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Introduction : La méningite bactérienne est une pathologie grave mettant en jeu le pronostic nécessitant une prise en charge précoce en réanimation. Matériel et Méthodes : Il s’agit d’une étude de cohorte rétrospective étalée sur 14 ans (1992-2006) menée en réanimation médicale. Nous avons étudiés les données démographiques, cliniques, biologiques, thérapeutiques et évolutives des patients âgés de plus de 16 ans atteints de méningite bactérienne communautaire. Les variables analysées ont été comparées entre le groupe des survivants et celui des décédés. Statistique : t test, Chi2, régression logistique. Résultats : 201 patients ont inclus (139 Hommes/62 Femmes, âge : 35 ± 16 ans, SAPSII : 6,4 ± 4,5). L’altération de la conscience a été observée chez 51 patients (Glascow coma scale (GCS) : 12 ± 3). La mortalité moyenne était de 19,9%. En analyse univariée, les variables associées à la mortalité étaient : âge > 60 ans, APACHE II > 12, délai d’hospitalisa-tion > 72h, GCS ≤ 10, défaillance viscérale, absence de raideur de la nuque, pouls > 100 b/mn, tachypnée, pression artérielle moyenne < 90 mm Hg, glycémie 1,8g/l et glucorrachie < 0,4 g/l. En analyse multivariée, 7 facteurs indépendants étaient retenus : un âge > 40 ans (Odds Ratio (OR) = 4,7 ; IC95%1,6 ± 13,6 ), délai d’hospitalisation > 3 jours (OR = 2,5 ; IC95%3,2 ± 47,8 ), GCS < 10 (OR = 4,1 ; IC95%1,4 ± 11,6), tachypnée > 30 cycles/min (OR = 7,3 ; IC95% : 1,7 ± 32,3 ) , choc (OR = 19,8 ; IC95%4,1 ± 96), glycémie > 2 g/l (OR = 5,1 ; IC95%1,5 ± 17,2) et glucorrachie < 0,4 g/l (OR = 5,1 ; IC95%1,8 ± 17,8 ). Conclusion : l’âge avancé, le délai d’hospitalisation, la sévérité de la maladie à l’admission, l’hyperglycémie et l’ hypoglucorrachie constituent les principaux facteurs pronostics de mortalité en réanimation., Maroc Médical, Vol. 32, No 2 (2010)

Objectif : Le but du travail est de rapporter les cas d’insuffisance rénale aigue iatrogène survenue suite à la réalisation en urgence d’une tomodensitométrie cérébrale avec injection de produit de contraste iodé chez des patients souffrant de méningo-encéphalites. Matériel et méthodes : Ce travail prospectif a été mené dans un service de réanimation médicale de janvier 2002 à décembre 2008. Le critère de jugement principal était les variations de la créatininémie (>25% de sa valeur de base) dans les trois semaines après un scanner cérébral avec injection d’un produit de contraste iodé chez des patients atteints de méningo-encéphalites. Résultats : Etaient inclus 8 patients sur 360 cas de méningo-encéphalites soit une incidence de 2,2%. L’âge moyen était de 43 ± 17 ans. Le délai moyen d’apparition de l’insuffisance rénale aigue était de 43 ± 17 heures, avec une créatininémie moyenne de 66,8 ± 37 mg/l. Trois patients sont décédés. Conclusion : L’incidence de cet évènement indésirable reste faible mais mérite une attention particulière. Une réhydratation correcte avant toute pratique du scanner cérébral avec injection devrait être réalisée chez tout patient présentant une méningo-encéphalite., Maroc Médical, Vol. 31, No 4 (2009)

La méningite tuberculeuse reste une forme commune des infections du système nerveux central dans plusieurs pays en voie de développement où la tuberculose est endémique. Elle constitue la forme la plus grave de l’infection par le Mycobacterium tuberculosis. Elle est responsable de décès ou de séquelles neurologiques sévères dans plus de 50% des cas malgré le traitement antituberculeux. Afin d’améliorer le pronostic de la méningite tuberculeuse, la corticothérapie a été utilisée comme traitement adjuvant depuis plusieurs décennies. Ses effets sont restés controversés jusqu’à récemment où il y a de plus en plus de preuves de son efficacité sur l’évolution de la maladie en terme de mortalité et de séquelles neurologiques chez les survivants. Cette mise au point est une synthèse des différentes études réalisées sur la corticothérapie dans la méningite tuberculeuse., Maroc Médical, Vol. 30, No 2 (2008)

Objectif : Evaluer l’apport diagnostique de trois méthodes d’identification du Plasmodium. Matériel et méthodes : Etude prospective, sur deux ans, à Libreville (Gabon). Ont été inclus les patients suspects de paludisme. Trois techniques sont réalisées : goutte épaisse (GE), frottis sanguin (FS), Quantitative Buffy Coat (QBC) et ParaSight F (PS). Résultats : Sur les 418 prélèvements, la GE est positive dans 22,3 %, le FS 95,7 %, le PS 20,1 %, et le QBC 25,1 %. La sensibilité et la spécificité du PS sont respectivement de 86 % et 98 %, et celles du QBC sont respectivement de 100 % et 96 %. Conclusion : le PS apporte un argument supplémentaire pour l’identification de l’espèce, et permet un diagnostic rétrospectif., Maroc Médical, Vol. 28, No 2 (2006)

Le concept global de qualité des soins est complexe. Il faut savoir identifier les problèmes, mettre en œuvre des actions adéquates, en mesurer l’impact et suivre ses actions sans oublier que le patient doit constamment être au centre de la démarche. Ceci doit être effectué en analysant les structures et les aspects organisationnels, les procédures de soins et les résultats à l’aide d’indicateurs dont la validité et la fiabilité ne sont pas toujours de mise. Deux types de scores sont habituellement utilisés en réanimation : ceux mesurant la sévérité de l’affection, proposés comme facteurs pronostiques et moyens d’attribution des ressources et ceux mesurant l’activité quotidienne du personnel. Ces scores bien qu’incomplets continue à être considérés comme des outils de contrôle des coûts et de l’efficacité des services de réanimation., Maroc Médical, Vol. 27, No 2 (2005)

Ethylene glycol is present predominantly in antifreeze,and in industrial solvents. Accidental ingestion of ethylene glycol is relatively rare, but may be potentially lethal. It results in a depression of the central nervous system, a severe metabolic acidosis and an acute renal failure by tubular precipitation of calcium oxalate crystals. We report a case of ethylene glycol poisoning by through skin absorption.A 38-year-old man, working in a cement factory, with a history of cutaneous psoriasis for 10 years, was admitted to our hospital due to acute nausea, vomiting and diffuse abdominal pain, followed by generalized convulsive status epilepticus and worsening of his mental status. Biologic analysis showed severe metabolic acidosis and acute renal failure which required hemodialysis. On renal biopsy, there were intratubular crystals of calcium oxalate. Cerebral magnetic resonance imaging showed posterior encephalitis. Evolution was marked by normalization of renal function at two weeks and improvement of the mental status. Retrospectively, the patient's history-taking revealed that he manipulated ethylene glycol without gloves.Cutaneous contact with ethylene glycol may cause poisoning in presence of skin lesions. The triad neurologic involvement, renal failure due to oxalate crystals deposits and metabolic acidosis leads to the diagnosis of ethylene glycol intoxication. In the case of acute renal failure with oliguria, haemodialysis is the treatment of choice. It allows the removal of the toxic substance and its metabolites with correction of the metabolic acidosis. The precocity of the treatment may improve the prognosis.

The beneficial effect of corticosteroids has been well established, particularly in patients free of infection with the human immunodeficiency virus. In intensive care units, the high risks of infection to which patients are exposed specifically could offset the neurological benefit of corticosteroids. The purpose of the study was to assess the effects of corticosteroids in adult patients with tuberculous meningitis admitted to intensive care unit.Retrospective cohort study including all adult patients admitted to intensive care unit for tuberculous meningitis between January 1993 and December 2005. A propensity score case matching was performed using a multivariable logistic regression model, and matched pairs were examined for baseline characteristics and outcome by using conditional regression model. A multivariate Cox's proportional hazard model was used to assess the effects of corticosteroids in all patients adjusting for propensity score. The primary outcome was mortality at 60 days and the secondary outcome was the density of incidence of nosocomial infections.Two hundred and seventy patients were included. The mean age was 38+/-17 years, and the Glasgow coma scale was 12+/-3. The overall mortality was 43.3%. Ninety-four patients who had received corticosteroids were matched to 94 patients untreated with corticosteroids by the propensity score. The baseline characteristics were similar in the two groups except for hydrocephalus, which was more frequent in the group corticosteroids. The mortality rate was 47.9% in group Corticosteroids and 52.1% in group No corticosteroids (P=0.77). The case fatality rate in stage III patients, according to the British Medical Research Council criteria, was 61.5% in the group Corticosteroids versus 74.1% in the group No corticosteroids (P=0.33). Nosocomial infections were observed in 19.1 by 1000 days patient in group Corticosteroids versus 16.1 by 1000 days patient in group No corticosteroids (P=0.4). The outcome in all patients after adjusting for propensity score showed the same results.This study found no significant improvement in survival in adult patients with tuberculous meningitis admitted to intensive care who received dexamethasone. However, the confidence interval was in accordance with the 0.78 relative risk estimated by the meta-analysis Cochrane version 2008. There was no significant difference for nosocomial infections between the group Corticosteroids and the group No corticosteroids. A probable lack of statistical power may explain these results.

To assess mortality and to identify variables that could predict it in cirrhotic patients hospitalized to the medical intensive care unit (MICU) for hepatic encephalopathy (HE).Retrospective cohort study.From January 1995 to December 2004, the cirrhotic patients admitted consecutively in MICU were screened and those with altered level of consciousness were included. The MICU mortality rate was assessed. Nearly 80 variables were analyzed and compared between survivors and non-survivors.t test, chi(2) or Fisher exact tests, Kaplan-Meier and log rank, Cox regression analysis.A total of 180 patients (42 women-138 men, mean age: 59+/-10 years) were admitted (incidence: 2.6%). The SAPS II was 30.1+/-11, Acute Physiology Age and Chronic Health Evaluation II (APACHE II): 16.5+/-5.3, Child-Pugh score: 9.1+/-1.9 and GCS: 11+/-2.8. The causes of liver cirrhosis was identified in 41.2% of cases (viral: 35.6%, alcohol: 5.6%). Nearly 18% of patients had an antecedent of HE. The causes of HE were: infection (65.6%), upper gastrointestinal bleeding (32.2%), drugs (5%) and metabolic cause (5%). MICU mortality rate was 33.3% and seemed higher in gastrointestinal bleeding. Eighteen variables were significantly associated with poor prognosis in univariate analysis. Only three variables remained significant in multivariate analysis: systolic blood pressure90 mmHg (RR=4; IC 95%=2-8.1), total WBC12000 n/mm(3) (RR=3.1; IC 95%=1.8-5.3) and use of mechanical ventilation (RR=3.1; IC 95%=1.7-5.6).The MICU mortality of cirrhotic patients with HE was high and significantly associated with haemodynamic instability, hyperleucocytosis and mechanical ventilation.

Acute pancreatitis is rarely seen in systemic lupus erythematous.A 28-year-old woman without significant past medical history, was hospitalized for sepsis and diagnosed with acute pancreatitis, which was found to be the initial presentation of a newly diagnosed systemic lupus erythematous.Acute pancreatitis as an initial presentation of systemic lupus erythematous is rare and is reported in only 10 cases in the literature. Multiple factors are involved in the pathogenesis. The role of corticosteroids in its apparition or resolution is still a subject of controversy.

The usual glycemic supervision based on repeated measures of the capillary glycemia with the strip of which reliability can be taken at fault especially in critically ill patients. The objective of this work was to evaluate the reliability of capillary glycemia measurement in intensive care unit.[corrected] The study was performed in a medical intensive care unit, during six months (July to December 2004). The capillary glycemias were carried out with only one blood glucose monitor and were compared with the referenced glycemias. The correlation between two methods was carried out by the parametric Pearson coefficient. The error percentage of the blood glucose monitor was calculated. The agreement of two methods was evaluated by Bland and Altman test.Were performed 245 glycemic pairs for 198 patients, their mean age was 42.6 +/- 14.6 years, 30(15%) among them were diabetics. The referenced glycemia was 8.7 +/- 5.5 mmol/L and the capillary glycemia was 8.3 +/- 4.6 mmol/L. The correlation coefficient was 0.97 (p0.001); 56 percent of the values had an error percentage lower than 10, 27 percent between 10 and 20%, and there were 17 percent discordant values with an error percentage higher than 20. The method of Bland and Altman objectived a skew of 0.40 mmol/L and a bad precision of +/- 2.90 mmol/L.The reliability of capillary glycemias was not satisfactory with bad precision and high percentage of discordance. The capillary glycemias must be interpreted with precaution in intensive care unit.

To determine characteristics of acute aluminum phosphide poisoning (AAlPP) and to evaluate its severity factors.Retrospective cohort study.Consecutive cases of AAlPP admitted in medical ICU (Hospital Avicenne, Rabat, Morocco) between January 1992 and December 2002 were studied. AAlPP was identified by history, symptoms and toxicological results. Almost 50 parameters have been collected and compared between survivors and non-survivors groups. Data were analyzed using Fisher exact test and Mann-Whitney test.Twenty-eight patients were enrolled: 17 female and 11 male, average age = 24+/-11 years, SAPS II = 24.4+/-14.5. The ingested dose was 3.3+/-1.8 g. The self-poisoning was observed in 27 cases and delay before hospital admission was 11+/-13 hours. Mean Glasgow coma scale was 14+/-2. Shock was found in 22 (79%) cases. Average pH was 7.1+/-0.4 and bicarbonate concentration was 16.3+/-8.8 mmol/l. The ECG abnormalities were noted in 20 (72%) cases. The average mortality rate was 61%. The prognostic factors were SAPS II (p = 0.031), Apache II (p = 0.037), shock (p = 0.022), ECG abnormalities (p = 0.05), use of vasoactive drugs (p = 0.05) and use of mechanical ventilation (p = 0.003).AAlPP induced a significantly high mortality and haemodynamic disturbances were a risk factor of poor outcome.

We showed that the paraphenylenediamine (PPD) poisoning caused myocarditis but there is no data on the echocardiographic features. We report a case of myocarditis induced by PPD poisoning with echographic data. After ingestion of 5 g of PPD, a 18-year-old woman was admitted to the hospital with asphyxia and rhabdomyolysis. An electrocardiogram showed ventricular extrasystoles and negative T waves. The serum concentration of CK was 28,020 UI l(-1) (iso-enzyme MB = 840 UI l(-1)). A transthoracic echocardiography showed significant left and right ventricular hypokinesis (shortening fraction = 20% and left ventricular ejection fraction = 35%) and a left ventricular apical thrombus. Anticoagulation treatment with heparin was initiated. A follow-up echocardiogram performed on the 15th day showed normalization of ventricular function and disappearance of the thrombus. No embolic event was noted. Echocardiography is indicated in the myocarditis induced by PPD poisoning to prove the ventricular function as well as the presence of a thrombus.

The incidence of hyponatremia is unknown, their causes are multiple. The higher mortality, especially in intensive care units, is currently unexplained. The objective of this article is to evaluate the incidence of hyponatremia, to assess their causes and to identify predictors of prognosis in intensive care units.We included retrospectively all patients admitted at department of medical intensive care unit between January 1996 and February 2001, who presented at the admission, an hyponatremia (130 mmol/l). We excluded all patients who presented a hospital acquired hyponatremia, or hyponatremia associated with hyperglycemia13 mmol/l or with mannitol administration. Data were analysed by univariate methods, then by multivariate analysis.During the study period, 300 patients were identified among 2188: the incidence was 13.7% with 95% confidence interval (95% CI) between 9.8 % and 16.7%. Hypovolemic hyponatremia was observed in 25.7%, hypervolemic in 23.7% and normovolemic in 50.6%. In-hospital mortality was 37.7% (95% CI: 31.8% - 42.3%). Nine data were significantly associated with higher mortality in univariate analysis, but only 5 were identified as independant predictors of hospital mortality in multivariate analysis: hyponatremia125 mmol/l with a significant relative risk (RR) (RR = 2.10; 95% CI: 1.43-3.08; p0.001), Glasgow score9 (RR = 2.66; 95% CI: 1.25-5.66; p = 0.01), Glasgow score between 9 and 14 (RR = 1.94; 95% CI: 1.31-2.88; p0.001), shock (RR = 1.80; 95% CI: 1.10-3.05; p = 0.02) and blood urea concentration10 mmol/l (RR = 1.59; 95% CI : 1.08-2.34; p = 0.02).The frequency of hyponatremia is high; the normovolemic type represented 50%. Mortality is linked, in greater part, to organs dysfunction, but the severity of hyponatremia remained a significant predictor of mortality.

To compare nebulized salbutamol and nebulized adrenaline in acute severe asthma (ASA).Prospective controlled study.October 1998 at May 99, 44 patients (31 women and 13 men, 35 +/- 11 yrs) with ASA (defined as peak expiratory flow rate (PEF)150 l min-1 and normo- or hypercapnia) were randomized to receive either nebulized salbutamol (n = 22), 10 mg/h-1 during 2 h then 5 mg every 4 h or nebulized adrenaline (n = 22), 6 mg/h-1 during 2 h then 3 mg every 4 h. The efficacy was assessed by PEF, forced expiratory volume in one second (FEV1) and Fischl's score during eight hours and by arterial blood gases during the first hour. Side-effects were evaluated by heart rate, systolic blood pressure, serum potassium and blood glucose. Statistical tests: Wilcoxon, Fischer exact, ANOVA and Scheffe's test.Both groups were similar with respect to age, sex, severity, duration of asthma and length of crisis. With the two treatments, PEF increased significantly but no statistical difference were observed between the two groups during the eight hours: 117.7 +/- 41.6 l min-1 to 203.3 +/- 56.9 l min-1 in the salbutamol group; 116.4 +/- 36.8 l min-1 to 217.3 +/- 188.8 l min-1 in the adrenaline group; p = 0.77. FEV1, Fischl's score and arterial blood gases did not differ significantly between treatments at every time interval. There were no significant difference between the two groups in terms of side-effects. The intravenous way was necessary at 3 cases of the salbutamol group and 4 cases of adrenaline group (NS).The results suggest that nebulized adrenaline is as effective as nebulized salbutamol in the ASA without significant side-effects. The nebulization could reduce systemic effects of adrenaline.