Pediatric acute respiratory distress syndrome in a Moroccan intensive care unit: a retrospective observational study of 23 cases.

Acute respiratory distress syndrome (ARDS) is a life-threatening condition despite medical development. Unlike adult, ARDS, in pediatric population, has been recently defined in the Pediatric Acute Lung Injury Consensus Conference (PALICC), 2015. We conduct a retrospective descriptive study, in pediatric intensive care unit (PICU) of Hassan II University Hospital during a period of 2 years (2019 to 2021) in which we included 23 pediatric cases of ARDS defined using 2012 Berlin criteria. They represent 2.7% of all patients admitted in our unit (23 patients of 850 admissions), with a male predominance 17 males/6 females, the median of age was 4.6 years-old (2 months to 14 years-old). Pediatric acute respiratory distress syndrome (PARDS) cases were stratified as mild in 13% (n=3), moderate in 52% (n=12), and severe in 35% (n=8). The etiologies were of pulmonary origin (pneumonia, aspiration, pulmonary contusion, and foreign body) in 79% of cases (n=18), and extra-pulmonary origin (sepsis, burn and major trauma) in 21% (n=5). The management was based on lung protective invasive mechanical ventilation (95%, n=22), Prone positioning was applied (26%, n=6), inhaled nitric oxide (iNO) was used in (35%, n=8), recruitment maneuvers (56%, n=13), neuromuscular blockade (NMB) (74%, n=17) and extracorporeal membrane oxygenation (ECMO) in 1 case. The outcome was favorable in 65% (n=15) with a mean PICU-stay of 20 days (SD=16 days). Overall mortality rate was 35% (n=8), and 100% (n=5) in case of extrapulmonary (indirect) etiologies. It was proportional to the disease severity, 50% (4 of 8 cases), 33% (4 of 12 cases), and no death respectively in severe, moderate, and mild PARDS. PARDS in our context is a serious problem as it is more frequent in children < 5 years, a population considered as fragile, with a high mortality rate especially in indirect lung etiologies of PARDS.

Fatal Association of Eisenmenger Syndrome and Severe Preeclampsia.

Eisenmenger syndrome (ES) is the end stage of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD), which can occur in patients with large, unrepaired cardiac shunts (ventricular septal defects (VSD), atrial septal defects (ASD), and patent ductus arteriosus (PDA)). Pregnancy in Eisenmenger syndrome is uncommon and is poorly tolerated due to physiological changes that may lead to a risk of rapidly progressive cardiopulmonary decompensation, thrombotic complications, and sudden death. For these reasons, it is advisable, in this context, to avoid pregnancy or to undergo an early pregnancy termination within the tenth gestational week. The occurrence of severe preeclampsia in this situation leads to fatal maternal and fetal outcomes. We report the case of a 23-year-old female patient, gravida 1 nullipara at the thirty-fourth week of gestation, with a history of a persistent ductus arteriosus (PDA) in childhood that progressed to ES. She was admitted to the obstetric emergency for respiratory distress associated with signs of low cardiac output. CT pulmonary angiography and transthoracic echocardiography showed no pulmonary embolism, an enlarged pulmonary artery, dilated right cardiac chambers (ventricle and atrium) compressing the left ones, a right ventricular/left ventricular (RV/LV) ratio > 1, a persistent ductus arteriosus, and a calculated systolic pulmonary arterial pressure (PAPS) at 130 mmHg. She also had severe preeclampsia with evolutive HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome and intrauterine fetal death indicating fetal delivery under general anesthesia after platelets transfusion. At the end of the surgery, the patient presented a sudden death following a cardiac arrest despite 45 minutes of cardiopulmonary resuscitation.

Rhino-Orbital Cerebral Mucormycosis: A Fatal Evolution.

Rhino-orbital cerebral mucormycosis is a rare and serious fungal infection caused by fungi of the Mucorales order, most commonly by the species Rhizopus oryzae. It occurs generally in an immunocompromised host, and the contamination of healthy subjects remains exceptional. The clinical presentation is not specific. The diagnosis of rhino-orbital cerebral mucormycosis is difficult based on a range of clinical, microbiological, and radiological arguments. Imaging studies may include CT/MRI of the orbit, brain, and sinuses and show signs of aggressiveness, intracranial complications, and evolution under treatment. The standard treatment is antifungal therapy and necrosectomy. We report a case of a 30-year-old patient admitted to intensive care for the management of postpartum hemorrhage complicating severe preeclampsia who presented with rhinocerebral mucormycosis with left orbital extension. Adequate therapeutic management in the intensive care unit was provided; however, the patient died within seven days of septic shock with multiorgan failure. The mortality is determined by the correction of risk factors, the timing of initiation of the antifungal therapy, and surgical debridement.

The Challenging Aspect of Macrophage Activation Syndrome in the Setting of Sepsis or Systemic Inflammatory Response Syndrome (SIRS).

Macrophage activation syndrome (MAS) is a rare but potentially fatal disease. It is characterized by hyperinflammation, including the proliferation and activation of immune cells (CD8 T cells and NK cells) associated with hypercytokinemia. Patients present with fever, splenomegaly, and cytopenia, associated with a hemophagocytosis picture in the bone marrow. It can progress to a multiorgan failure syndrome (MODS), mimicking sepsis or a systemic inflammatory response syndrome (SIRS). We report the case of an 8-year-old girl admitted to the pediatric intensive care unit for the management of major trauma due to a domestic accident. She presented with a protracted fever in the context of a septic shock, despite appropriate treatment. The association with bicytopenia, hyperferritinemia, hypofibrinogenemia, and hypertriglyceridemia was suggestive of MAS which was confirmed by a bone marrow puncture showing hemophagocytosis. A Bolus of corticotherapy was then added to the supportive treatment and broad-spectrum antibiotherapy, with a good outcome.

Survival after Aluminum Phosphide Poisoning in Pregnancy.

Intoxication and drug overdose as suicidal attempt are rare in pregnancy. We report here the case of aluminum phosphide poisoning in a pregnant lady through oral and intravaginal administration which was managed with aggressive supportive measures without resorting to extracorporeal life support.

A case of massive hepatic infarction in severe preeclampsia as part of the HELLP syndrome.

Hepatic infarction is a rare and fatal complication associated with hemolysis, elevated liver enzymes and low platelets syndrome. It can develop into fulminant liver failure and lead to death in 16% of cases. A 25-year-old woman, with unremarkable prenatal history, was sent to gynecological emergency unit for management of severe preeclampsia at 30 weeks and 4 days of pregnancy. Initial laboratory studies revealed aspartate aminotransferase at 290 U/L, alanine aminotransferase at 193 U/L and a normal value of hemoglobin, platelets and the prothrombin time. Behind the persistence of high blood pressure despite dual therapy, an emergent cesarean section was performed. However, two days after surgery, the patient accused an epigastric pain and was subsequently noted to have developed HELLP syndrome: thrombocytopenia (77000 /ul), anemia (hemoglobin 9.1 g/dL) and worsened liver injury (aspartate aminotransferase 2809 U/L; alanine aminotransferase 2502 U/L). A thoraco-abdominopelvic computed tomography (CT) was performed, which revealed massive hepatic infarction more marked on the right lobe, by showing the existence of diffuse hypodense plaques, poorly limited, not enhanced after injection, interesting all hepatic segments. The vascular permeability of the portal and subhepatic was preserved. During the surveillance, the laboratory tests worsened (hemoglobin = 4,6 g/dl; platelets count = 20000 /ul; WBC = 26000 /ul; CRP = 340 mg/l; albumin = 16 g/l, prothrombin time (PT) = 50%). The patient received antibiotics, she was transfused by red blood cells and platelets concentrates, she also received albumin with the pleural effusion drainage. The damaged hepatic areas stayed stable in control CT and the patient gradually improved here biological test, to become normal at 11 days after delivery. Hepatic infarction is an extraordinarily rare complication of preeclampsia. The diagnosis should be suspected by noting elevated liver enzymes, thrombocytopenia and typical images of hepatic infarction on abdominal CT. Early recognition and multidisciplinary management is necessary to prevent hepatic failure and death.

[Perthes syndrome: about two pediatric cases]. / Syndrome de Perthes: à propos de deux cas pédiatriques.

Perthes syndrome is defined by the association among subconjunctival hemorrhage, cervicofacial cyanosis and petechiae up to neurological manifestations. Violent compression of the thorax or thoracoabdominal block after forced inspiration with glottis closure due to effort is the mechanism responsible for the syndrome. Prognosis is generally good if the compression is brief and cardiopulmonary resuscitation has been started early. The purpose of this study was to describe the features of Perthes syndrome among children.

Status Epilepticus Caused by an Herbicide Poisoning.

Triclopyr is a pyridine derivative, widely used as an herbicide. It controls plant growth by interfering with plant growth hormones, auxins. It should have few effects in humans as these are nonexistent in mammals. It can prove however very severe in cases of acute poisoning.

Seizures following Intoxication with a Common Antituberculosis Drug.

Isoniazid is an antimycobacterial agent commonly prescribed in most tuberculosis chemotherapy regimens. Its side effects are widely known including mainly liver toxicity and peripheral neuropathy. The toxic effects of isoniazid are dose-related. Toxic doses are estimated at 35-40 mg/kg and fatal doses at 150 mg/kg. Treatment consists primarily of basic life support, antiepileptic drugs, and pyridoxine. The case is of one of the children with intentional isoniazid poisoning, the drug belonging to an uncle currently under antituberculosis treatment, resulting in tonic-clonic seizures. During her hospitalization in the paediatric intensive care unit, her neurological status as well as her lab values was closely monitored, and despite initial deterioration, the patient was discharged from critical care a week after full recovery.

Accidental Modopar© Poisoning in a Two-Year-Old Child: A Case Report.

Levodopa is a dopamine precursor and a mainstay treatment in the management of Parkinson's disease. Its side effects induce dyskinesia, nausea, vomiting, and orthostatic hypotension. Acute levodopa acute poisoning is uncommon, with only a few reported cases in the medical literature. Treatment of poisoning by levodopa is mainly supportive. The case of a child admitted to a hospital for acute levodopa poisoning is presented in this report.

A Case of Spontaneous Pneumomediastinum with Subcutaneous Emphysema in Children.

Spontaneous pneumomediastinum is defined as free air or gas contained within the mediastinum, which almost invariably originates from the alveolar space or the conducting airways. It is rare in pediatric patients; however, occasional cases are reported to result from forced Valsalva's maneuver due to cough, emesis, a first attack of wheeze, or asthma exacerbations. We report the case of a 7-year-old previously healthy girl, with a history of persistent dry cough one day before, who was brought to our unit with face, neck and chest swelling. The chest X-ray and computed tomography (CT) scan showed subcutaneous emphysema with pneumomediastinum and pneumopericardium without evidence of the origin of this air leak. Laboratory tests and the bronchoscopy were normal. The patient was admitted in the pediatric critical care and received noninvasive monitoring, analgesia, oxygen, and omeprazole as a prophylaxis for a gastric ulcer. The patient improved, subcutaneous emphysema resolved, and she was discharged on the third day.

Spontaneous Pneumomediastinum in Labor.

Spontaneous pneumomediastinum and subcutaneous emphysema also known as Hamman's syndrome is a very rare complication of labor that is often related to the valsalva maneuver during the labor. In most case, Hamman's syndrome is a self-limiting condition, rarely complicated unless there are underlying respiratory diseases. Chest X-ray can be a useful early diagnostic technique in severe clinical presentation. We report an uneventful pregnancy in a primigravid parturient, which was complicated in the late second stage of labor by the development of subcutaneous emphysema, pneumomediastinum, and mild pneumothorax. Spontaneous recovery occurred after four days of conservative management. This condition shows the major interest of labor analgesia especially locoregional techniques.

Reversible blindness and preeclampsia.

Neurological manifestations of preeclampsia are serious and very variable. We report the case of a woman at 34 weeks gestation with preeclampsia who developed blindness within hours without alteration of consciousness. The imagery was in favor of posterior reversible encephalopathy. The therapeutic management consisted of emergency fetal extraction, the administration of antihypertensive drugs and magnesium sulfate. The outcome was favorable with complete recovery of visual function. This case reflects the heterogeneity of the clinical presentation of preeclampsia, as the only neurological manifestation was cortical blindness, with no associated consciousness disorder.

Wernicke's Encephalopathy Complicating Hyperemesis during Pregnancy.

Wernicke's encephalopathy is caused by severe thiamine deficiency; it is mostly observed in alcoholic patients. We report the case of a 28-year-old woman, at 17 weeks of gestational age, with severe hyperemesis gravidarum. She presented with disturbance of consciousness, nystagmus, ophthalmoplegia, and ataxia. The resonance magnetic imagery showed bilaterally symmetrical hyperintensities of thalamus and periaqueductal area. The case was managed with very large doses of thiamine. The diagnosis of Wernicke's encephalopathy was confirmed later by a low thiamine serum level. The patient was discharged home on day 46 with mild ataxia and persistent nystagmus. Wernicke's encephalopathy is a rare complication of hyperemesis gravidarum. It should be diagnosed as early as possible to prevent long-term neurological sequela or death. Thiamine supplementation in pregnant women with prolonged vomiting should be initiated, especially before parenteral dextrose infusion. Early thiamine replacement will reduce maternal morbidity and fetal loss rate.

Prolonged neuromuscular block in a preeclamptic patient induced by magnesium sulfate.

Recent large use of magnesium in the obstetric population should incite anesthesiologists to control its side effects and drugs interactions. We report a case of a 30-year-old woman, with severe preeclampsia and HELLP syndrome, receiving sulfate magnesium and nicardipine, who underwent a cesarean section under general anesthesia. She developed a prolonged and deep neuromuscular blockade, which was antagonized three hours later with neostigmine. In case of therapeutic hypermagnesaemia, non-depolarizing relaxants must be used in reduced doses, and at increased time intervals, with appropriate neuromuscular monitoring.

Peganum harmala L. Intoxication in a Pregnant Woman.

Peganum harmala L. is a plant widely distributed in the Mediterranean region. It is commonly used in traditional medicine in Morocco as sedative and abortifacient but exposes users to the risk of overdose and poisoning. The pharmacologically active compounds of this plant include a number of ß -carboline and quinazoline alkaloids responsible of its pharmacological and toxicological effects. We report the case of a 24-year-old woman, 22 weeks pregnant, intoxicated with the seeds of Peganum harmala L. On admission, she had disturbance of consciousness, uterine contraction, and oliguria. Laboratory tests revealed renal failure and liver injury, and she benefited then from hemodialysis. During hospitalization, she was intubated after deterioration of consciousness and presented a spontaneous expulsion of the fetus. After extubation, she kept unusual sequelae: cerebellar ataxia and peripheral polyneuropathy. Physicians in regions using Peganum harmala L. as traditional medicine must be able to detect symptoms of its toxicity, in order to establish early gastrointestinal decontamination. The prognosis of this intoxication is variable; most cases can be managed successfully; but in high doses of intoxication, evolution can be fatal.

Atropa belladonna intoxication: a case report.

Atropa belladonna is a poisonous plant also called deadly nightshade. Its roots, leaves and fruits contain alkaloids: atropine, hyocyamine and scopolamine. The risk of poisoning in children is important because of possible confusion with other berries. Atropa belladonna acute intoxication is a severe condition, it's should be considered in the presence of anti-cholinergic toxidrome, the differential diagnosis include other plants or psychoactive drugs containing atropine. The treatment is mainly symptomatic including gastrointestinal decontamination with activated charcoal. In severe cases, physostigmine can be used as an antidote. We report the case of 11 year old girl with Atropa belladonna poisoning which was administrated in a therapeutic purpose as a remedy to jaundice. The child presented essentially a central anti-cholinergic syndrome. She was admitted in the intensive care unit, the progression was favorable with symptomatic treatment.