[Identification of plasmid-encoded cephalosporinase ACC-1 among various enterobacteria (Klebsiella pneumoniae, Proteus mirabilis, Salmonella) isolated from a Tunisian hospital (Sfax 997-2000)]

Because a multiresistant K. pneumoniae outbreak detected in an intensive care unit of a parisian hospital, combined to the production of the plasmid-encoded cephalosporinase ACC-1, a probable importation via a patient was suggested from another country (Tunisia). The investigation was conducted to examine 35 clinical strains of enterobacteria resistant to ceftazidime without synergy towards Augmentin. Other test of synergy with two inhibitors, BRL 42715, Ro 48-5545 was performed by diffusion method and deposit of 10 micrograms of inhibitor on disks containing ceftazidime, cefoxitin and cefotetan. Synergies were obtained suggesting a probable production of ACC-1 type among six isolates of K. pneumoniae (two), Proteus mirabilis (one) and Salmonella (three) issued from different units. The isoelectric focusing on gel revealed at least one band of beta-lactamase activity at 7.8 but also demonstrated the simultaneous production of several probable beta-lactamases including TEM-type, SHV-2 and ACC-1 among S. enterica ser. Livingstone. The PCR of the gene blaacc-1 was positive. The sequencing (1160 pb) of two products showed high identity (99-100%) with the gene blaacc-1 deposited in 1999. Finally the ACC-1 type reported in Tunisia was probably imported in France via a patient. Because a simultaneous synthesis of ESBL and ACC-1 type, its presence may be invisible and need more investigation.

Intrauterine exchange transfusion of the fetus under ultrasound guidance: first successful report

The authors report the first successful case of fetal exchange transfusion performed in Rh disease. The patient was a gravida 3, para 1; a first ultrasound guided intra-funicular transfusion was carried out at 28 gestation weeks (Coombs test: 256, Liley's chart: zone III, fetal hemoglobin: 5.7 g/l). One week later a fetal exchange transfusion was decided because of the appearance of ascites, sinusoidal heart rate pattern, and Manning's score at 4. At 29 weeks of gestation an ultrasound-guided umbilical cord puncture was performed with a 16-gauge Tuohy needle, a catheter for epidural analgesia (Perifix) was inserted through the trocar. A total exchange of +126/-96 cm3 of 50% hematocrit (Hct) concentrated and irradiated blood without leukocyte and platelet was performed increasing fetal hemoglobin concentration from 3.9 to 11.9 g/l. A 2,040-gram girl was delivered by cesarean section at 33 gestation weeks with Apgar score of 7/9/9 and she was given 4 total exchange transfusions in the Neonatal Intensive Care Unit. Two years later her development is normal. This new procedure seems easier than fetoscopy to achieve umbilical cord puncture and avoid excess blood volume while exact correction of anemia is possible. With more concentrated blood (70% Hct) the duration of the procedure is shortened.

[A simplified severity index in resuscitation. Validation by a prospective study (280 cases)]

The index studied (simplified acute physiology score, or SAPS) is calculated from 14 measurable clinical and laboratory data obtained during the first 24 hours from admission. It was tested in a prospective study involving 280 consecutive patients treated in a 16-bed intensive care unit. Good correlations were found between SAPS and mortality rate and between SAPS and the two most widely used scoring systems: the Knaus index or APS (acute physiology score) and the Cullen index or TISS (therapeutic intervention scoring system), both evaluating therapeutic effectiveness. SAPS data being easy to collect, the simplified index could be used in many intensive care units or even applied to old case-records. Its main value lies in comparisons between two groups of patients with the same death probability and in evaluations of activities in intensive care units.

[Fatal poisoning by alcohol-free aniseed aperitif]

A case of chronic poisoning with alcohol-free "pastis" leading to the death of a 32 year old alcoholic patient is reported. The mean daily amount of ingested glycyrrhizinic acid was 0.35 g. "Torsades de pointes" secondary to severe hypokalemia were observed and prolonged cardiac arrest occurred. There was evidence of chronic hypokalemic myopathy and of rhabdomyolysis with acute renal failure. Furthermore, the origin of an associated cardiomyopathy is discussed.

Lacrimal drainage system inflammatory masses from retained silicone tubing

In two cases studied we found inflammatory masses of the lacrimal system associated with retained silicone material. We saw the first patient two years after a failed dacryocystorhinostomy. A mass of the superior punctum mimicking a lacrimal sac or canalicular neoplasm consisted of chronic granulomatous inflammation centered around retained silicone tubing. In the second patient, a foreign body giant cell inflammatory reaction occurred in the lacrimal sac in which there were retained knots of silicone tubing. We believed the inflammation in these patients to be caused by the knots and the cut ends of the silicone tubing present in the lacrimal drainage system.

[Echographic image of gallbladder partitioning. 8 cases]

Correlations between ultrasonographic and pathological findings were studied in 8 patients presenting "partitions" of the gallbladder. These partitions were due to an acute cholecystitis in 7 patients. This ultrasonographic image appears to be a clinically significant valid finding of cholecystitis.

[Semiology of pseudotumoral forms of hydatid cyst of the liver. Apropos of 7 cases]

Seven hydatid cysts of the liver were detected by ultrasound and confirmed surgically. On ultrasound scans they were mimicked tumors (Type IV according to the classification established by W. Hassine) and there was a high level of echoes. Two masses were surrounded by a spiral completely free of echoes. Five masses were limited by a border completely free of echoes.