Risk factors for critical forms of SARS-CoV-2 infection in fully vaccinated patients: a prospective observational study

The novel coronavirus disease of 2019 (COVID-19) vaccination is a critical prevention measure to help sort out the COVID-19 crisis. Nonetheless, since the beginning of the pandemic, it has been well-documented that older adults as well as people enduring an immunocompromised condition are the most likely to develop a severe COVID-19 form owing to a less robust immune system and therefore a weaker immunologic response to COVID-19 vaccination. Herein, we report an observational prospective monocentric study of a series made up of 30 patients fully vaccinated against Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) out of a total of 139 patients admitted to the medical intensive care unit (ICU) for a critical form of COVID-19 between February 2021 and October 2021. This observational study was conducted during the peak of the pandemic outbreak and therefore its main aim was to describe the epidemiological and sociodemographic features of fully vaccinated patients who endured critical forms of COVID-19. Immunocompromised people as well as those with chronic underlying comorbidities are more likely to develop critical forms of COVID-19. Moreover, it seems that vaccine efficacy decreases gradually over time. SARS-CoV-2 variants may also undermine vaccine effectiveness. Supplemental doses would be of paramount in higher-risk people to build on protective immunity against COVID-19. Further randomized controlled trials are also desperately needed to determine the optimal interval between primary series and booster doses of the several COVID-19 vaccines chiefly for the vulnerable people.

Neutrophil-Lymphocyte Ratio as a Prognostic Factor for 15-Day Mortality of Patients infected in ICU

Introduction

The determination of the groups at risk of death at admission in patients with bacterial infection in the ICU is important. Several prognostic factors have already been identified, however the neutrophil/lymphocyte ratio (NLR) has the advantage of being common and inexpensive.

Objective

To determine the threshold value of NLR to determine the group at risk of 15-day mortality and the overall survival of patients according to this threshold.

Methods

This was a retrospective cohort conducted in the intensive care unit of the Ibn Rochd University Hospital in Casablanca over a period of 2 years (January 2019 - January 2021), among hospitalized patients with bacterial infection, acquired or nosocomial. The sample size was calculated a priori and multivariate statistical analyses (multiple logistic regression, Youden index and Kaplan Meier survival estimation and Log Rank) were performed using Rstudio software. The significance level was less than 5%.

Results

A total of 200 patients were included in the study, 136 patients were alive at 15 days, there were no differences in age between the two groups. Factors associated with patient mortality at 15 days were: gender, use of vasoactive drugs, use of mechanical ventilation, type of sepsis, site of infection, SOFA score (p < 0.000), Apache score (p = 0.009) and NLR at admission (p = 0.001). The cut-off value for NLR was 15.07 with a mean discriminant value of 64.1%. The difference in median overall survival of patients in the two groups according to the threshold value was statistically significant 22 +/- 1.9 days and 11 +/-1.12 days (p = 0.042).

Conclusions

The NLR appears to be a prognostic factor for 15-day mortality. The knowledge of prognostic factors and threshold values of these indicators allow the prediction of at-risk groups in order to best adapt their management.

Key messages

The use of common and inexpensive biological prognostic markers are a reliable alternative to identify at-risk patients to optimize their management in developing countries. The RNL is a good biological prognostic markers of mortality of patients infected in ICU.

Myasthenia gravis in an old woman discovered during sedation for diagnostic digestive fibroscopy: Case report

Introduction and importance: Myasthenia gravis is an autoimmune disease characterized by the destruction of postsynaptic acetylcholine receptors in skeletal striated muscles. It is most common in young women. Myasthenia can be diagnosed by the detection of anti-acetylcholine receptor antibodies. Treatment includes anticholinesterase drugs, thymectomy, and restricting drugs that may aggravate myasthenia. The authors report a rare case of accidental revelation of myasthenia gravis in an elderly woman during sedation for diagnostic gastrointestinal fibroscopy. Case presentation: A 85-years-old female patient scheduled for diagnostic gastrointestinal fibroscopy presented signs of myasthenic crisis during the perioperative with severe respiratory failure. The diagnosis of myasthenia was confirmed by bioassay and electromyogram (EMG). Her chest CT scan showed a thymoma. The evolution was favorable as a result of early and appropriate management. Conclusion: Myasthenia can occur in perioperative settings outside the usual circumstances. The prognosis depends on early and adapted management.

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Myasthenia gravis is rare in women of advanced age.

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The myasthenic crisis can be inaugural of the disease whatever the age without distinction of sex.

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This case reports a form of discovery of the myasthenic crisis outside the usual circumstance.

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The early diagnosis and the implementation of a medical treatment allow extubating the patient quickly and successfully.

COVID-19: Patient care after discharge from the Intensive Care Unit

INTRODUCTION

The Ibn Rochd CHU is a tertiary care structure that provides care for the most severe cases of COVID-19 requiring hospitalisation in intensive care. The objective of study is to describe the complementary medical and psychological care of patients with COVID-19 in the endocrinology department after a stay in intensive care.

PATIENTS AND METHODS

This is a descriptive observational study of patients transferred from the intensive care unit to the endocrinology service following a COVID-19 infection during the period from 17 April 2020 to May 26, 2020. Clinical characteristics of the patients and complications related to COVID-19 infection were studied; a nutritional assessment using the MNA nutritional status assessment questionnaire; psychological assessment using quality-of-life questionnaires (Hamilton depression and anxiety, HAD, SF36, PCLS); a treatment satisfaction questionnaire (TQCMII) and an assessment of patient autonomy by the ADL score.

RESULT

Our study included 41 patients with an average age of 55 years (19-85 years), a sex ratio M/F of 1.05, 43.9% were diabetic, 34.1% hypertensive, 4.9% asthmatic and 5% obese, and 51.2% were severe and critical cases. The average ICU stay is 8.42 days, requiring intubation in 12.2% of cases. All patients were treated with the Hydroxychloroquine, Azithromycin, vitamin C, zinc and corticosteroid protocol, 14.6% had undernutrition and 65.9% had a risk of undernutrition. The average BMI was 25.34 kg/m² (17-42), 61% had experienced weight loss, which was greater than 8 kg in 26.1% of cases, 12.2% of patients were not autonomous, 12.2% had moderate depression, 2.4% severe depression, 14.6% mild to moderate anxiety, 12.2% severe anxiety and 29.3% suffered acute post-traumatic stress disorder.

CONCLUSION

Patients with COVID-19 are, in addition to the complications from coronavirus infection, vulnerable to undernutrition, psychological and motor complications. Additional care before discharge is essential for better integration of patients into their families.

Acute spontaneous hematoma of the corpus callosum in a COVID-19 patient: a case report

Neurovascular involvement is a frequent occurring reported in COVID-19 patients. However, spontaneous hematomas of the corpus callosum are exceptionally seen. The authors of this article aim to report an unusual case of corpus callosum hematoma in a COVID-19 patient and discuss potential etiologies and mechanisms responsible for intracranial hemorrhage.

Nutritional status assessment in patients with Covid-19 after discharge from the intensive care unit

Introduction

The nutritional diagnosis and early nutritional management of COVID-19 patients must be integrated into the overall therapeutic strategy.

The aim of our study is to assess the nutritional status of patients with COVID-19 after a stay in intensive care, to describe the prevalence of undernutrition, to determine the factors influencing undernutrition and to describe the nutritional management.

Tools and methods

This is a descriptive observational study of adult patients admitted to the endocrinology service for additional care after a stay in intensive care during the period from April 17, 2020 to May 26, 2020. The assessment tool used was the Mini Nutritional Assessment (MNA).

Results

Our study included 41 patients; the average age of the patients was 55 years, 51.2% had a severe or critical form of COVID-19, 75.6% stayed in intensive care, 12.2% had a loss of autonomy. The average BMI was 25.2 kg/m² (17–42 kg/m²), 42.5% were overweight, 61% had weight loss, 26.2% had weight loss greater than 10%, 14.6% of our patients were undernourished, 65.9% were at risk of undernutrition, 19.5% had hypoalbuminemia, 17.1% had hypoprotidemia, 19.5% hypocalcemia, 34.1% anemia, 12.2% hypomagnesemia and 51.2% had a deficiency in vitamin D. A positive correlation was found between poor nutritional status and a longer stay in intensive care (>5 days) (p = 0.011) and lymphopenia (p = 0,02).

Conclusion

Despite a personalized diet, 14.6% of patients presented undernutrition. Particular attention should be paid to patients with a long stay in intensive care.

Coronavirus disease-19 (COVID-19) associated with acute pancreatitis: case report

The SARS-CoV-2 primarily attacks the respiratory system and the most common symptoms include cough, shortness of breath, and fever. However, its tropism for the digestive system has been demonstrated and its clinical digestive manifestations are increasingly recognized. Nevertheless, little attention has been paid to pancreatic lesions included in SARS-CoV-2 infection. This case describes the presentation of acute pancreatitis as a complication associated with SARS-CoV-2 infection and the importance of looking for this complication in any patient with COVID-19. Data was collected from a patient admitted with COVID-19 to intensive care in July 2020. The patient was diagnosed with acute pancreatitis associated with SARS-CoV-2. Other causes of acute pancreatitis were excluded for both patients (including alcohol, obstruction/gallstones, drugs, trauma, hypertriglyceridemia, hypercalcemia). This case highlights acute pancreatitis as a complication associated with COVID-19 and highlights the importance of measuring lipasemia and performing an abdominal computed tomography (CT) scan in patients with COVID-19.

COVID-19 and fortuitous discovery of chronic lymphocytic leukemia: biological findings and therapeutic challenges

With the major spread of SARS-COV-2 around the world, its association with various pathologies has been reported. However, hemopathy has rarely been revealed during a coronavirus infection. The authors of this article aim to emphasize the diagnostic and therapeutic challenges faced while treating COVID/hemopathy patients.

Syndrome de sécrétion inappropriée d’hormone antidiurétique secondaire à la rispéridone et la carbamazépine: à propos d’un cas

Le syndrome de sécrétion inappropriée de l'hormone antidiurétique (SIADH) représenterait environ 50% de tous les cas diagnostiqués d'hyponatrémie. Seule une faible proportion de SIADH serait d'origine médicamenteuse. Nous rapportons le cas d'une patiente suivie pour un trouble schizo-affectif qui a développé le SIADH après avoir commencé un traitement à base de la rispéridone et la carbamazépine. Les résultats des tests biochimiques suggéraient un SIADH secondaire à l'utilisation de la rispéridone et la carbamazépine. La patiente a été traitée avec succès par l'arrêt des deux médicaments et une restriction hydrique. Après correction de la natrémie la décision thérapeutique était de mettre la patiente sous clozapine. Elle est actuellement sous 400mg avec des taux de natrémie stables. Les psychiatres doivent être conscients du risque d'hyponatrémie sévère associé aux médicaments psychotropes. Il est donc primordial de surveiller les électrolytes, en particulier le sodium, chez les patients prenant des antipsychotiques et des anticonvulsivants.

Intravenous immunoglobulin vs plasma exchange in treatment of mechanically ventilated adults with Guillain-Barré syndrome

Introduction

The aim of the study is to compare efficacy of IvIg versus PE in treatment of mechanically ventilation adults with GBS in intensive care unit.

Methods

It is a prospective, non randomized study, realized in a medical ICU from 2006 to 2010. We included all patients with GBS who required mechanical ventilation (MV). We defined two groups: group 1 (group treated by IvIg: 0.4 g/kg/day for 5 days) and group 2 (group treated by PE: 4 PE during 10-14 days). We collected demographic characteristics, clinical and therapeutic aspects and outcome. Statistical analysis used: The quantitative variables are expressed on mean ± standard derivation and compared by Student test. The statistic analysis has been based on SPSS for windows. P < 0.05 is considered as significant.

Results

Forty-one patients (21 in group 1 and 20 in group 2) were enrolled. The mean age was 37.4 ± 9.2 years, with a masculine predominance (75.4%). Electromyogram in all patients found acute inflammatory demyelinating polyradiculoneuropathy in 80.5% of patients. The mean length of hospitalization was 45.3 ± 9.2 days. The length of hospitalization of the IvIg group is less long than PE group (p = 0.03). The weaning of the MV was more precocious in IvIg group than PE group (p = 0.01). Also, the beginning of motility recuperation was precocious at IvIg group than PE group (p = 0.04).

Conclusion

Our work reveals a meaningful difference for the MV weaning and precocious recovery in IvIg group compared to PE group.

[Does hypertension impact on the mortality of hemodialysis patients?]

Hypertension is very common in standard haemodialysis patients in spite of a wide use of antihypertensive medications. Up to the last decade it was reported in dialysis nts, as in the general population, as a powerful mortality risk factor. More recently several reports have challenged this view, and hypotension rather than hypertension has been claimed as the real culprit. That a risk factor has an opposite effect on mortality in conditions such as dialysis than in the general population has been termed - reverse epidemiology ,,, and suggests that our therapeutic approach toward blood pressure control in dialysis should be reconsidered. In fact, this counter intuitive concept is explained by the effect of time. Hypertension is a long-term mortality risk factor, that in a population crippled by short-acting risk factors (e.g. diabetes, congestive heart failure, malnutrition...) has not the opportunity to express itself. The clear cut noxious effect of hypertension on mortality in the years when dialysis patients were young and fit has disappeared in the present aged and highly co-morbid population. This does not mean that hypertension becomes beneficial once dialysis has been started. Hypotension is a marker of a high risk of early mortality, hypertension is a cause of late mortality. There is no evidence that hypertension might be protective in dialysis patients. Avoiding hypertension remains a capital goal of maintenance dialysis.

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.

Colistin and rifampicin in the treatment of nosocomial infections from multiresistant Acinetobacter baumannii

INTRODUCTION

The increased incidence of nosocomial infections by multi-drug resistant Acinetobacter baumannii creates demand on the application of some combinations of older antimicrobials on that species. We conducted the present observational study to evaluate the efficacy of intravenous and aerosolized colistin combined with rifampicin in the treatment of critically patients with nosocomial infections caused by multiresistant A. baumannii.

PATIENTS AND METHODS

Critically ill patients with nosocomial infections caused by A. baumannii resistant to all antibiotics except colistin in a medical intensive care unit. Diagnosis of infection was based on clinical data and isolation of bacteria. The bacterial susceptibilities to colistin were tested. Clinical response to colistin+rifampicin was evaluated.

RESULTS

Twenty-six patients (43.58+/-18.29 years, Acute Physiology and Chronic Health Evaluation II Score (APACHE II): 6.35+/-2.99), of whom 16 cases of nosocomial pneumonia treated by aerosolized colistin (1x10(6) IU three times/day) associated with intravenous rifampicin (10 mg/kg every 12h), nine cases of bacteraemia treated by intravenous colistin (2x10(6)IU three times/day) associated with intravenous rifampicin (10 mg/kg every 12h) in which three cases associated with ventilator associated pneumonia and one case of nosocomial meningitis treated by intrathecal use of colistin associated with intravenous rifampicin. The clinical evolution was favourable for all ill patients. Concerning side effects, we have noticed a moderate hepatic cytolysis in three patients.

CONCLUSION

This is the first clinical report of colistin combined with rifampicin for treatment of A. baumannii infection. Despite the lack of a control group and the limited number of patients, the results seem to be encouraging.