[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.

Fulminant mulch pneumonitis in a previously healthy child.

Chronic granulomatous disease (CGD) is associated with multiple and recurrent infections. In patients with CGD, invasive pulmonary infection with aspergillus species remains the greatest cause of mortality. Acute fulminant presentations of fungal pneumonia are catastrophic. It is a medical emergency, and currently the treatment is based on association of corticosteroids and antifungal therapy. We describe the case of an 11-year-old boy, with late initial presentation of CGD, which was revealed by fulminant aspergillus pneumonia. He was successfully treated with an association of high doses of steroids and voriconazole.

The prevalence of healthcare-associated infection in medical intensive care units in Tunisia. Results of the multi-centre nosorea1 study.

OBJECTIVES: To determine the prevalence of Healthcare-Associated Infection (HAI) in medical Intensive Care Unit (ICU), risk factors for these infections and identify the predominant infecting organisms. METHODS: A 1-day point-prevalence study within all medical ICUs in Tunisia, all patients occupying an ICU bed over a 48-hour period were included. Rates of HAI, resistance patterns of microbiological isolates and potential risk factors for HAI were recorded. RESULTS: One hundred and three patients were collected from 15 Tunisian medical ICUs. HAI prevalence was 25.2% CI 95% [15-35].The most frequent HAIs were hospital acquired pneumonia in 19 cases (59%) and catheter related infection in 5 cases (15%). Independent factors associated with HAI occurrence were SAPSII score ≥ 33 with OR 1.047; CI 95% [1.015-1.077], p=0.003 and recent hospitalization with OR 4.14 CI 95% [1.235-13.889], p=0.021. Non-fermenting pathogens were the most frequent microorganisms reported in ICUs ecology, prior colonization and HAIs of the screened patients. CONCLUSION: HAIs are frequent in medical ICUs in Tunisia, which emphasize the importance of specific measures for surveillance and infection control in critically ill patients. Implementing a national monitoring system of HAI should be a major priority of public health in Tunisia.

Value of troponin levels in the diagnosis of cardiac dysfunction in moderate scorpion envenomation.

CONTEXT: Cardiac dysfunction is one of the most serious consequences of scorpion envenomation. The best tool to evaluate cardiac function is echocardiography, but it is not available at all emergency departments. Many studies aimed to describe biological predictive factors of cardiac dysfunction in scorpion envenomation. Troponin is one of these biomarkers but its correlation with myocarditis is not well established. The aim of this study was to evaluate correlation between troponin levels and cardiac dysfunction in moderate scorpion envenomation. METHODS: A retrospective monocentric study including patients admitted in the emergency department for moderate scorpion envenomation with troponin measurement during their early management. On arrival, an electrocardiogram and a chest X-ray were realized for all patients. RESULTS: We enrolled 132 patients with a mean age at 31.3 ± 24.4 years and a 1.35 sex-ratio. All patients had moderate systemic manifestations. There were 28 patients with clinical manifestations of cardiac dysfunction without life-threatening troubles (21.2%). Troponin was undetectable in 69 patients (56%). The mean value of troponin level (pg/ml) was higher in patients with clinical manifestations of left ventricular dysfunction (1.80 ± 3.8 vs. 0.11 ± 0.5; p = 0.02). Troponin levels were significantly higher in patients with positive T wave on electrocardiogram. CONCLUSION: In patients with moderate scorpion envenomation with positive T wave, high values of troponin suggest the presence of cardiac dysfunction.

[Vertebral osteomyelitis due to Candida tropicalis secondary to candidemia. A case report]. / Spondylodiscite à Candida tropicalis secondaire à une candidémie. À propos d'un cas.

Candida spp. vertebral osteomyelitis is rare. Clinical presentation is unspecific. Diagnosis requires mycological culture of a biopsy specimen. Therapeutic management is based on prolonged course of azole or liposomal amphotericin B. We report the case of Candida tropicalis vertebral osteomyelitis with epidural involvement in a 27 years-old male patient, followed for S-ß-thalassemia and with a history of candidemia. The fungus was isolated from a needle biopsy of the vertebral disk. The outcome was favorable under antifungal treatment by amphotericin B and voriconazole.

[Bilateral proximal pulmonary embolism without associated hypoxemia. Case report]. / Embolie pulmonaire proximale bilatérale sans hypoxémie associée. À propos d'un cas.

INTRODUCTION: Pulmonary embolism is a classic complication in intensive care. It is characterized by hypoxemia secondary to perturbed ventilation/perfusion ratios. We report a case of proximal and bilateral pulmonary embolism that occurred without associated hypoxemia. A spiral computed tomography (CT) scan was performed to explore unexplained fever in a patient with a negative infectious investigation. We discuss the mechanisms underlying the absence of hypoxemia in this patient. CLINICAL CASE: A 43-year-old patient with no significant pathological history was admitted to intensive care for the management of multiple injuries following a road accident. During resuscitation, the patient developed a proximal and bilateral pulmonary embolism without signs of hypertension of the pulmonary artery or associated hypoxemia. The patient improved under treatment. DISCUSSION: This case shows that bilateral proximal pulmonary embolism may be associated with normal gas exchange. The absence of hypoxemia could be explained by the bilateral nature of the pulmonary embolism that led to balanced ventilation/perfusion ratios on both sides. Furthermore, bronchoconstriction was bilateral, explaining the maintenance of a stable ventilation/perfusion ratio on both sides. CONCLUSION: The presence of unexplained fever in a victim of multiple trauma, despite the absence of hypoxemia, suggests the diagnosis of pulmonary embolism.

Severe scorpion envenomation: pathophysiology and the role of inflammation in multiple organ failure.

Scorpion stings occur on every continent except Antarctica. The correlation between young age and severity of clinical manifestations after this envenomation is well-established. Several studies have emphasized the relevance of pro-inflammatory mediators in the pathophysiological manifestations of human scorpion envenomation. Moreover, there is a significant association between pro-inflammatory cytokine levels in the blood and the severity of scorpion envenomation. Release of these cytokines increases the severity of the visceral damage induced by the direct action of the venom and the activation of both the sympathetic and parasympathetic nervous systems.

A rare complication of viper envenomation: cardiac failure. A case report.

Viper envenomation is common in North Africa. Cardiac complications are not common features of snakebites, the clinical picture of which is usually dominated by toxin-associated neurological, hematological, and vascular damage. There are rare reports of acute myocardial infarction and/or ischemia caused by snakebites, while myocarditis after envenomation has not yet been reported, to our knowledge. We report the case of a 43-year-old woman admitted to our intensive care unit after viper envenomation complicated by acute heart failure with acute pulmonary edema, in a state of cardiogenic shock, accompanied by multi-organ failure, intravascular disseminated coagulation, and neurological damage. Some of the mechanisms that may be involved in this heart failure are discussed, including the possibility of acute myocarditis.

[Posttraumatic thromboembolic complications: Incidence, risk factors, pathophysiology and prevention]. / Les complications thromboemboliques post-traumatique : incidence, facteurs de risques, physiopathologie et prévention.

Venous thromboembolism (VTE) remains a major challenge in critically ill patients. Subjects admitted in intensive care unit (ICU), in particular trauma patients, are at high-risk for both deep vein thrombosis (DVT) and pulmonary embolism (PE). The rate of symptomatic PE in injured patients has been reported previously ranging from 1 to 6%. The high incidence of posttraumatic venous thromboembolic events is well known. In fact, major trauma is a hypercoagulable state. Several factors placing the individual patient at a higher risk for the development of DVT and PE have been suggested: high ISS score, meningeal hemorrhage and spinal cord injuries have frequently been reported as a significant risk factor for VTEs after trauma. Posttraumatic pulmonary embolism traditionally occurs after a period of at least 5 days from trauma. The prevention can reduce the incidence and mortality associated with the pulmonary embolism if it is effective. There is no consensus is now available about the prevention of venous thromboembolism in trauma patients.

Post-concussive syndrome after mild head trauma: epidemiological features in Tunisia.

BACKGROUND: Minor head injury is one of the major diagnoses requiring management in emergency departments (ED) but its squeals are not well studied in our country. OBJECTIVE: To describe the prevalence of post-concussive syndrome and its impacts on life activities, up to 6 months of follow-up, among patients having a minor head injury and discharged from ED. METHODS: A prospective bi-centric study including adults having a minor head trauma and consenting to be followed up to 6 months after discharge. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was used at baseline, after 15 days, at 1 month, at 3 months and at 6 months post-injury to assess concussive symptoms. We also used the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) to describe impacts of minor head trauma on life activities. RESULTS: There were 130 consenting patients at baseline interview. Proportion of patients describing post-concussive symptoms at baseline was 71/130. At 6 months of follow-up, post-concussive syndrome was diagnosed among 21.4 % of participants. Sustaining symptoms at 6 months post-injury were mainly anger and irritability (12.5 %). Correlations between high RPQ sum rates since 15 days' post-injury call and the sum total rates of RHFUQ were significant. The major significant impact of minor head trauma at 6 months of follow-up was among domestic activities. CONCLUSION: The two most important findings of this study were the huge proportion of patients having minor head injury and discharged from ED without any explanation of possible symptoms after head trauma and the unknown impacts on life activities.

[Prognostic factors of hyperbaric oxygen therapy in hemorrhagic radiation cystitis]. / Facteurs pronostiques d'efficacite de l'oxygénothérapie hyperbare dans le cadre de la cystite radique hemorragique.

OBJECTIVE: To emphasize prognostic factors of hyperbaric oxygen therapy (HBOT) on hematuria at 3 and 12 months in the context of a radiation cystitis. MATERIAL AND METHODS: A cohort of 134 patients was treated from 2008 to 2013 in the hyperbaric medicine center of Toulouse University Hospital, France for radiation cystitis. Hematuria was ranked using the SOMA score. HBOT has been applied according to a standardized protocol of 20 renewable sessions, with pure oxygen to 2.5 ATA. The median number of sessions at 12 months was 50. RESULTS: HBOT had an efficacy of 83% at 3 months and 81% at 12 months. Twenty percent of patients had minor side effects. Compared to the pre-HBOT period, the number of hospitalizations decreased by 75% following treatment. The efficacy at 3 months was predictive of efficacy at 12 months (P<0.0001). There was an inverse correlation between the initial grade and efficacy at 3 months (P=0.026) and 12 months (P=0.001). A high WHO status diminished HBOT efficacy at 3 and 12 months (P=0.0014 and P<0.0001, respectively). An anticoagulant intake decreased the HBOT response at 12 months (P=0.002). Other parameters had no effects on efficacy. CONCLUSION: The efficacy at 3 months seems to be predictive of efficacy at 12 months. The initial hematuria grade is inversely correlated with efficacy at 3 and 12 months. It appears necessary to achieve at least 32 HBOT sessions. Moreover, a high WHO status and an anticoagulant intake seem to have a negative prognostic value. LEVEL OF EVIDENCE: 4.

[Vertebral collapse revealing primary hyperparathyroidism in a 14-year-old girl]. / Tassement vertébral révélant une hyperparathyroïdie primaire chez une adolescente.

Primary hyperparathyroidism, widely prevalent in women after menopause, remains rare in children and adolescents. Sporadic forms are the most frequent. Clinical manifestations are general, renal, gastrointestinal, cardiac, or bony. Diagnosis is biological and radiological. The imaging modalities allow assessment of the disease impact and identification of the parathyroid adenoma.

[Up-to-date on the HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets)]. / Actualité sur le syndrome HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets).

HELLP syndrome is an acronym for Hemolysis, Elevated Liver enzymes and Low Platelets. It is generally considered in the literature as a particular clinical form of pre-eclampsia, a severe complication of the second half of pregnancy. However, this syndrome can occur in isolation in the absence of pre-eclampsia symptoms. Its pathophysiology remains still unclear. The clinical picture is often incomplete and fruste at first. To date, its diagnosis and management is still the subject of much controversy. Associated or not with a vascular and renal manifestations, the HELLP syndrome is a high-risk maternal disorder. The objective of this article is to review the pathophysiological and clinical data and current treatment.

[Post-trauma cerebral thrombophlebitis revealed by psychiatric disorders]. / Une thrombophlébite cérébrale post-traumatique révélée par des troubles psychiatriques.

Head injuries are described in the literature as a rare but possible etiology of cerebral venous thrombosis although no pathophysiological link has been identified. Trauma-related venous thrombi occurring in the brain produce a broad spectrum of clinical presentations. A purely psychiatric term is exceptional, leading to misinterpretation and late diagnosis. Positive diagnosis has been greatly improved by advances in magnetic resonance imaging with venous phase angiography, currently the gold standard exploration. We report the case of a patient who presented with post-trauma cerebral venous thrombosis revealed by psychiatric disorders.

Fungemia caused by Yarrowia lipolytica.

Yarrowia lipolytica is weakly pathogenic yeast, which is rarely isolated from the blood. We report unusual cases of Y. lipolytica fungemia occurred between October 2012 and June 2014 in the intensive care unit (ICU) of the UH Habib Bourguiba Sfax. During this period, 55 cases of Y. lipolytica septicemia were diagnosed. There were 44 men and 11 women (sex ratio = 4).The median age was 43 years. The broad-spectrum antibiotics (100 %), the catheterization (96 %), and the prolonged hospitalization in ICU (91 %) were the main risk factors. Patients were hospitalized in ICU, mostly, for polytraumatism (45.4 %), pneumopathy (9 %), and post-operative complications (7 %). Fever unresponsive to broad-spectrum antibacterial therapy was the predominant sign of infection (83.6 %). Y. lipolytica was isolated in one or several blood cultures (14.5 %) and in the catheter tip culture of nine patients (16.3 %).Treatment was based on intravenous amphotericin B (58.2 %), fluconazole (45.4 %) and/or removal catheter (69 %). Apyrexia or blood cultures sterilization was obtained for 34 patients (61.8 %). Y. lipolytica candidemia is an opportunistic and emerging human yeast pathogen. It can reach to the bloodstream of immunocompromised or critically ill patients during hospitalization through intravascular catheterization. Further clinical data need to be evaluated for formulating management strategies of seriously ill patients infected with uncommon fungal agents.

Surface osteosarcoma: Clinical features and therapeutic implications.

INTRODUCTION: Surface osteosarcoma are rare variant of osteosarcoma that include parosteal osteosarcoma, periosteal osteosarcoma and high grade surface osteosarcoma. These lesions have different clinical presentation and biological behavior compared to conventional osteosarcoma, and hence need to be managed differently. GOAL: The aim of this study is to analyze the clinico-pathological features and outcome of a series of surface osteosarcoma in an attempt to define the adequate treatment of this rare entity. PATIENT AND METHOD: It is a retrospective and bicentric study of 18 surface osteosarcoma that were seen at the KASSAB's Institute and SAHLOUL Hospital from 2006 to 2013. The authors reviewed the clinical and radiologic features, histologic sections, treatments, and outcomes in this group of patients. RESULTS: Seven patients were male (38.9%) and 11 were female (61.1%) with mean age of 25 years (range from 16 to 55 years). Eleven lesions were in the femur and 7 in the tibia. We identified 11 parosteal osteosarcoma (six of them were dedifferentiated), 3 periosteal osteosarcoma and 4 high grade surface osteosarcoma. Six patients had neoadjuvant chemotherapy and all lesions had surgical resection. Margins were wide in 15 cases and intra lesional in 3 cases. Histological response to chemotherapy was poor in all cases. The mean follow up was 34.5 months. Six patients (33.3%) presented local recurrence and 8 patients (44.4%) presented lung metastases. Six patients (33.3%) died from the disease after a mean follow up of 12 months (6-30 months); all of them had high grade lesions. CONCLUSION: Histological grade of malignancy is the main point to assess in surface osteosarcoma since it determines treatment and prognosis. Low grade lesions should be treated by wide resection, while high grade lesions need more aggressive surgical approach associated to post operative chemotherapy.