 acquired P. aeruginosa vaginal carriage with a median delay of 15 days (6-42) i.e. an incidence of 8.94 per 1000 days of expectant management. Five neonates born to 11 positive mothers were colonized or infected, three of whom died of fulminant sepsis. The duration of antibiotic treatment and multiple pregnancy were identified as independent risk factors. The epidemiological investigation revealed a vertical transmission between mothers and neonates, and suggested selective pressure of antibiotic treatment.

Acute pancreatitis caused by severe Legionella pneumophila infection.

We report three cases of severe community-acquired Legionella pneumophila pneumonia with acute pancreatitis. Pancreas involvement is unusual. The clinical presentations consisted of painless pancreatitis with only elevation of serum pancreatic enzymes (case 1), tender abdomen with edematous pancreas on computed tomography scan (case 2) and necrosis (case 3). We discuss the possible mechanisms of L. pneumophila associated acute pancreatitis for which the pathophysiology is still undetermined: infection, toxin release or cytokine secretion.

Streptococcus salivarius acute meningitis with latent petromastoiditis.

A 48-y-old woman, with a previous history of neurosurgical intervention for a trigeminal neurinoma, presented with acute meningitis due to Streptococcus salivarius. There were significant changes in the petrous region, as revealed by MRI, leading to the diagnosis of associated latent subacute mastoiditis.

Hypothermia with indoor occurrence is associated with a worse outcome.

OBJECTIVE: To describe patients admitted to intensive care unit (ICU) for hypothermia, evaluate prognostic factors, and test the hypothesis that patients found indoors have a worse outcome. DESIGN AND SETTING: Retrospective clinical investigation in a medical ICU. PATIENTS: Eighty-one consecutive patients admitted to ICU, with a body temperature of 35 degrees C or lower and rewarmed passively or with minimally invasive techniques, over a 17-year period. MEASUREMENTS AND RESULTS: Patients were analyzed by age, gender, and causes of hypothermia and split into two groups (indoors and outdoors), according to the location where hypothermia occurred. Prognostic factors were determined by univariate method and stepwise logistic regression. The major complications were acute renal failure (43 %), aspiration pneumonia (22 %), rhabdomyolysis (22 %), and acute respiratory distress syndrome (12%). Principal comorbidities in the outdoor patients (21%) were alcohol and drug intoxication, and those in the indoor patients (79 %) were sepsis and neuropsychiatric disorders. Stepwise logistic regression identified two variables predictive of death: illness severity at admission (SAPS II > or = 40) and the location where hypothermia occurred (indoors versus outdoors). CONCLUSIONS: With equivalent body temperature, patients found indoors were more severely affected and died more frequently than those found outdoors.

Fatal Mycobacterium tuberculosis brain abscess in an immunocompetent patient.

A non-HIV-infected 63-y-old woman presented seizures and coma during the course of Mycobacterium tuberculosis infection. Computerized tomography scan led to the diagnosis of a large compressive brain abscess. The patient died with multiorgan failure. Systematic central nervous system investigations should be done in cases of disseminated tuberculosis.

Pro- and anti-inflammatory cytokines during acute severe pancreatitis: an early and sustained response, although unpredictable of death. Parisian Study Group on Acute Pancreatitis.

OBJECTIVES: To define the pro- and anti-inflammatory cytokine response during acute severe pancreatitis and to evaluate its predictive value on hospital mortality. DESIGN: Prospective, multicenter study. SETTING: Nine multidisciplinary intensive care units (ICUs). PATIENTS: Fifty patients with a diagnosis of acute pancreatitis who were admitted to the ICUs during a 14-month period were prospectively enrolled. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Plasma concentrations of tumor necrosis factor (TNF)-alpha interleukin (IL)-1beta, IL-6, IL-10, IL-1 receptor antagonist (IL-1ra) were determined at the inclusion and during the ICU stay at Days 1, 3, 8, and 15. The patient population was analyzed by age, gender, previous health status, preexisting organ dysfunction, and type of acute pancreatitis. Physiologic variables were measured at inclusion and during ICU stay to calculate the new Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the number of organ system failures. Prognostic factors were determined by univariate methods and stepwise logistic regression analysis. Fifty patients were included, among whom 34 at the time of the ICU admission. Preinclusion symptom history was < or = 48 hrs in 78% of the patients. Eleven patients (22%) died during their hospital stay. At inclusion, 46 of 50 patients had elevated IL-6 serum levels (1512 +/- 635 pg/mL; normal value < 10 pg/mL), 36% of the patients had raised TNF-alpha concentrations, and all patients had an anti-inflammatory response (IL-10, 92 +/- 15 pg/mL [normal value < 10 pg/mL]; and/or IL-1ra, 7271 +/- 2530 pg/mL [normal value < 200 mg/mL]). During the follow-up period, pro- and anti-inflammatory cytokines remained elevated in at least 75% of the population. Positive correlations were found between inclusion pro- (IL-6) and anti-inflammatory cytokine concentrations at Day 1 (IL-10, IL-1ra; p < .0001) and between cytokines levels and the Simplified Acute Physiology Score II. While hospital mortality was linked to six factors in univariate analysis (age, cirrhosis, delay between hospitalization and ICU admission, severity of illness, and IL-10 and IL-6 plasma levels) when using stepwise logistic regression, only severity scoring indexes were predictive of death. CONCLUSIONS: During acute severe pancreatitis, the pro- and anti-inflammatory cytokine response occurred early and persisted in the systemic circulation for several days. Although associated with the patient's severity at inclusion and outcome, cytokine plasma concentrations were unable to predict death accurately in individual patients. If confirmed, these results should be taken into consideration when selecting patients who are apt to benefit from new therapies aimed at modifying the immune inflammatory response.

[Organ procurement from cardiac arrest donors: outcome of kidney grafts and recommendations]. / Prélèvements d'organes sur donneurs décédés à coeur arrêté: devenir des greffons rénaux, propositions.

OBJECTIVES: To compare literature data with results obtained with organs procured from donors who died from cardiac arrest and to make proposals for this mode of organ procurement in France. METHODS: Over the last 10 years, 10 organ donors (2%) among a series of 486 donors in a state of brain death, had died of cardiac arrest. The arrest were perfused with double-balloon catheters. The outcome of the subsequent kidney grafts was compared with data in the literature. RESULTS: Fifteen of the 18 kidneys from cardiac arrest donors were functioning 1 month after implantation compared with 17 of the 20 kidneys from braindeath donors with beating hearts. The rate of acute tubular necrosis was 55% in the cardiac arrest kidneys and 40% in the beating-heart kidneys. Serum creatinine at 1 yeart was 145 +/- 69 mumol/l 17 +/- 29 mumol/l respectively. DISCUSSION: These results and those reported in the literature demonstrate that kidney procurement from cardiac arrest donors is feasible. If intensive care and surgery units are well organized, this type of organ procurement could provide a larger number of organs for transplantation. Emergency teams must be available for preparing and transferring the organs.