[Inverted Takotsubo Syndrome due to Severe Scorpion Envenomation: Report of one Case]. / Syndrome de Takotsubo dans sa forme Inversée Secondaire à une Envenimation Scorpionique Grave: À Propos D'un Cas.

Scorpion envenomation (SE) is common in tropical and subtropical regions. Cardio-respiratory manifestations, mainly cardiogenic shock and pulmonary oedema are the leading causes of death after scorpion envenomation. Cardiac failure can be due to massive release of catecholamines, myocardial damage induced by the venom or myocardial ischemia. Although it has been exceptionally reported, Takotsubo syndrome during SE can help to better elucidate the pathophysiology of this cardiomyopathy. We report a case of inverted Takotsubo following a SE in a 26-year-old patient admitted to the Intensive care unit department for severe scorpion envenomation. His evolution was favorable. We concluded that cardiac involvement in this case fulfills all clinical and paraclinical criteria of Takotsubo syndrome emphasizing the importance of catecholaminergic discharge during scorpion envenomation. We discuss again the management of this syndrome in this specific condition.

Lonomia caterpillar envenoming in French Guiana reversed by the Brazilian antivenom: A successful case of international cooperation for a rare but deadly tropical hazard.

In the American continent, larval forms (caterpillars) of the Lonomia genus can cause systemic reactions in human beings. In this Paper, we report the third case of Lonomia envenoming recorded in French Guiana in 25 years, and the first in which specific antivenom was administered. Severe symptoms of the envenoming were observed in our patient including pain; coagulopathy and systemic hemorrhage. They are caused by skin contact with caterpillars. Recovery, however, was quite satisfactory thanks to the international cooperation of the health authorities in both France and Brazil.

[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.

[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.

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.

[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.

[Prognostic factors of pneumococcal meningitis. Retrospective study of 31 cases]. / Facteurs de pronostic des méningites à pneumocoque. Etude rétrospective de 31 cas.

AIM: Our aim was to study the susceptibility of Streptococcus pneumoniae to antibiotics in patients with pneumococcal meningitis and to search for the prognosis factors in those patients. METHODS: We have studied retrospectively 31 cases of pneumococcal meningitis. Comparaisons were performed with univariate analysis. RESULTS: The mean age was 36.7 +/- 20.5 years (ranged: 9 and 78 years). The sex ratio was 3,4. The susceptibility of Streptococcus pneumoniae to penicillin G was affected in 10 cases (33% of isolated pneumococcus. The MIC to penicillin G was > or =2 in only one case. The hospital mortality was 26% (8/31). With univariate analysis, factors associated with death were: age > or =55 years (Ss p= 0,006, OR: 17.2 IC95%: 2.3-134), albuminorachie > or = 7 g/l (p = 0.002, OR: 22; IC95%: 1.9-2.51), shock (p = 0.031, OR: 6.7; IC95%: 1.05-42) and Glasgow Coma Score (GCS) < or =8 (p = 0.001, OR: 20; IC95%: 2.68-149). CONCLUSION: No susceptibility to penicillin G is not associated with a worse outcome in patients with pneumococcal meningitis. An age > or =55 years, albuminorachie > or =7 g/l shock and Glasgow Coma Score < or =8 at admission were determinant of the prognosis in our study.

[Posttraumatic meningitis: incidence, bacteriology, and outcomes]. / La meningite post-traumatique: incidence, microbiologie et pronostic.

BACKGROUND AND PURPOSE: The aim of our study was to search for the incidence, the responsible organisms and the favoring causes of death of post-traumatic meningitis (PTM). METHODS: This retrospective study was conducted over a seven-year period (January 1st, 1996 - December 31, 2002) in the ICU and the neurosurgery department of the Habib-Bourguiba University Hospital, Sfax, Tunisia. RESULTS: Over the study period, 38 patients presented PTM (0.96% of patients hospitalized for head injury), 92% of them had received antibiotic prophylaxis on admission. Mean time between head injury and the diagnosis of PTM was 9+/- 8 days (range: 2-34 days). The most common isolated organisms were multidrug resistant A. baumanii, and K. pneumoniae and reduced susceptibility S. pneumoniae. Factors predictive of prognosis in the 14 days following the diagnosis of meningitis were Glasgow coma score (GCS) on the day of diagnosis of PTM, absence of nuchal rigidity, CSF protein, CSF/blood glucose ratio, and S. pneumoniae as the causal agent of PTM. CONCLUSIONS: Antibioprophylaxis in patients with head trauma must be avoided to prevent the emergence of multidrug resistant bacteria when PTM occurs. GCS on the day of diagnosis of PTM, CSF protein concentration, CSF/blood glucose ratio, and S. pneumoniae as the causal agent of PTM are predictive factors of mortality of patients with PTM.

[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.

[Thrombotic microangiopathies in the intensive care unit]. / Les microangiopathies thrombotiques en réanimation.

OBJECTIVES: To analyze the clinico-biological manifestations, identify the causes and evaluate the outcome of patients with severe thrombotic microangiopathies admitted in a Tunisian intensive care unit. METHODS: Retrospective study over a period of 10 years (1995-2004) in an intensive care unit. RESULTS: Were included in this study 9 cases with a mean age of 29.2+/-9 years (range 15-44 years). Fever was observed in 5 patients, neurological impairment in 5 and digestive manifestations in 6. Haemolytic anaemia, thrombocytopenia and acute renal failure were observed in 100% of the cases. In our study, the aetiologies of thrombotic microangiopathies were: complicated pregnancy in 6 cases, systemic lupus erythematosus in 1 case. In contrast, no aetiology was found in 2 patients. Plasma exchange was performed in 5 patients, while 4 patients received only plasma infusion. After an average stay of 18+/-12.5 days, evolution was marked by the death 3 patients. CONCLUSION: The incidence of severe thrombotic microangiopathies is rare in Tunisian ICU. The clinical manifestations are not specific. Despite the improvement in the outcome by exogenous plasma supply, thrombotic microangiopathies with severe organ dysfunctions leading to hospitalization in the intensive care unit are associated with a high mortality rate.

[Contamination of blood cultures drawn from central vein catheter and peripheral venipuncture. Prospective study of 75 pairs]. / La contamination des hémocultures prélevées sur cathéters veineux centraux et sur veine périphérique. Etude prospective de 75 couples d'hémocultures.

OBJECTIVE: To determine the frequency of contamination, the sensitivity, specificity, and predictive values of cultures done with blood drawn through a central venous catheter or peripheral venipuncture. DESIGN: Prospective cohort study of critical ill medical surgical intensive care patients in whom samples for paired culture were drawn through a central venous catheter or peripheral venipuncture during a period of 8 months (from August 1st 2001 to Mars 31st 2002). RESULTS: During the study period, 75-paired cultures were studied. Fifteen peripheral blood cultures (20%) and 27 central blood cultures (36%) were positive and 6 peripheral blood cultures (8%) and 15 central blood cultures (20%) were contaminated (P=0.034). The organism most commonly responsible for contamination was Coagulase Negative Staphylococcus (16% of central blood cultures and 6.7% of peripheral blood cultures). The frequency of contamination was of 42.9% for blood cultures drawn through a femoral central venous catheter, of 10% for jugular, and of 19% for subclavian central venous catheter (P=0.22). For catheter draws compared with peripheral venipuncture, sensitivity was 100 and 75%, specificity was 76.2 and 90.5%, positive predictive value was 44.4 and 60% and negative predictive value was 100 and 95%. CONCLUSION: Cultures of blood drawn through a catheter are more sensible and less specific than those obtained from a peripheral venipuncture and the organism most commonly responsible for contamination of blood cultures is Coagulase Negative Staphylococcus.

[Traumatic unilateral renal artery thrombosis and protein C deficiency. A case report]. / Thrombose post-traumatique de l'artère rénale et déficit en protéine C. A propos d'un cas.

Post traumatic renal artery thrombosis is rarely described in the literature. This pathology can result from stretch injury to inelastic intima of the renal artery, or by the direct flow to the abdomen causing compression injury to the renal artery against the vertebral column. However, the association of this pathology with hematologic diseases (in particular protein C deficit) was never described. We report an observation of a 28-year-old man with an uneventful history who was admitted to the intensive care unit for traumatic head injury associated with post traumatic renal artery thrombosis requiring nephrectomy. The etiologic investigation of this thrombo-embolic complication reveals a protein C deficit. Our patient was improved under treatment. This original observation confirms that post traumatic renal artery thrombosis can be associated with hematologic diseases (in particular protein C deficit).

[Celiac disease, cerebral venous thrombosis and protein S deficiency, a fortuitous association?]. / Maladie coeliaque, thrombose veineuse cérébrale et déficit en protéine S, une association fortuite?

INTRODUCTION: Celiac disease is a pathology which is rarely associated with thrombosis complications. Cerebral vascular thrombosis has never been described in patients with a celiac disease. OBSERVATION: We report an observation of a 21-year-old girl with a history of celiac disease who was hospitalized in the intensive care unit for convulsive status epilepticus secondary to a cerebral venous thrombosis. The etiologic investigation of this thrombo-embolic complication revealed protein S deficit. Our patient improved under symptomatic treatment. COMMENT: This original observation confirms that celiac disease can be associated with cerebral venous thrombosis.

[Predictive value of pericatheter skin cultures in detecting catheter-related infections in a medical-surgical intensive care unit]. / Apport diagnostique de l'écouvillonnage de la zone d'insertion cutanée dans l'exploration des infections liées aux cathéters veineux centraux dans un service de réanimation médicochirurgicale.

OBJECTIVE: To evaluate the predictive value of pericatheter skin cultures in detecting catheter-related infections in critically-ill patients. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: Over a 5 months period (from August 1(st) 2001 to December 31 2001), 500 patients were hospitalised, and 108 central venous catheters were prospectively examined. For each catheter, blood cultures, pericatheter skin cultures and semiquantitative culture of the catheter tip were performed. RESULTS: The median duration of catheterization was 8 days (interquartile: 8 days). Catheter was removed because of suspected infection in 54 cases (50%). Systemic catheter-related infection was found in 12 cases (11%) and the responsible organism was a gram-negative rod in 11 cases (92%). The negative predictive values of pericatheter skin cultures in the diagnosis of catheter-related infections and in case of suspected catheter-related infection were 89 and 86%, respectively. CONCLUSION: These results indicate that the pericatheter skin cultures are not an effective procedure for the conservative diagnosis of catheter-related infections and that the skin-insertion wound is not the major source of catheter-contamination in our unit.