[Nemaline rod myopathy revealed by acute respiratory failure after an outpatient cataract surgery]

We report the case of a 63-year-old patient admitted to the ICU for an acute respiratory failure one week after an outpatient cataract surgery that revealed a nemaline rod myopathy. We present this rare myopathy whose particularities are its aetiology, which can be inherited, mostly with a congenital onset, or sporadic, and the variability of the age at presentation. We discuss the exceptional onset of severe unknown underlying diseases in the context of outpatient surgery.

[Prognosis of systemic diseases diagnosed in intensive care units]

OBJECTIVES

The aims of this study were to evaluate the prognosis of patients with systemic rheumatic disease diagnosed in medical intensive care unit (MICU) and to determine whether the outcome is different for patients with systemic rheumatic disease previously known hospitalized in MICU.

METHODS

Retrospective evaluation, over a ten-year period, of 88 cases of systemic rheumatic disease selected in two groups: group I: diagnosed in MICU, group II: previously known and treated.

RESULTS

Group I: 18 patients with necrotizing vasculitis (n = 6), extra-intestinal manifestations of inflammatory bowel disease (n = 4), systemic lupus erythematosus (n = 3), miscellaneous (n = 5). Group II: 70 patients with rheumatoid arthritis (n = 31), necrotizing vasculitis (n = 12), systemic lupus erythematosus (n = 12), polymyositis (n = 4), extra-intestinal manifestations of inflammatory bowel disease (n = 5), miscellaneous (n = 6). The main admission diagnoses were infectious diseases (p < 0.005) or iatrogenic complications in the group II (p < 0.01) and acute exacerbation of systemic rheumatic disease in the group I (p < 0.0001). Age; simplified acute physiologic score (SAPS); number of acute organ system failure; number of patients requiring mechanical ventilation, haemodialysis or right heart catheterization were not different between the two groups. The durations of mechanical ventilation and stay in the MICU were shorter in the group II (p < 0.005). MICU mortality rate was higher in the group II (p < 0.05), with a five years cumulative proportion of surviving statistically lower (p < 0.05). Mortality rate of the entire population (37.5%) was similar to that of a non-selected population with comparable SAPS. Multivariate analysis showed that SAPS, number of acute organ system failure and iatrogenic complications were the main prognostic factors (p = 0.05).

CONCLUSIONS

The prognosis was better for patients with systemic rheumatic disease diagnosed in MICU. Infectious diseases were the main cause of death, probably in relation with immunosuppressive treatments.

Adrenocortical function during septic shock

OBJECTIVE

To investigate, in patients with severe septic shock, the adrenocortical function assessed by daily plasma cortisol determinations during the first 72 h and by the short synthetic ACTH stimulation test performed within 24 h of the onset of shock.

DESIGN

Prospective clinical investigation.

SETTING

Medical intensive care unit in a university teaching hospital.

PATIENTS

40 consecutive patients with documented septic shock requiring at least hemodynamic resuscitation and respiratory support.

INTERVENTIONS

There were no interventions.

MEASUREMENTS AND RESULTS

Basal cortisol concentrations were increased with a mean value of 36.8 micrograms/dl (range 7.9-113). Of the overall cortisol determinations 92% were above 15 micrograms/dl. No statistically significant differences in basal cortisol concentrations were found when survival, type of infection, and positive blood cultures were considered. Patients with hepatic disease had significantly higher cortisol (50.1 (+/- 6.2) micrograms/dl versus 35.9(+/- 3.3) micrograms/dl, p = 0.035) levels compared to other patients. No correlations were found between basal plasma cortisol concentrations and factors such as SAPS, OSF, hemodynamic measurements, duration of shock, and amount of vasopressor and/or inotropic agents. Cortisol concentrations had significant but weak correlation with ACTH levels in survivors (r = 0.4; p = 0.03; n = 28) but not in non-survivors (r = 0.03; p = 0.85; n = 52). Cortisol levels in non-survivors increased significantly from enrollment time to the 72nd hour of the survey (day 1: 38.9(+/- 3.8) micrograms/dl versus day 3: 66.7(+/- 17.1) micrograms/dl; p = 0.046) and were significantly higher than those recorded in survivors. Responses to the short ACTH stimulation test were not significantly different between survivors and non-survivors. According to the different criteria used to interpret the response to the ACTH stimulation test, incidence of adrenocortical insufficiency was highly variable ranging from 6.25-75% in patients with septic shock. Only one patient had absolute adrenocortical insufficiency (basal cortisol level below 10 micrograms/dl; response to the ACTH stimulation test below 18 micrograms/dl).

CONCLUSION

Our data suggest that in a selected population of patients with severe septic shock single plasma cortisol determination has no predictive value. The short ACTH stimulation test performed within the first 24 h of onset shock can neither predict outcome nor estimate impairment in adrenocortical function in patients with high basal cortisol level. Adrenal insufficiency is rare in septic shock and should be suspected when cortisol level is below 15 micrograms/dl and then confirmed by a peak cortisol level lower than 18 micrograms/dl during the short ACTH stimulation test.

Hemodynamic changes in acute adrenal insufficiency

OBJECTIVE

Acute adrenocortical insufficiency is an unusual cause of isolated shock. The purpose of this study is to describe the cardiovascular changes in 6 patients with acute adrenal insufficiency presenting with hemodynamic instability.

DESIGN

Retrospective and prospective study.

SETTING

Medical intensive care unit in a university hospital.

PATIENTS

6 patients studied by right cardiac catheterization.

MEASUREMENTS AND RESULTS

Results before glucocorticoid treatment show two possible hemodynamic states: 1) myocardial depression with hypovolemia in 3 patients, and 2) hyperdynamic shock with high cardiac output and diminished systemic arterial resistance in 3 other patients. The 3 patients presenting hyperdynamic shock were all given intravenous fluid therapy of over 20 ml/kg before the first hemodynamic measurement. For 2 other patients with low cardiac index and high systemic arterial resistance studied prospectively, 20 ml/kg intravenous fluid therapy transformed the hemodynamic state to hyperdynamic shock. The cardiovascular effect of glucocorticoid treatment studied in 4 patients was resulted in an improvement in the left ventricular systolic work index.

CONCLUSIONS

Diagnosis of acute adrenocortical insufficiency must be considered if clinical manifestations are present suggesting septic shock without any obvious infectious cause in patients having undergone considerable intravenous fluid therapy as an initial course of treatment.

[Echocardiographic abnormalities in the stage IV of HIV infection]

Fifty patients in stage IV of HIV infection (including 41 AIDS patients) were prospectively studied by echocardiography. Thirteen of them showed abnormalities: 4 had pericardial effusion, 1 endocarditis, 7 myocardial disorders and 1 primary pulmonary arterial hypertension. Pericardial effusion, also present in patients who had pleuropulmonary Kaposi's sarcoma, was not specific. Myocardial disorders concerned the diastolic function in 1 case, the segmental kinetics in 2 cases and the whole systolic function in 4 cases (3 had congestive myocardiopathy and 1 had transient systole alteration without left ventricular dilatation). The mechanism of global left ventricular disorders was multifactorial, and several hypotheses were discussed: infectious myocarditis, adrenergic or nutritional deficiency myocarditis, cardiotoxicity of antiviral drugs, common pathology with HIV encephalopathy. The prognosis of congestive myocardiopathy was poor in AIDS patients and undetermined in stage IV non-AIDS patients. Echocardiography is capable of detecting these lesions, and its use may contribute to a better care of these patients.

[Iodoform poisoning. 3 cases]

Three cases of iodoform poisoning are described following dressings with 10% iodoform gauze (0.10 x 5 m) on extended wounds. Five, ten and sixteen days after the beginning of dressings, the patients became confuse, hallucinated, and one of them was subsequently comatose. Vomiting, fever, tachycardia with premature ventricular beats and shortening of P-R interval, slight increase of transaminases and proteinuria were observed. Within a few days (3 to 8) after the iodoform dressings were discontinued, the signs of iodoform toxicity disappeared. The toxicity of iodoform is probably unrecognized if the rarity of the observations published and the amount of iodoform gauzes annually sold are compared.

[Electroencephalographic silence after intoxication with a carbamate tranquilizer]

A case of acute meprobamate poisoning in a 43 year-old-woman is reported. Twenty five hours after admission in the intensive care unit, deep coma and cerebral electrical silence were observed whereas the meprobamate plasmatic concentration was 250 mg/l. The patient recovery was uneventful. Meprobamate analysis must be performed for unexplained coma with isoelectric EEG.

Urinary bladder distention presenting as venous obstruction and hypovolemic shock

A confused patient presented with hypovolemic shock and signs of arterial and venous obstruction of the left lower extremity; the correct diagnosis of urinary retention was made after phlebography. Vascular complication in bladder distention is unusual and diagnosis may require radiologic investigation.

Aluminium determination in the skin of patients with and without end-stage renal failure

Aluminium (Al) concentration in the skin was determined by inductively coupled plasma optical emission spectrometry to look for a correlation between Al exposure and skin content in patients with end-stage renal failure. Skin Al concentrations were higher in dialyzed patients than in the nondialyzed group (1.02 +/- 0.30 vs. 0.26 +/- 0.10 micrograms/g; p less than 0.001). Moreover, in the dialyzed group, the patients treated for more than 100 months had a higher concentration of Al in the skin than the others (1.20 +/- 0.26 vs. 0.80 +/- 0.18 micrograms/g; p less than 0.05). Al skin content correlated better with the deferoxamine infusion test (DIT) than with Al blood plasma concentration. In conclusion, our data confirm that the DIT is a valuable tool for the evaluation of body Al content.