Search

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is an adjuvant treatment for severe acute respiratory distress syndrome (ARDS) with refractory hypoxemia. Contraindications to therapeutic anticoagulation must be ruled out prior to ECMO implementation. We report the case of a 17-year-old male admitted in intensive care unit (ICU) for penetrating chest trauma due to multiple gunshot wounds. The body computed tomography (body CT scan) documented right pulmonary contusions and a homolateral hemothorax. His condition rapidly deteriorated with refractory hypoxemia due to lung contusion requiring invasive mechanical ventilation (IMV) and polytransfused hemorrhagic shock. During his stay in ICU, venovenous ECMO (VV-ECMO) was implemented twice, firstly for trauma-induced ARDS and secondly after thoracic surgery. This case emphasizes the successful use of VV-ECMO in posttraumatic ARDS without increasing the risk of bleeding.

Introduction: Non-life-threatening blunt chest trauma (BCT) admitted in emergency department (ED) are at risk of acute respiratory failure (ARF) and respiratory complications during their intensive care unit (ICU) follow-up. They may require a special focus to adopt specific prophylactic strategies and proper orientation. The aim of this study was to identify different risk factors for ARF in mild BCT.Methods: This retrospective, monocentric study from January 2015 to December 2020 included all patients with mild BCT admitted to the ED and managed in ICU for at least 48 hours with spontaneous breathing at admission. Occurrence of ARF was defined by PaO2/FiO2 ratio (PaFI) under 200 and need of ventilator support in the first 72 hours after admission. Using univariate and multivariate analysis, the risk factors of ARF incidence after BCT were investigated. We also studied the global ability of the TTS score to predict ARF occurrence by a ROC curve. Finally, we assessed the most significant and sensitive TTS score threshold. Results: A total of 190 BCT patients was included and 23.7% of them developed an ARF. A TTS score greater than 8 was independently associated with early ARF. A TTS score threshold of 6 significantly predicted the ARF incidence with a sensitivity (91%) and negative predictor value (94%) in mild BCT. The others risk factors independently associated with ARF were chronic respiratory disease, high score SOFA and loco regional analgesia.Conclusion: A significant amount of risk factors of ARF following mild BCT were highlighted in our study and must be considered for the proper management of those patient. It is the first study to enhance that a low TTS score threshold could help the mass screening and proper orientation of mild BCT. This study provides the basis for the development of a new risk stratification tool (TTS score) for mild BCT patients who may develop respiratory complications.

Introduction: Immune checkpoint inhibitors (ICIs) are a major breakthrough in cancer treatment. Their increasingly frequent use leads to an uprising incidence of immune-related adverse events (irAEs). Among those, myocarditis is the most reported fatal cardiovascular irAE, frequently associated with ICI-related myositis. Case series: Here, we report three cases of ICI-induced myocarditis/myositis with an extremely severe myasthenia gravis-like (MG-like) presentation, highlighting the main challenges in irAEs management. These patients were over 60 years old and presented an ongoing melanoma, either locally advanced or metastatic, treated with ICI combinations. Shortly after the first or second ICI infusion, they were admitted in an intensive care unit (ICU) for grade 3 ICI-induced MG-like symptoms leading to acute respiratory failure (ARF) requiring invasive mechanical ventilation (IMV). The initial misdiagnosis was later corrected to severe ICI-induced seronegative myocarditis/myositis upon biological results and histopathology from muscular/endomyocardial biopsies. All of them received urgent high-dose corticosteroids pulses. The oldest patient died prematurely, but the two others received targeted therapies leading to complete recovery for one of them. Discussion: These cases highlight the four main challenges of irAEs, encompassing the lack of knowledge among physicians, the risk of misdiagnosis due to numerous and non-specific symptoms, the frequent overlapping forms of irAEs, and the extremely rare MG-like misleading presentation of myocarditis/myositis. The exact pathophysiology of irAEs remains unclear, although a major involvement of the lymphoid compartment (specifically T lymphocytes) was evidenced. Therapeutic management is based on urgent high-dose corticosteroids. For the severest forms of irAEs, case-by-case targeted immunosuppressive therapies should be urgently administered upon multidisciplinary meetings. Conclusion: These cases highlight the lack of knowledge of irAEs among physicians, aggravated by misleading overlapping forms, requiring specific management in trained units and multidisciplinary care. Severe MG-like presentation of irAEs constitutes an absolute therapeutic emergency with high-dose corticosteroids and targeted immunosuppressive therapy.

Background: Adult hemophagocytic lymphohistiocytosis (HLH) is highly lethal in the ICU. The diagnostic and therapeutic emergency that HLH represents is compounded by its unknown pathophysiological mechanisms. Here, we report on a large cohort of adult HLH in the ICU (ICU-HLH). We analyzed prognostic factors associated with mortality to define the diagnostic and therapeutic challenges in this specific population.Methods: This retrospective study included adult patients diagnosed with HLH in four ICUs in Marseille, France between 2010 and 2020. Patients who fulfilled the HLH-2004 criteria (≥ 4/8) and/or had an HScore ≥ 169 were diagnosed with HLH. HLH was categorized into four groups according to etiology: sepsis-associated HLH, intracellular infection-associated HLH, malignancy-associated HLH, and idiopathic HLH.Results: Two hundred and sixty patients were included: 121 sepsis-associated HLH (47%), 84 intracellular infection-associated HLH (32%), 28 malignancy-associated HLH (11%), and 27 idiopathic HLH (10%). The ICU mortality rate reached 57% (n = 147/260) without a statistical difference between etiological groups. Independent factors associated with mortality in multivariate analysis included age (OR (5 years) = 1.31 [1.16–1.48], p < 0.0001), SOFA score at ICU admission (OR = 1.37 [1.21–1.56], p < 0.0001), degradation of the SOFA score between ICU arrival and HLH diagnosis (Delta SOFA) (OR = 1.47 [1.28–1.70], p < 0.0001), the presence of bone-marrow hemophagocytosis (OR = 5.27 [1.11–24.97], p = 0.04), highly severe anemia (OR = 1.44 [1.09–1.91], p = 0.01), and hypofibrinogenemia (OR = 1.21 [1.04–1.41], p = 0.02).Conclusions: In this large retrospective cohort study of critically ill patients, ICU-HLH in adults was associated with a 57% mortality rate, regardless of HLH etiology or specific treatment. Factors independently associated with prognosis included age, presence of hemophagocytosis in bone-marrow aspirates, organ failure at admission, and worsening organ failure during the ICU stay. Whether a rapid diagnosis and the efficacy of specific therapy improve outcome is yet to be prospectively investigated.

Background Adult hemophagocytic lymphohistiocytosis (HLH) is highly lethal in the ICU. The diagnostic and therapeutic emergency that HLH represents is compounded by its unknown pathophysiological mechanisms. Here, we report on a large cohort of adult-acquired HLH in the ICU. We analyzed prognostic factors associated with mortality to define the diagnostic and therapeutic challenges in this specific population, Methods This retrospective study included adult patients diagnosed with HLH in four ICUs in Marseille, France between 2010 and 2020. Patients who fulfilled the HLH-2004 criteria (> 4/8) and/or had an HScore > 169 were diagnosed with HLH. HLH was categorized into four groups according to etiology: sepsis-associated HLH, intracellular infection-associated HLH, malignancy-associated HLH, and idiopathic HLH. Results 260 patients were included: 121 sepsis-associated HLH (47%), 84 intracellular infection-associated HLH (32%), 28 malignancy-associated HLH (11%), and 27 idiopathic HLH (10%). The ICU mortality rate reached 57% (n = 147/260) without a statistical difference between etiological groups. Independent factors associated with mortality in multivariate analysis included age (OR (5 years) = 1.31 [1.16–1.48], p

International audience; Gram-negative bacillary meningitis occurring post-trauma and following neurosurgical procedures has been described widely. However, reports of spontaneous cases are sparse, particularly communityacquired cases. Spontaneous community-acquired Escherichia coli meningitis is a rare (although increasingly seen) and specific entity that is poorly reported in the literature. A review of the literature identified only 43 cases of community-acquired E. coli meningitis reported between 1946 and 2016. This article describes two new cases of spontaneous community-acquired E. coli meningitis encountered in Marseille, France, and presents the results of a literature review on spontaneous community-acquired E. coli meningitis.

International audience; Rationale: Despite a vaccine being widely available, measles continues to occur frequently, with sometimes lethal consequences. Patients concerns: The mortality rate reaches 35% and measles represents 44% of the 1.4 million deaths which are due to preventable diseases. Severe forms of measles are reported, mainly in young, unvaccinated adults, and in specific populations. The risk factors for severe measles include no or incomplete vaccination and vitamin A deficiency. Apart from secondary measles-related infections, severe measles is mainly represented by neurological, respiratory, and digestive symptoms. Diagnoses: Strengthening the hypothesis that there is a link between vitamin A deficiency and severe measles in this paper we report the case of a 25-year-old unvaccinated man hospitalized for severe and complicated measles. Outcomes: The evolution was good after administration of intramuscular vitamin A as well as intravenous ribavirin. Lessons: Measles remains a fatal and serious disease. The early use of ribavirin and vitamin A shows significant improvements regarding morbimortality and should be systematic in severe cases.

Contexte : les pneumonies acquises sous ventilation mécanique (PAVM) sont fréquentes et associées à une morbi-mortalité importante chez les patients de réanimation sous ventilation mécanique invasive pendant plus de 48 heures. Parmi les PAVM documentées, le Staphylococcus aureus méticilline-sensible (SAMS) est responsable de 10 à 25% des PAVM. Les pénicillines antistaphylococciques (PAS) constituent le traitement de première intention de ces PAVM à SAMS malgré leur indisponibilité fréquente due à des ruptures de stock, leurs multiples effets indésirables (EIs) et leur efficacité récemment controversée en comparaison avec la céfazoline (céphalosporine de première génération). Méthode : afin de déterminer les facteurs de risque d’échec thérapeutique des PAVM à SAMS, nous avons mené une étude rétrospective monocentrique dans une réanimation polyvalente française sur une période de 6 ans.Résultats : parmi une cohorte de 131 patients, les facteurs tels que l’âge plus avancé (p 0.029), un score de fragilité plus élevé (index de Charlson, p 0.018), et la présence d’une co-infection fungique (aspergillose pulmonaire invasive p 0.015) étaient associés à l’échec thérapeutique des PAVM à SAMS. De même, une bactériémie concomitante de la PAVM était indépendamment associée à l’échec thérapeutique (OR 3.83, 95% CI 1.011 – 32.2, p 0.048). A contrario, le sexe féminin (OR: 0.327, 95% CI 0.1 – 0.713, p 0.008) et le traitement par céfazoline (OR 0.3 95%CI 0.042-0.86 p 0.030) constituaient des facteurs protecteurs contre l’échec thérapeutique. De plus, la céfazoline était associée à une tendance à la diminution des EIs (4.8% versus 10.6%, p 0.66) par rapport à la cloxacilline (PAS) ainsi qu’à moins de rechute/récidive de PAVM à SAMS (9.5% versus 23%, p 0.316). Conclusion : dans cette étude et de manière congruente avec la littérature, l’âge, le sexe masculin, et les bactériémies étaient indépendamment associés au risque d’échec thérapeutique des PAVM à SAMS. Le traitement par céfazoline était indépendamment associé au succès thérapeutique et était mieux toléré que la cloxacilline.