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.

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.

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.