Aspects électrophysiologiques du syndrome intermédiaire au cours des intoxications aux organophosphorés

Acute organophosphate poisoning, whether accidental or suicidal, is frequent in developing countries and produces significant morbidity and mortality. Organophosphates inhibit cholinesterase activity at the neuromuscular junction and cause extensive muscle paralysis, particularly for respiratory function. Poisonings evolve in three stages: cholinesterase crisis, intermediate syndrome and delayed neuropathy. Electrophysiological aspects have been poorly studied. We report the case of a 25-year-old woman admitted to intensive care unit with muscarinic signs and respiratory failure after attempted suicidal organophosphate poisoning. Cholinesterase activity was low and the electrophysiological study disclosed the characteristic aspect of intermediate syndrome. The patient died due to septic complications. This syndrome is exceptional with a poorly understood pathophysiology. The electrophysiological study is essential for diagnosis.

Paludisme grave d'importation chez l'adulte: étude rétrospective de dix cas admis en réanimation à Casablanca

INTRODUCTION

We report a retrospective study in the medical intensive care unit of the Casablanca Ibn-Rochd University hospital.

MATERIAL AND METHODS

All patients over 14 years of age with falciparum malaria, who were admitted to ICUs between 1996 and 2001, were included. The main epidemiological features, criteria of admission, treatment, and outcome were investigated.

RESULTS

Ten patients were included for severe imported malaria. The mean age was 32+/-4 years. All patients had acquired falciparum malaria in sub-Saharan Africa. Chemoprophylaxis was inadequate in all patients. The mean time from symptom onset to treatment initiation was 9+/-2 days. Criteria of admission were impaired consciousness (7), acute renal failure (4), and respiratory distress (3). The most worrying factors were the severity of consciousness disorders, the acute respiratory distress syndrome, the metabolic acidosis, and the refractory shock. All patients presented with nosocomial respiratory infection related to Gram-negative bacilli, in the evolution. All patients received quinine therapy with loading dose and symptomatic treatment. Five patients died.

CONCLUSION

The lethality of severe imported malaria is still high despite optimal management in ICUs. Improving chemoprophylaxis and an earlier diagnosis may reduce significantly the mortality rate.

Aspects cliniques et électrophysiologiques de l’intoxication aiguë aux organophosphorés

INTRODUCTION

Acute organophosphate (OP) intoxications, accidental or voluntary, are responsible for a high mortality. They cause extensive muscular paralysis by acetyl cholinesterase activity inhibition at the neuromuscular junction level.

AIM

To underline the rarity and the characteristic electrophysiological pattern during cholinergic crisis.

OBSERVATION

A 28-year-old woman was admitted to the medical intensive care unit for Malathion acute intoxication with signs of glandular hypersecretion, complicated tetraparesis, and respiratory distress. The cholinesterase activity was 17%. The electroneuromyography showed multiple motor responses to the same stimulation, which is characteristic of the cholinergic crisis. Other electrophysiological parameters, in particular low-frequency repetitive stimulations, were normal. The evolution was favourable after symptomatic treatment and respiratory assistance.

DISCUSSION AND CONCLUSIONS

Organophosphate intoxications evolve in three phases: acute cholinergic crisis, intermediate syndrome, and delayed neuropathy. While the electrophysiological aspects of delayed neuropathy are best characterized, those of crisis and intermediate syndrome remain very little studied. The persistence of acetylcholine in the synaptic slit would explain the multiple motor responses to single stimulation during the crisis.

Rhabdomyolyse et intoxication à la paraphénylène-diamine

OBJECTIVE

The aim of this study is to describe clinical description, biological findings, outcome and prognostic factors of paraphenylene-diamine poisoning.

PATIENTS AND METHODS

We report a cohort study spreaded over 6 years (1999-2004), realized in Medical Intensive Care Unit in Ibn-Rochd University Hospital at Casablanca (Morocco). This study included 315 patients admitted for paraphenylene-diamine (PPD) poisoning. Diagnosis was based on: poisoning reported by the patient or his family, clinical data, biological findings and qualitative determination of PPD. Epidemiological parameters was obtained at admission. Every day, clinical and biological data, therapy and gravity scores were collected and a mean was calculated.

RESULTS

315 patients were admitted over this period. The mean age was 23+/-9 years. We noticed a clear female predominance (sex-ratio=9.86). The intoxication was voluntarily aiming at autolysis in 93.3% of the cases. The patients were admitted at about 5+/-5.3 hours after the intoxication. The clinical chart was at first dominated by the respiratory and renal symptoms. The mean of CPK was 132,351.8+/-164,978 UI/l. The treatment was especially symptomatic. The mortality was 47%. The multivariate analysis concluded that acid urinary pH, hyperglycaemia, hard muscles, betamimetic drugs and MPM II>0.14 were associated with a poor prognosis.

CONCLUSION

The PPD poisoning represents the first cause of toxic rhabdomyolysis in our context and responsible of high mortality. For that, it's necessary to control PPD trade, to inform the medical persons and a rapid management.

Cryptococcose neuroméningée chez un sujet immunocompétent

The authors report a case of cryptococcal neuromeningitis (CNM) in a 27-year-old man, non HIV-infected, with a normal CD(4) T-lymphocyte count. He had a clinical history of subacute meningitis. The evolution was fatal. CNM is a rare infection the prognosis of which remains bad, even in immunocompetent patient.

[The intermediate syndrome during organophosphorus pesticide poisoning]

Acute intoxication by organophosphate pesticides is frequent in Morocco. We report two cases of malathion poisoning complicated by intermediate syndrome. The purpose of this work is to describe distinctive features of this syndrome, it arises 48-96 h after the cholinergic crisis and it is characterized by respiratory paresis with difficulties of weaning from the assisted respiratory, deficit of proximal limbs, neck flexors, and cranial nerves. This syndrome coincides with the prolonged inhibition of the acetylcholinesterase, and is not due to the necrosis of muscular fiber's necrosis. Both clinical and electromyographic features are explained by a combined pre- and postsynaptic dysfunction of the neuromuscular transmission. The difficulty of this syndrome lies in its rarity and also its severity, because of the respiratory failure, which justifies medical supervision in intensive care unit, for at least 96 h, in expectation for the respiratory distress, all the more cholinergic syndrome is intense.

[Botulism in Casablanca. (11 cases)]

Botulism is a rare but severe disease. Whereas until 1980, only one case of botulism had been reported in our department, in 1999, a real botulism epidemic took place in Morocco. To our knowledge, it's the first outbreak of that kind in Morocco. We report here an epidemiologic and descriptive study of 11 patients suffering from botulism, admitted at the Infectious Diseases department and in the Medical Intensive Care Unit of Ibn Rochd University Hospital, from August, the 10th to October, the 1st, 1999. Clinical diagnosis of botulism was made, at the admission, on ocular signs (diplopia, ptosis), swallowing troubles and/or muscle weakness. There was no fever, no trouble of conscience and normal reflexes, at the early stage of the disease. The average age of patients was of 23.9 years +/- 12.07. Three patients were first admitted in the Medical Intensive Care Unit. The period before symptom appearance varied between 7 and 96 hours. Dysphagia sore throat, dry mouth and dysphonia were always found in all patients, with normal conscience. The fever was noted in 3 cases, polypnea in 3 cases leading to respiratory assistance in 2 cases. Neurologic findings were dominated by ptosis and hypotonia. The search of botulism toxin B in blood was positive in 6 cases. The electromyography showed clear signs of botulism. The evolution was favourable in 10 cases. Respiratory complications were found in 2 cases and infectious complications in 4 cases. One patient died. The period of hospitalization varied between 10 to 24 days with an average stay of 15.8 days. Eating "mortadella" has been noticed in 7 patients) and investigations permitted to identify the factory of "mortadella" as well as the toxin's type B responsible for these poisoning. It appears clearly that it is important to reinforce hygiene controls. Physicians and specialists in public health must be aware of the severity of this illness, knowing that the recovery is shortened when the treatment is administered on an early stage of the disease.

[Phantom thoracic opacity]

The etiology of the respiratory distress syndrome is dominated by pulmonary edema and the septic shock. We report a rare etiology of a respiratory distress secondary to a rupture of a well treated tuberculous latero-tracheal adenopathy. A 24-year-old woman was treated a year ago for a peripheral and mediastinal lymph node tuberculosis confirmed by the biopsy of a left supra clavicular adenopathy, by two months of isoniazid-rifampicin-pyrazinamide-ethambutol and seven months of isoniazid-rifampicin. The patient completed 9 month treatment with a good clinical and radiology course. Two months after stopping the antibacillary treatment, the patient was admitted to an intensive care unit with a respiratory distress syndrome requiring both intubation and artificial ventilation. The bronchial aspiration brought back plain pus. The telethorax from admission was normal and the retrospective history suggested the diagnostic of a ganglio-bronchial fistula which was confirmed by bronchial fibroscopy demonstrating right latero-tracheal fistula. The course was good with recovery of consciousness on the seventh day. Direct bacilloscopies and culture were negative. The digestive fibroscopy was normal. Finally, fistulization of a tuberculous adenopathy must be considered among the etiologies of respiratory distress even in a patient appropriately treated for mediastinal lymph node tuberculosis.

[Combination of Emla cream and nitrous oxide for venous cannulation in children]

OBJECTIVE

To assess the efficacy of an combination of Emla cream and N2O for venous cannulation in children.

STUDY DESIGN

Prospective, randomized, double blind trial.

PATIENTS

The study included 75 unpremedicated children, aged 3 months to 5 years, ASA physical class I and II, undergoing an elective surgical procedure, randomized into three groups.

METHODS

In group I and III, children received Emla cream one hour before entering the theatre. In group II, children received a placebo. Children of group I and III also inhaled 50 vol% nitrous oxide in oxygen and those of groupe II 100 vol% oxygen, 3 min prior and during venous cannulation. A blinded observer recorded the following items: pain assessment with CHEOPS scoring, conditions of venous puncture and behaviour of children. Heart rate, blood pressure and oxygen saturation were assessed at three timepoints: before, 3 min after facial mask application and following venous cannulation.

RESULTS

There were non significant differences between the three groups for the conditions of venous cannulation. The CHEOPS score was better in group I (7[4-11]), compared to group II (10[6-13]; P < 0.01) and to group III (9[6-12]; P < 0.01).

CONCLUSION

Emla cream combined with nitrous oxide is effective for venous cannulation in providing satisfactory analgesia and in controlling anxiety elicited by the vision of needle.

[Intermediary syndrome in acute malathion poisoning]

BACKGROUND

Acute poisoning by an organophosphorus insecticide is frequently observed in Morocco. We report a case of malathion poisoning complicated by an intermediate syndrome.

CASE REPORT

A 42-year-old woman was hospitalized 3 hours after ingestion of 50 g of malathion. Intubation and ventilatory assistance was required due to failing consciousness and bronchial plugging. On day 4, a neurological syndrome suggestive of the intermediary syndrome with diaphragmatic palsy made it necessary to continue ventilatory assistance to day 20.

DISCUSSION

The intermediary syndrome occurs 24 to 96 hours after the acute cholinergic phase of organophosphorus poisoning. It consists of an exclusive neuromuscular involvement. The intermediate syndrome is confined to an abnormality of neuromuscular function in specific muscle groups: proximal limb muscles, neck flexors, motor cranial nerves and respiratory muscles, with difficult weaning from respiratory assistance. The intermediary syndrome is quite uncommon. The risk of respiratory failure emphasizes the need for close monitoring in an intensive care setting for at least 96 hours, depending on the intensity of the cholinergic syndrome.

[Mesenteric infarction secondary to antithrombin III deficiency]

AT III is a physiologic inhibitor of blood clot formation: its deficiency is manifested by venous thrombosis. The authors reported case of mesenteric venous infarction in a 42-years-old woman. AT III deficiency was transient and caused by an oral contraceptive. In patients with AT III acquired deficiency it is necessary to suppress any risk factors of venous thrombosis.

[Severe cerebral lesions in pregnancy toxemia]

The authors report a case of pre-eclamptic toxemia, characterised by extensive cortical, sub-cortical and vertebro-basilar neurological lesions. The appearance of these lesions and their course were suggestive of the role played by toxemic vasculitis and vasospasm.

[Pulmonary edema following laryngospasm in a child]

A case is reported of a pulmonary oedema secondary to a laryngospasm in a 10-year-old child during a scheduled orchidopexy. Anaesthesia was induced with 50% nitrous oxide in oxygen and halothane via a face mask. Pulmonary oedema occurred before the relief of the laryngospasm and its course was uneventful after tracheal intubation and mechanical ventilation with PEEP. Hydrostatic forces or an increased capillary permeability are likely causes of the oedema. The outcome is usually favourable.

[Block of spermatic cord in surgery of the testis]

This study analyses 25 cases of spermatic cord blockade for scrotal surgery (hydrocele, spermatocele, tumor of epididymis). The spermatic cord was infiltrated, after identification of the pubic tubercle, with a mean total dose of 17 +/- 3 ml of a 2% lidocaine solution not containing adrenaline. The scrotal skin was infiltrated separately at the site of incision. Analgesia was excellent in 22 patients. The duration of analgesia was 82 +/- 33 min. No adverse effects occurred. It is concluded that the blockade of the spermatic cord is a convenient anaesthesia technique for testicular surgery.

[An unusual case of HELLP syndrome]

The Hellp's syndrome is a complication of gravidic hypertension which associates the microangiopathic hemolysis, the cytolytic hepatic anomalies and a thrombocytopenia. There are resemblences between the biologic and histologic forms of the thrombotic microangiopathy and Hellp's syndrome. In this publishing, we report one case of Hellp's syndrome which the particular character is that the hepatic and hemolytic biologic anomalies are still very discrete, where as the thrombopenia is deep; this led us to rediscuss about the authencity of Hellp's syndrome. A neurologic complication, particulary gravissim, is noticed in one case, it concerns the intracerebral hematoma with left deficiency syndrome.