Treatment of NORSE/FIRES with Tocilizumab in a child and a young adult

New Onset Refractory Status Epilepticus (NORSE) is a rare and devastating condition occurring in a previously healthy patient. It is called Febrile Infection Related Epilepsy Syndrome (FIRES) when preceded by a febrile infection. It often leads to intensive care treatment, including antiseizure drugs in combination with anaesthetic agents, and sometimes ketogenic diet. The mortality rate is high, and severe epileptic and neuropsychiatric sequelae are usually observed. Based on the possible role of neuroinflammation, intravenous immunoglobulin, corticosteroids and immunomodulatory treatment (anti-IL1, IL6) can be added. We describe here a child and a young adult with FIRES, both treated by Tocilizumab. We observed a rapid positive response on the status epilepticus and a good tolerance, but different neurological outcomes for our two patients. Further prospective studies may be necessary both to confirm the efficacy and the safety of this promising treatment and to optimize the immunomodulatory strategy in FIRES/NORSE.

High-flow cannula for frail patients with SARS-CoV-2 infection non-eligible for intensive care unit management

OBJECTIVES

High-flow nasal cannula (HFNC) was widely used during the COVID-19 pandemic in intensive care units (ICU), but there is no recommendation for elderly patients non-eligible for ICU management. We aimed to describe the outcomes of HFNC treatment in patients with COVID-19 who are not eligible for ICU management.

METHODS

Retrospective bicentric cohort study performed between September 1, 2020 and June 30, 2021 in two infectious diseases departments of Colmar Hospital and Antoine Beclere University Hospital, France.

RESULTS

Sixty-four patients were treated with HFNC: 33 in Colmar and 31 in Beclere hospital (median age: 85 years; IQ, 82-92). Of these, 16 patients survived (25%). Surviving patients had a lower Charlson comorbidity index score than deceased patients (five vs six; p = 0.02).

CONCLUSIONS

Despite a high death rate, with survivors being younger and having fewer comorbidities, HFNC is an easy tool to implement in non-ICU wards for the frailest patients.

Pulmonary Nocardiosis as an Opportunistic Infection in COVID-19

Secondary bacterial pneumonia infection is frequent in COVID-19 patients. Nocardia are responsible for opportunistic pulmonary infections especially after steroid treatment. We describe a case of pulmonary nocardiosis following critical COVID-19 pneumonia in an 83-year-old male. Two weeks after initiation of dexamethasone 6 mg/L, the patient developed a new episode of acute dyspnea. The sputum cultures identified Nocardia cyriacigeorgica. In spite of intravenous imipenem and cotrimoxazole treatment the patient died. Physicians should be aware of the possibility of nocardiosis in case of deterioration of respiratory status of severe COVID-19 inpatients and perform Nocardia evaluation. This evaluation requires prolonged culture.