Hyperbaric oxygen therapy for vaso-occlusive crises in nine patients with sickle-cell disease

INTRODUCTION

Vaso-occlusive crisis (VOC) is the most frequent complication of sickle-cell disease and is associated with significant acute bone pain.

OBJECTIVE

To evaluate the feasibility and efficacy of hyperbaric oxygen therapy (HBOT) for severe VOC.

METHODS

We report our retrospective experience with HBOT in VOC in nine patients and 15 HBOT sessions.

RESULTS

All nine patients had received appropriate conventional treatment prior to HBOT. Pain scores using a Visual Analog Scale (0 to 10) determined whether HBOT was effective or not in improving symptoms. While no change in pain score occurred before the HBOT session, pain scores fell significantly from 3.3 prior to HBOT to 1.9 24 hours after HBOT (P = 0.002). While morphine dosage increased before HBOT (median morphine dose 23 mg per day and 35.95 mg per day respectively on Day -2 and Day -1, P = 0.04), the median morphine dose one day after HBOT (Day +1 23 mg per day) tended to be lower than Day -1 (P = 0.08), and decreased to zero 2 days after HBOT (P = 0.004). Two patients had ear pain during compression, requiring rapid interruption of the HBOT session, although neither patient had any sequelae.

CONCLUSION

HBOT is feasible in sickle cell disease and appears to be effective in reducing the pain of VOC rapidly.

[Promotility drugs use in critical care: indications and limits?]

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.

[Successful treatment of life-threatening Panton-Valentine leucocidin positive Staphylococcus aureus pneumonia with antibiotics and immunoglobulins targeting the toxin production]

We report a patient who presented a severe Panton-Valentine-secreting methicillin-susceptible Staphylococcus aureus pneumonia with threatening multi-organ failure including acute respiratory distress syndrome, cardiac failure, renal failure and disseminated intravascular coagulation. Clinical and biological disease course using empiric therapy with treatment directed against toxin production (linezolid, clindamycin and intravenous immunoglobulins) was found to be quickly effective.

[Perioperative management of a patient with an acquired von Willebrand syndrome]

We report the case of a man suffering from a monoclonal gammapathy with an acquired von Willebrand disease in a perioperative context. This pathology is rare, but is important to diagnose because of the possible haemorrhagic complications encountered. We describe the main therapeutic options available today to prevent bleeding during major surgery.

[Peripheral polyneuropathy after heat stroke]

The authors report the case of a woman who developed a peripheral polyneuropathy after heat stroke. All the classical aetiologies of neuropathy were excluded. The final diagnostic was residual peripheral neuropathy provoked by heat stroke. The sequella of heat stroke are dominated by cerebellar compromise, but this case shows that peripheral polyneuropathies exist even if they are rare. They raise the issue of care because of severe neurological sequella.

Case report: combination artemether-lumefantrine and haemolytic anaemia following a malarial attack

A case of a patient who was admitted to hospital in Paris, France, in February 2001 with autoimmune haemolytic anaemia, probably due to artemether-lumefantrine therapy, is presented. Such a complication has previously been observed in patients receiving drugs containing aryl-amino-alcohols but never before in a patient receiving lumefantrine and may be associated with the increase in episodes of blackwater fever seen in recent years.

L'œsophage noir, une complication exceptionnelle du patient de réanimation

We report a new case of acute necrotizing oesophagitis, diagnosing on a patient hospitalised in intensive care unit. This pathology is still a rare event; the definition excludes patients with a history of recent caustic ingestion. Oesophageal necrosis can be diagnosed at endoscopy by the presence of black necroting appearing oesophagus. Contrary to the caustic oesophagitis whose treatment is often surgical, treatment of the acute necrotizing oesophagitis is primarily medical. The prognosis for patients who develop acute necrotizing oesophagitis is generally poor, even if one can hope for the cure without after-effect of it.

[Upper mesenteric venous thrombosis revealing familial resistance to activated protein C]

INTRODUCTION

Mesenteric venous thrombosis is a rare disease but potentially severe because of the prognosis of intestinal infarction with high mortality rate (60%).

OBSERVATION

We report the case of a 55 year-old man who presented with an upper mesenteric venous thrombosis related to a familial resistance to C reactive protein through factor V Leiden mutation.

COMMENTS

The discovery of a mesenteric venous thrombosis requires aetiological research that is usually multifactorial. Among the most frequent genetic coagulation abnormalities observed resistance to C reactive protein due to G202110A prothrombin gene mutation is the most common. Although factor V Leiden mutation is less frequent, it requires anticoagulation therapy for life in the case of the appearance of a thrombosis.

[Methemalbuminnemia after massive hemolysis during blackwater fever]

We report a case of blackwater fever with brown plasma due to the presence of methemalbumin. The discovery of plasma with this color is a rare event at the laboratory. This compound appears during intravascular hemolysis or hemorrhagic pancreatitis when the ability of haptoglobin and hemopexin to bind free hemoglobin has been exceeded. In these cases some of heme is oxidized to hematin and taken up by serum albumin to form an albumin-hematin complex called methemalbumin. The major clinical problem is to evoke the diagnosis of methemalbuminemia and not confuse with methemoglobinemia. In our case, methemalbumin was detected and quantified using a scanning spectrophotometer. Its diagnostic and clinicals consequences are discussed.

[Early rupture of a cryopreserved arterial allograft]

Cryopreserved arterial allografts are used in vascular surgery to treat infected arterial prosthesis. This treatment reduces mortality and morbidity compared to conventional surgery. We observed a case of early rupture of the allograft with the death of the patient due to a misdiagnosis. Recent findings show that cases of rupture have been described, and that current cryopreservation protocols may be the cause of degeneration. To avoid a sudden death for the patient, this complication must be known to diagnose quickly and treat surgically before a final haemorrhagic shock.

Traumatic extrathoracic lung herniation

Traumatic extrathoracic lung herniation is an exceptional complication of blunt chest trauma. We report the case of a 46-year-old man who was involved in a motorcycle accident and who suffered a left clavicle fracture-dislocation associated with multiple rib fractures and massive herniation of the left upper lobe through an upper anterior chest wall defect. Immediate surgical repair through an atypical transcostal vertical thoracotomy resulted in full recovery of pulmonary function at 1 year.

[Paraplegia and the sitting position]

The sitting position in neurosurgery may lead to complications such as air embolism and neurological complications. We report the case of a 16-year-old male who suffered from post-operation paraplegia after surgery for Arnold Chiari disease. This patient had several risk factors and serious morphological spinal abnormalities. We propose to include monitoring of somatosensory evoked potentials (SSEP) during this surgery in order to detect this type of devastating incident.

[Severe pneumococcal meningitis and ceftriaxone allergy]

We report the case of a 51-year-old man with an allergy to amoxicillin/acid clavulanique who presented with Streptococcus pneumoniae meningitis. Initial treatment consisted of an association of antibiotics including ceftriaxone. Six days after treatment was initiated the patient developed skin reaction and the diagnosis of allergy to ceftriaxone was established by the dosage of specific IgE. Typically Streptococcus pneumoniae meningitis is treated with vancomycin and a third-generation cephalosporin. This association had to be modified because cross allergy to cephalosporins could have developed in this patient who had previously reacted to penicillins.

[Diagnosis of ventilator-associated pneumonia: a prospective comparison of the telescoping plugged catheter with the endotracheal aspirate]

OBJECTIVE

Quantitative culture of endotracheal aspirates (EA) is widely accepted for the diagnosis of ventilator-associated pneumonia (VAP). The aim of the study was to compare the diagnostic accuracy of the EA with the blinded plugged telescoping catheter (PTC) in patients suspected of VAP.

STUDY DESIGN

Prospective non-randomised observational study.

PATIENTS AND METHODS

31 patients suspected of having VAP underwent 46 bronchial samplings. An EA and a blinded PTC were performed successively in each case; the PTC result was taken as the reference standard. The EA and PTC cultures were defined positive if the result of bacterial cultures yielding were > or = 10(5) cfu.mL-1 and > or = 10(3) cfu.mL-1 respectively.

RESULTS

The diagnosis of VAP could be established in 19 cases when PTC was taking as gold test. The overall agreement between the two techniques was 76%. EA had a sensitivity of 89.5%, a specificity of 66.7%, a negative predictive value of 90% and a positive predictive value of 65.4%.

CONCLUSION

EA is a good diagnostic test when a non-invasive test has been chosen. The diagnosis of VAP could be excluded in 90% of cases when the EA cultures yielding were < 10(5) cfu.mL-1. His low specificity could drive in an over treatment of bronchopulmonar bacterial colonization. The accuracy of the EA compares well with that of the TPC for the diagnostic of VAP.

[Obesity, diabetes mellitus, and gas gangrene: a major therapeutic challenge]

Soft tissue infections are uncommon but prognosis is severe (20 to 50%). Management consists in surgical debridement, antibiotic therapy against anaerobic and aerobic bacteria, and appropriate intensive care. When available, hyperbaric oxygen therapy is an integral part of the treatment. We report the case of 56-year-old female patient with diabetes (150 kg) was hospitalized in our unit a few days after surgical treatment of a buttocks abscess for clinical signs of peripheral gas gangrene. Surgical exploration showed necrotizing soft tissue infection with fasciitis. Adequate therapy using antibiotics, surgery daily and hyperbaric oxygen was given. Therapy had to be adapted to the patient's obesity. Outcome was good with recovery and few sequelae, allowing transfer to a medical ward.

[BIS monitoring may allow the detection of severe cerebral ischemia]

PURPOSE

To show that the bispectral index (BIS) is not only a monitor of the depth of anesthesia but that acute decreases of the index may be related to severe cerebral ischemia.

CLINICAL FEATURES

Several clinical observations suggest that an unexplained fall of the BIS may be the result of cerebral ischemia. Somatosensory evoked potentials decreased in parallel to the decrease in BIS during carotid clamping in a 58-yr-old patient undergoing carotid endarterectomy. In a 62-yr-old patient undergoing resection of an aortic aneurysm, the BIS decreased from 40-50% to 8% as the cardiac index and central venous O(2) saturation decreased. The BIS returned to normal values when the low cardiac output was corrected pharmacologically.

CONCLUSION

While the BIS is a well accepted monitor of the depth of anesthesia, several factors, unrelated to anesthesia, can modify the index. Thus, to adjust the level of anesthesia based solely on the BIS could be inappropriate. While the sensitivity and specificity of the BIS for this indication have not been determined, we suggest that the BIS may be useful to detect severe cerebral ischemia.

[Febrile coma and multiple organ failure: suspected hemoglobinopathy SC]

We report the case of febrile fatal coma in a 51-year-old man from Burkina Faso. Magnetic resonance imaging (MRI) shows cerebral fat embolism. Haemoglobin electrophoresis shows probably haemoglobinopathy SC. A short review of the literature demonstrate the need to consider this complication in patients with neurological or respiratory disorders, in areas where this disease is highly prevalent, irrespective of age. It also emphasizes the diagnostic contribution of MRI and discusses the mechanism, the diagnosis as well as the difficulty of choosing the appropriate therapeutic course.

[Acute neurotoxic organophosphate poisoning: insecticides and chemical weapons]

OBJECTIVE

To review clinical and therapeutic bases of an organophosphate poisoning, either with insecticide or nerve agent.

DATA SOURCES

References were obtained from computerized bibliographic research (Medline), from personal data (academic memoir, documents under approbation of the National Defense Office), from Internet's data.

DATA SYNTHESIS

Generally, organophosphate poisoning occurs during accidental exposure with agricultural insecticide or suicide. The effects of organophosphate compounds are due to the inhibition of the enzyme acetylcholinesterase. The intoxication symptoms can be divided into muscarine-like, nicotine-like effects, effects on the central nervous system and symptoms related to the dysfunction of the neuromuscular junction. The interest of biological acetylcholinesterase's measuring is minimal because it is weakly specific or sensitive. The immediate severity is due to hypoxia. Respiratory failure results from the lack of central drive inflated with excessive bronchial secretions, bronchospasm and respiratory muscles paralysis. The secondary complications are early myopathies whose gravity is correlated with the decrease of acetylcholinesterases, or later neuropathies induced by a different mechanism. Beside the symptomatic measures, atropine is the specific anticholinergic treatment. When promptly used, oximes can regenerate cholinesterases. The attempted effects of the treatment are mouth dryness, pupilar dilatation and flushing of the skin. Nerve agents are lethal toxics which have a short onset time and produce severe neurological pathology. In a terrorist incident, it is as important to identify rapidly the toxic agent and provide emergency decontamination as to manage medical care. An effective response must be multidisciplinary, involving clinicians, toxicologists, Emergency Medical Service and public's health personnel.

[Four hours for a record, or a severe fuminating cellulitis: can Saccharomyces cerevisiae be the causal agent?]

A 31-year-old woman presented with a subcutaneous cellulitis which occurred within four hours following a minor wound of a knee. This very short delay could be explained neither by the health state, nor the mechanism of injury, nor the bacteria usually responsible for such a cellulitis. Considering the clinical characteristics (high gas production) and the professional context (wine cellar employee), Saccharomyces cerevisiae, a yeast used for wine or bread production, may explain this complication.

[Necrotizing cervico-mediastinal cellulitis. Apropos of 3 cases]

OBJECTIVE

To outline the most appropriate treatment of descending necrotizing mediastinitis.

MATERIALS AND METHODS

Three adult patients had mediastinitis occurring from a descending odontogenic infection in one case and oropharynx infection in two cases. All patients underwent extensive surgical debridement and a cervicomediastinal drainage through a cervical incision. All patients survived.

DISCUSSION

Soft-tissue infections of the neck with mediastinitis demand early diagnosis aided by CT scan in order to decrease their threat to life. Extensive surgical debridement and a cervico mediastinal drainage through a cervical incision is adequate when mediastinitis is limited to the upper mediastinum. Thoracotomy has to be performed when the process spread below the carina. Patients must be treated initially aggressively with the aid of multidisciplinary support team (intensive care physicians, thoracic and head and neck surgeons). Early surgery must treat both neck and mediastin. While usually associated with greater than 40% mortality, all the patients in this series survived.

[Intracranial aneurysm and coronary ectasia]

BACKGROUND

Coronary aneurysms are uncommon and can exceptionally be associated with other aneurysmal localizations.

CASE REPORT

A 34 year-old man with a history of aneurysm of the coronary arteries revealed by myocardial infarction without a wave six months earlier, presented cerebral hemorrhage secondary to an aneurysmal rupture of the anterior communicating artery.

DISCUSSION

Other aneurysmal localizations such as the abdominal artery, pulmonary artery, hepatic artery, popliteal artery, coronary venous system or the left ventricle have been associated with coronary artery aneurysm. Only one case of coronary and cerebral aneurysm has been previously reported in the literature in an 8-year-old child with X-linked lymphoproliferative syndrome and EBV-induced infectious mononucleosis. Our case suggests that systemic aneurysmal disease may be a clinical entity and that cerebral angiogram should be discussed in patients with a coronary artery aneurysm.

Superior vena cava gunshot wound: successful management

Superior vena cava gunshot wounds are rare and usually associated with high mortality before patients reach the hospital. We present an exceptional case with a 16 hour preoperative delay and a final recovery.

[Rhabdomyolysis and truncular sciatica. 2 cases studied by MRI]

We report two cases of acute rhabdomyolysis in pelvic girdle muscles with sciatic palsy secondary to compression of the sciatic nerve trunk, with clinical and MRI correlation. The diagnosis of rhabdomyolysis is based on clinical and biological data, but diagnosis of compression complications secondary to swelling of the muscles, especially the compression of nerve trunk, is done by imaging. T2 weighted images give a definite anatomical evaluation. They show enlarged high signal intensity muscles and anatomic relationship with the sciatic nerve from its emergence out of pelvis, giving a good correlation between rhabdomyolysis and the compressed nervous trunk. It helps for planning a possible surgical fasciotomy. However, MRI provides only morphological informations, but not differentiates edema from necrosis in involved muscles.

[Diffuse toxoplasmic encephalitis in a non-immunosuppressed patient]

Diffuse encephalitic toxoplasmosis is an unusual presentation of toxoplasmosis, in which neuroradiological investigations may not show focal abcesses. Until now it was only reported in immunocompromised patients. In immunocompetent patients, cerebral toxoplasmosis is very unusual, and appears as multiple abcesses, like the classic form in immunocompromised patients. We report the case of an immunocompetent patient who presented a diffuse encephalitic toxoplasmosis; CT and MR examinations showed only nonspecific features of brain swelling and cortical infarct due to vasculitis.

[Continuous infusion of vancomycin in post-neurosurgical staphylococcal meningitis in adults]

Eight adult patients with post-surgery meningitis caused by methicillin-resistant staphylococci were treated with continuous intravenous infusion of vancomycin in mean doses of 50 mg/kg/day. This treatment, which lasted 3 to 6 weeks, was well tolerated by the kidneys and resulted in cure in all cases; its effect on the ear was not evaluated. Stable concentrations of 4 to 7 mg/l in cerebrospinal fluid were obtained after the 48th hour of treatment.