Therapeutic plasma exchange in the treatment of COVID-19 induced cytokine storm: the first Moroccan experience.

INTRODUCTION: COVID-19 induced cytokine storm is a well-documented phenomena that contributes significantly in the disease's evolution and prognosis. Therefore, therapies such as therapeutic plasma exchange, constitute a mainstay of therapeutic management especially for critically-ill patients. METHODS: We conducted a monocentric retrospective cohort study in the Resuscitation Department of the Mohammed VI University Hospital of Oujda-Morocco, to evaluate the efficiency of therapeutic plasma exchange on critically-ill COVID-19 patients over a 6 months period. We divided our patients into two groups: patients who received TPE (Therapeutic Plasma Exchange) sessions (TPE group) and patients who only benefited from the standard protocol treatment (non TPE group). RESULTS: Our study included a total of 165 patients, 34.5% of which benefited from TPE sessions. We observed an improvement of oxygenation parameters (SpO2 and PaO2/FiO2 ratio) and a progressive respiratory weaning, as well as a significant decrease of biomarkers indicative of inflammation (lymphocyte count, CRP (C Reactive Protein), IL-6, Ferritin) and coagulopathy (d-dimers, fibrinogen) in the TPE group after 5 consecutive TPE sessions. In comparison with the non-TPE group, The TPE-group patients had a shorter ICU (Intensive Care Unit) length of stay, required less frequently mechanical ventilation, and we more likely to be extubated. Furthermore, the TPE group had a lower mortality rate. DISCUSSION: Multiple studies have reported the safety and efficiency of therapeutic plasma exchange in the COVID-19 induced cytokine storm. Given the urgent character of the pandemic at the time, each center followed its own protocol in implementing plasma exchange. CONCLUSION: Similar to the results reported in the literature, our study reports positive results after using TPE specifically in terms of respiratory weaning and an improvement of the cytokine storm biomarkers, and more importantly a lower mortality rate.

Pneumosinus Dilatans of the Frontal and Ethmoidal Sinuses Revealed by Conscience Disorder and Respiratory Distress: Case Report and Literature Review.

An abnormal enlargement of the air-filled paranasal sinuses is referred to as pneumosinus dilatans. Typically discovered incidentally through radiological examinations, it infrequently manifests as cosmetic, neurological, ocular, or rhinological pathologies. Thorough evaluation for associated conditions is essential in patients with pneumosinus dilatans, including meningiomas of the anterior skull base or the optic nerve sheath. In our work, we report a 75-year-old female patient who presented with dysarthria and lower facial asymmetry. The computed tomography (CT) scan revealed pneumosinus dilatans of the frontal and ethmoidal sinuses with subfalcine herniation. During hospitalization, the patient presented with conscience disorder secondary to ischemic stroke and respiratory distress secondary to aspiration pneumonia. In our work, we also discuss reported cases of the English literature.

Charting the Unknown: Green Urine After Propofol in Pediatric Trauma.

The phenomenon of green urine discoloration, while rare, represents a captivating clinical puzzle that challenges the distinction between benign and pathological conditions. In this report, we present an intriguing case involving a 15-year-old trauma patient admitted following a motorcycle collision, where the ensuing unconsciousness necessitated propofol induction for intubation and sedation. Remarkably, around 48 hours post-admission, the patient displayed green urine discoloration, which resolved spontaneously within just 12 hours. This case serves as a compelling illustration of the uncommon occurrence of propofol-induced green urine in the context of critical care management, underscoring the imperative need to discern and appreciate medication-related chromatic alterations in urine.

Severe Sepsis Secondary to Toxic Megacolon Revealing an Inflammatory Bowel Disease.

Patients with inflammatory bowel disease can present with numerous infectious complications, including intra-abdominal abscess, perforations of the intestine, fistula formation, and the occurrence of septicemia. Toxic megacolon (TM) is a potentially fatal complication of inflammatory bowel disease (IBD) and is associated with high morbidity and mortality. In this case report, we report a 49-year-old male patient who was admitted to the intensive care unit for the management of severe sepsis that was secondary to an inaugural toxic megacolon complicating a silent inflammatory bowel disease, with a Lichtiger score of 11. Nonresponse to anti-bacterial therapy, noradrenaline, and intravenous corticosteroid therapy required an emergency total colectomy. After surgery, the patient died because of his unresolved septic shock. Correct management of this condition requires an accurate assessment of the patient's history, a correct physical examination, abdominal radiographs, and sigmoid coloscopy, and frequently requires surgery. The indications for surgery in cases of toxic megacolon, massive hemorrhage, perforation, peritonitis, or non-response to medical therapy are the most important ones. Patients with a history of inflammatory bowel disease are particularly prone to infectious complications since therapy for these inflammatory diseases is based on the use of immunosuppressive drugs and frequent abdominal surgeries.

Post COVID-19 trigeminal neuritis: Case report.

Neurological symptoms are prevalent in Coronavirus disease 2019 (COVID-19) cases, ranging from 30% to 80% depending on the severity of the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We have documented a case of a 26-year-old woman who suffered from trigeminal neuritis caused by COVID-19, but responded well to corticotherapy. Two primary mechanisms may explain the neuroinvasive and neurovirulent properties of human coronaviruses. Neurological symptoms can persist long after recovery from COVID-19.

Emphysematous pyelonephritis complicated by septic shock treated with antibiotic therapy alone: a case report.

Emphysematous pyelonephritis (EPN) is a rare and serious complication of urinary tract infections that mainly occurs in diabetic patients. It results in the development of aerobic gas-forming bacteria1. Diagnosis is based mainly on a computed tomography scanner. Therapeutic management is based on the patient's clinical condition and radiological classification. Case presentation: We present a case of a 64-year-old female patient with type 2 diabetes under insulin and hypertension under amlodipine, who was admitted to the intensive care unit for a state of septic shock on EPN. The patient received resuscitation measures and antibiotic therapy, and the evolution was favorable. The patient was transferred to the urology unit after 10 days of hospitalization in the intensive care unit. Discussion: EPN is frequently caused by gram-negative cocci and generally develops in diabetics. The clinical signs of EPN are not very specific and are essentially based on the signs of acute pyelonephritis, which responds badly to treatment. Conclusions: It is essential to take preventive measures in diabetic patients to avoid this complication. Early diagnosis allows for avoiding surgery by preserving the kidney.

Spontaneous liver rupture after uncomplicated delivery: medical case report.

Spontaneous hepatic rupture is an uncommon and fatal complication that most often occurs in the setting of severe pre-eclampsia. Case presentation: In this article, the authors describe a case of spontaneous liver rupture occurring on the sixth day of an uncomplicated pregnancy in postpartum. Discussion: According to the literature, liver rupture in the obstetrical setting is mostly linked to pre-eclampsia and HELLP syndrome. Conclusion: A collaborative multidisciplinary approach is required to define adequate medical and surgical management when there is suspicion of liver rupture in pregnant women.

Chemotherapy-Induced Leukoencephalopathy Revealed by Seizure and Alteration of the Mental Status.

Leukoencephalopathy is progressive demyelination of the white matter, induced by a variety of factors. Among the causes of leukoencephalopathy, chemotherapy is an uncommon cause that generates potentially reversible lesions. The clinical presentation is classically made of alterations in mental status, hallucinations, hypertension, seizures, and acute visual changes. Imaging plays an important role in the diagnosis of this entity, especially by conventional and diffusion-weighted magnetic resonance imaging which enables an accurate diagnosis by identifying symmetric white matter lesions, especially in the parietal and occipital lobes. Herein, we report a 54-year-old female patient, newly diagnosed with non-metastatic moderately differentiated adenocarcinoma of the cecum. The patient received her first cancer chemotherapy (5-fluorouracil at 300 mg/m2). Five days later she was admitted to the intensive care unit for confusion following two generalized seizures. Conventional and diffusion-weighted magnetic resonance imaging was performed and showed diffuse white matter lesions of the parietal and occipital lobes. A diagnosis of 5-fluorouracil-induced leukoencephalopathy was established. The diagnosis of leukoencephalopathy should be considered in patients receiving cancer chemotherapy with alterations in mental status and seizures.

The Efficacy and Safety of Prolonged Oral Anticoagulation for the Prevention of Thromboembolic Events in Patients Recovered From COVID-19 1 Year After Hospital Discharge: The SARCOV-19 Prospective Registry.

Our objective in this study is to know the predictors of thromboembolic events 1 year after hospitalization for severe COVID-19 and the benefit of preventive oral anticoagulation for 1 month to placebo after release. We conducted a prospective study to determine the benefit of preventive anticoagulation upon discharge from the hospital and to determine the predictive factors of thromboembolic events. We included 720 patients in the SARCOV-19 Registry, with a mean age of 62.07 (±18.11), and 61.1% male. After 1 year, 60 thromboembolic events were observed, 45 in patients on a placebo, and 15 in patients on a direct oral anticoagulant. The predictive factors determined for these events were the presence of cardiac disease, elevation of D-dimer during hospitalization, myocardial damage defined by elevation of troponins more than 6 times normal, and the use of mechanical ventilation. However, the use of preventive anticoagulation protects against thrombotic events and reduces the risk of a thromboembolic event at 1 year with a relative risk of 0.49 compared to a placebo. The prolongation of the preventive anticoagulation at the exit will protect with a decrease of almost 50% of the risk against thrombotic events and this without increasing the risk of bleeding.

Acute alithiasic pancreatitis following the use of Risperidone in a young man with schizophrenia: As a rare case report.

Acute pancreatitis due to antipsychotic treatment is a rare but serious complication. Risperidone is among the rarest atypical antipsychotics associated with acute pancreatitis. Here, we report the case of acute pancreatitis developing 2 years after the use of Risperidone in a young man with schizophrenia. The mechanism and the time of occurrence in this case are at odds with what is generally reported in the literature.

Wernicke encephalopathy revealed by areflexic flaccid tetraparesis associated with gravidarum hyperemesis.

Wernicke's encephalopathy is an acute neuropsychiatric syndrome resulting from thiamine deficiency, which is associated with significant morbidity and mortality. The diagnosis of Wernicke's encephalopathy is based on the clinical manifestations and rapid reversal of symptoms with thiamine. Case presentation: The authors present the case of a 25-year-old female patient at the 19th week of gestation (Gravid 1 para 0) with an unremarkable medical history who was admitted to the hospital for an areflexic flaccid tetraparesis with ataxia after persistent vomiting. The brain and spinal MRIs did not reveal any abnormalities, and the evolution was marked by an important improvement after supplementation with thiamine. Conclusion: Gayet Wernicke encephalopathy is a medical emergency. Clinical symptoms are inconstant and varied. MRI is the reference examination to confirm the diagnosis, but in 40% of cases it is strictly normal. Early thiamine administration can prevent morbidity and mortality in pregnant women.

Acute neurogenic stunned myocardium in a patient with Guillain-Barré syndrome: case report.

Autonomic dysfunction is a prevalent symptom of Guillain-Barré syndrome (GBS); cardiovascular involvement in this scenario has been mentioned infrequently in the literature. Case Presentation: A 65-year-old man with GBS presented with reversible left ventricular systolic failure. On first presentation, our patient had no history or indications of heart malfunction. During the clinical manifestation of his autonomic dysfunction, he had electrocardiographic alterations, modestly increased cardiac enzymes, significant left ventricular systolic dysfunction, and segmental wall motion irregularity. Once the initial episode was over, these anomalies and his symptoms resolved quickly. Discussion: We believe the reversible left ventricular dysfunction was caused by the toxic impact of elevated catecholamines as well as transiently injured sympathetic nerve endings in the myocardium, which was apparently caused by GBS. We recommend that echocardiography be performed in patients who exhibit clinical signs of autonomic dysfunction, particularly if they are associated with abnormal electrocardiographic findings, cardiac enzyme elevation, or hemodynamic instability, so that appropriate medical therapy can be instituted as soon as possible. Conclusion: GBS is a not a very rare situation in our context. Thus, doctors are supposed to know the life-threatening complications such as neurogenic stunned myocardium and be prepared to dodge it.

A rare case of cade oil poisoning complicated by acute pancreatitis and acute tubular necrosis.

Introduction: Cade oil is often used in traditional medicinal practices despite of its toxic effects, hence the occurrence of intoxication incidents often requiring intensive care. Case presentation: We present the case of a young patient with no prior medical history who was exposed to significant doses of Cade oil both on skin and ingested, and who subsequently developed an apyretic consciousness disorder warranting an admission to our ICU department for specialized management. Discussion: in this chapter we discuss the place of cade oil within Morocco's unsupervised medicinal practices. We also detail the spectrum of cade oil poisoning which is rarely reported in the literature, before discussing the therapeutic options. Conclusion: The phenol derivatives of Cade oil, which is still used frequently and widely, are responsible of an acute intoxication, mainly impairing the cardiovascular, respiratory and renal functions. A pancreatic involvement is rarely reported.

Acute ischemic stroke after first dose of inactivated COVID-19 vaccine: A case report.

The acute cerebral ischemia induced by the COVID-19 vaccine is one of the side effects. We report the first case of a patient who suffered from a neurological deficit mimicking a stroke after receiving his 1st dose of the inactivated COVID-19 vaccine BIBP (Sinopharm) and who mainly developed cerebral venous thrombosis. Our reported case is a 36-year-old man who was admitted to our intensive care unit 2 days after his first injection dose of the inactivated COVID-19 vaccine BIBP (Sinopharm). He presented a numbness in his left arm and legs with headaches 24 hours after the vaccine injection. In the second day, he had asymmetry of the face which was aggravated by the installation of disturbance of consciousness and a state of agitation. His vital signs were normal. A brain CT scan without injection was done showing a right deep parietal ischemic stroke. The treatment was initiated by aspirin. cerebral MRI showed a very extensive stroke ischemic in the superficial and deep right parietal territory with the onset of hemorrhagic rearrangement of the right basal ganglia, magnetic resonance imaging angiography of the supra-aortic trunks was normal. The patient gradually improved and was discharged after 15 days of his stay in the intensive care unit. The installation of ischemic stroke reported in our young patient after receiving his first dose of inactivated COVID-19 vaccine BIBP; could be a new immune response to the vaccine.

Factors influencing the length of stay in the moroccan intensive care unit in patients surviving critical COVID-19 infection.

Introduction: our objective is to determine the factors that influence the length of hospitalization of patients admitted to an intensive care unit. Methods: We have conducted a mono-centric retrospective cohort of 417 patients admitted in intensive care unit for a critical infection by COVID-19, for this purpose we have realized an analytical study using the linear regression model. Results: In our study, the average length of hospitalization for a critical infection with COVID-19 is 6 days (SD = 7Days), regarding the factors that influence the length of hospitalization, the length of time between the consultation and the onset of symptoms higher thann 8 days affects the length of hospitalization (coefficient = 1.2 days; CI = 0.769; 2.102 and pValue = 0.009), the presence of obesity which also affects the length of hospitalization (Coefficient = 1.6 days CI ((0.009; 3.265), and pValue = 0.049). During hospitalization, the use of mechanical ventilation, the use of tocilizumab, having a billateral nosocomial pneumonia are all factors that impact the length of hospitalization. Conclusion: It is recommended to emphasize the importance of early consultation after the onset of respiratory symptoms in the patients who are admitted to the intensive care unit in order to improve the length of their stay.

Pneumorachis and pneumocephalus: Case report of a rare blunt chest trauma complication.

INTRODUCTION: Pneumorachis, air in the spinal canal, is very rare and its association with pneumocephalus following blunt thoracic trauma remains exceptionally uncommon. CASE PRESENTATION: We present the case of a 65-year-old patient, a pedestrian hit by a car driving at very high speed. The lesion assessment on admission showed a bilateral hemothorax of moderate abundance, a right pneumothorax of low abundance and a left pneumothorax of moderate abundance, subcutaneous cervico-dorsal emphysema, pneumocephalus and significant pneumorachis at the cervico-dorsal level without fracture of the base of the skull, sinuses or the spine. DISCUSSION: We discuss the different etiologies of pneumorachis, the main hypotheses of the constitution of this air effusion and the principles of management. CONCLUSION: Pneumorachis associated with pneumocephalus in a traumatic context without bone lesions is an extremely rare entity, its discovery should lead to further investigations to look for any spinal or basilar skull fracturethat could expose to an infectious risk or require a surgical procedure.

A very rare case of chylomicronemia revealed by cerebral thrombophlebitis in a 4-month-old infant.

INTRODUCTION: Hyperchylomicronemia is a disorder of lipid's metabolism that can present fatal complications such us such venous or arterial thrombosis, pancreatitis, and cardiovascular incidents. CASE PRESENTATION: In this report case we report a 4months old patient who was admitted in the emergency room for hypotonia and during the blood sampling we were surprised by the macroscopic latescent aspect of the blood. During the investigations we found that the patient had a fatty cerebral venous thrombosis that revealed hyperchylomicronemia. Furthermore, the patient presented tuberculosis cerebral abscess and stage A pancreatitis and was successfully treated. DISCUSSION: Primary hypertriglyceridemia results from the accumulation of genes polymorphisms encoding for proteins involved in the triglycerides metabolism but before thinking about primary origin a secondary one should be pushed aside. Biological investigations should test lipoprotein lipase activity that can be absent or reduced to confirm a lipid disorder, then lipoprotein electrophoresis and genetic study can deliver the diagnosis. The management of this disease is based on low fat diet that should not be over than 25-30g per day, also statin, fibrate, omega 3 acid, heparin and insulin can be used. CONCLSUION: Adequate treatment and exploration permits to obtain the optimum care to avoid any complications.

Acute kidney injury in critically ill patients with COVID-19: prevalence, risk factors and mortality in eastern Morocco.

INTRODUCTION: Acute kidney injury (AKI) is commonly seen in critically ill hospitalized patients with COVID-19 and its incidence reaches 60% in this setting. The aim of this work was to determine the prevalence, characteristics, risk factors and mortality of AKI in patients admitted to the intensive care unit (ICU) for COVID-19. PATIENTS AND METHODS: This observational retrospective case series was conducted between February 1, 2020 and December 31, 2020 at the ICU of the university hospital Mohammed VI of Oujda, Morocco. all COVID-19 patients hospitalized in the ICU with acute respiratory failure were included. AKI was defined and classified into three stages using the KDIGO criteria 2012. We excluded patients with end-stage kidney disease and those who were under 18 years old. RESULTS: Six hundred adult patients were included and 65.5% of them were men. Sixty patients had minimal lung damage (< 25%), 105 patients had mild lung damage (25-50%), 186 had severe lung damage (50-75%) and 193 patients had very severe lung damage (> 75%). A total of 210 patients (35%) developed AKI, of whom 78 (37.2%) had mild AKI (stage 1) and 132 (62.8%) severe AKI (stages 2 and 3). Patients in the severe and mild AKI groups had a higher rate of comorbidities, especially hypertension (mild AKI [46.2%] vs. severe AKI [36.4%] vs. no AKI [27.4%], p = 0.002) and diabetes (mild AKI [52.6%] vs. severe AKI [33.3%] vs. no AKI [26.4%], p < 0.001). During hospitalization, 23.3% of patients with AKI received kidney replacement therapy. In-hospital mortality was observed in 51.3% for mild AKI, 55.3% for severe AKI and 21% in patients who did not have AKI (p < 0.001). CONCLUSION: Our findings revealed that not only severe AKI, but also mild AKI was correlated to in-hospital mortality. Whatever the severity of the kidney impairment, it remains a major prognostic element.

Mirizzi SD caused a rare case of Angiocholitis ictero-uremigene with shock septic: Case report and review of literature.

Introduction: Mirizzi syndrome is an obstructive jaundice caused by extrinsic compression of the common bile duct by a stone embedded in the cystic duct [1].Cholangitis is a diagnostic and therapeutic emergency whose main risk is that of septic shock [1]. It can also progress to "Ictero-Uremigenic Angiocholitis" associated with sometimes extremely serious renal failure [2]. Case presentation: We reported the case of a 73-year-old patient admitted to the emergency room with septic shock on severe cholangitis. Given the presence of acute febrile cholangitis with criteria of septic shock on the one hand and acute renal failure on the other hand, the diagnosis of ictero-uremigenic Angiocholitis was made. Discussion: Angiocholitis is an inflammation and infection of the bile ducts, the etiologies of which are diverse, among them: Mirizzi's syndrome [1].The anatomical basis of Mirizzi syndrome has generally been attributed to an abnormal relationship between the cystic duct and the common hepatic duct [3]. Angiocholitis constitutes a diagnostic and therapeutic emergency, its complications threaten the vital prognosis [4]. Ictero-uremigenic Angiocholitis where the septic component dominates represents a real picture of sepsis, cholestatic jaundice, oliguria with renal failure [2]. Conclusion: fortunately rare, but always to be feared, the ictero-uremigenic Angiocholitis produces a typical picture of Angiocholitis, accompanied by a serious septic shock which passes largely to the fore associating in a very short period of time an organic renal insufficiency [2], the Age over 70 is a serious factor, it constitutes a therapeutic emergency requiring desobstruction of the main bile duct and possibly recourse to hemodialysis [4].