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Background: High incidence of ventilator associated pneumonia (VAP) has been reported in critically ill patients with COVID-19. Among these patients, we aimed to assess the incidence, outcomes and risk factors of VAP recurrences. Methods: We conducted an observational retrospective study in three French intensive care units (ICUs). Patients admitted for a documented COVID-19 from March 2020 to May 2021 and requiring mechanical ventilation (MV) for ≥48 h were included. The study main outcome was the incidence of VAP recurrences. Secondary outcomes were the duration of MV, ICU and hospital length of stay and mortality according to VAP and recurrences. We also assessed the factors associated with VAP recurrences. Results: During the study period, 398 patients met the inclusion criteria. A total of 236 (59%) of them had at least one VAP episode during their ICU stay and 109 (46%) of these patients developed at least one recurrence. The incidence of VAP recurrence considering death and extubation as competing events was 29.6% (IC = [0.250–0.343]). Seventy-eight percent of recurrences were due to the same bacteria (relapses). Patients with a VAP recurrence had a longer duration of MV as compared with one VAP and no VAP patients (41 (25–56) vs. 16 (8–30) and 10 (5–18) days; p < 0.001) and a longer ICU length of stay (46 (29–66) vs. 22 (12–36) and 14 (9–25) days; p < 0.001). The 90-day mortality was higher in the recurrence group as compared with the no VAP group only (31.2 vs. 21.0% (p = 0.021)). In a multivariate analysis including bacterial co-infection at admission, the use of immunosuppressive therapies and the bacteria responsible for the first VAP episode, the duration of MV was the only factor independently associated with VAP recurrence. Conclusion: In COVID-19 associated respiratory failure, recurrences affected 46% of patients with a first episode of VAP. VAP recurrences were mainly relapses and were associated with a prolonged duration of MV and ICU length of stay but not with a higher mortality. MV duration was the only factor associated with recurrences.

Summary Background Most diseases encountered in the intensive care unit are associated with major stress that can potentially trigger Takotsubo syndrome. Many severe cardiovascular complications are associated with Takotsubo syndrome, yet little is known about Takotsubo syndrome in the intensive care unit. Aims We sought to determine the incidence of Takotsubo syndrome, and to describe its clinical features and outcome in an intensive care unit. Methods This prospective single-centre study included all patients admitted consecutively over a 12-month period who had transthoracic echocardiography, electrocardiography and a troponin I assay performed on admission, at 24 and 48 hours after admission, and at discharge and in the case of clinical worsening. Results The incidence of Takotsubo syndrome was 4.6% (13/280 patients) and female sex predominated (69.2%). The median age of the subgroup with Takotsubo syndrome was 64 (56–72) years. Pulmonary disease and sepsis were the most frequent triggers (46.2% and 38.5%, respectively). Median left ventricular ejection fraction was 29.0% (20.0–37.0). Patients with Takotsubo syndrome presented with shock and arrhythmias and needed ventilation more frequently than patients without Takotsubo syndrome (69.2% vs. 36.3%, P = 0.035; 46.2% vs. 13.5%, P = 0.006; and 92.3% vs. 60.7%, P = 0.021), but mortality rates were similar. The median delay to cardiac index recovery, when impaired, was 2.0 (1.0–2.75) days, and that of left ventricular ejection fraction was 12.5 (7–14.75) days. Conclusion Takotsubo syndrome in the intensive care unit is not uncommon and is associated with substantial haemodynamic and respiratory instability. New-onset arrhythmias and respiratory and haemodynamic worsening could arouse suspicion of and prompt screening for Takotsubo syndrome in the intensive care unit.

Background Cardiac injury has been reported in up to 30% of COVID-19 patients. However, cardiac injury was mainly defined by troponin elevation without description of associated structural abnormalities and its time course has never been studied. Research question What are the electrocardiographic and echocardiographic abnormalities as well as their time course in critically ill COVID-19 patients? Study design and methods The cardiac function of 43 consecutive COVID-19 patients admitted in two intensive care units (ICU) was prospectively and repeatedly assessed combining electrocardiographic, cardiac biomarkers and transthoracic echocardiographic analyses from ICU admission (D0) to ICU discharge or death or to a maximum follow-up of 14 days. Cardiac injury was defined by troponin elevation and newly diagnosed electrocardiographic and/or echocardiographic abnormalities. Results At D0, 49% of patients had a cardiac injury and 70% of patients experienced cardiac injury within the first 14 days of ICU stay, with a median time of occurrence of 3[0-7] days. The most frequent abnormalities were electrocardiographic and/or echocardiographic signs of left ventricular (LV) abnormalities (87% of patients with cardiac injury), right ventricular (RV) systolic dysfunction (47%), pericardial effusion (43%), new-onset atrial arrhythmias (33%), LV relaxation impairment (33%) and LV systolic dysfunction (13%). Between D0 and D14, the incidence of pericardial effusion and of new-onset atrial arrhythmias increased, the incidence of electrocardiographic and/or echocardiographic signs of LV abnormalities as well as the incidence of LV relaxation impairment remained stable, whereas the incidence of RV and LV systolic dysfunction decreased. Interpretation Cardiac injury is common and early in critically ill COVID-19 patients. Electrocardiographic and/or echocardiographic signs of LV abnormalities were the most frequent abnormalities and patients with cardiac injury experienced more RV than LV systolic dysfunction.

Aims of the study Most interventional and observational studies include cardiac arrest from cardiac origin. However, an increasing proportion of cardiac arrest results from an extra-cardiac origin, mainly respiratory. The aim of our study was to compare the characteristics and outcome of cardiac arrest patients according to the presumed cardiac or respiratory causes. Methods This retrospective multicenter observational study included out-of-hospital cardiac arrest patients from presumed cardiac and respiratory origin treated with therapeutic hypothermia. Demographic data (age, sex, initial rhythm as shockable or non-shockable, durations of no-flow and low-flow), clinical evolution in ICU, lactate and outcome (CPC scale at ICU discharge) were compared between patients according to the presumed cardiac or respiratory origin of the cardiac arrest. Results Two hundred and fifty-one cardiac arrest patients were included, 156 from presumed cardiac origin (62%) and 95 from presumed respiratory origin (38%). Patients with presumed cardiac cause presented more frequently a shockable rhythm (68% vs. 5%, p Conclusions Compared to presumed cardiac origin, a worse outcome and a different mode of death are associated with the presumed respiratory origin, resulting from a greater insult preceding cardiac arrest. The presumed cause of cardiac arrest could be integrated in the multimodal prognostication process.

Introduction L’anemie hemolytique auto-immune (AHAI) est une entite rare dont le pronostic est intimement lie a la maladie associee des formes secondaires. L’AHAI du patient reanimatoire est mal documentee et s’accompagne d’un taux de mortalite eleve. L’interet des echanges plasmatiques (EP) est controverse et est difficilement etudiable dans la maladie des agglutinines froides (MAF) d’evolution fulminante. Observation Nous rapportons le cas d’un patient de 75 ans, sans comorbidite, qui a presente un livedo racemosa interessant l’ensemble de la peau, avec une splenomegalie et un ictere a bilirubine libre. On notait un phenomene de Raynaud apparu 3 ans auparavant. Le patient est pris en charge en reanimation pour l’installation d’une insuffisance renale KDIGO 3 et l’inefficacite d’une corticotherapie sur l’hyperhemolyse et la profondeur d’une AHAI a anticorps froids anti-C3d. Un pic monoclonal IgMk de 3,6 g/L est identifie dans un contexte de cryoglobulinemie de type I, et l’absence d’anomalie du complement. L’immunophenotypage caracterise une macroglobulinemie de Waldenstrom. Il n’est pas trouve d’argument pour une origine infectieuse ni pour une connectivite. Le patient necessitait une epuration extrarenale (EER) qui est realisee avec un rechauffement et une intensification de la corticotherapie. Devant la mauvaise tolerance cardiocirculatoire de l’anemie et des dysfonctions du circuit d’hemodialyse attribuees aux entites associees a l’IgMk monoclonale, une premiere serie d’EP selon un schema j1–j2–j5 est pratiquee pour encadrer le support transfusionnel erythrocytaire. Le fluide de substitution etait de l’albumine 4 % avec une masse plasmatique de 1–1,5. Le rendement transfusionnel est ameliore parallelement a l’amendement en 24 h des stigmates d’hemolyse intravasculaire. Le rituximab (RTX) est initie a j5 (=j1 RTX) et sera associe a la bendamustine (j2–j3 du RTX) et l’ibrutinib quotidien. La reticulocytose etant indosable, de la darbepoetine alfa est instauree. A j15, une rechute de l’AHAI est constatee, suivie d’une epistaxis compliquee de choc hemorragique attribuable a l’ibrutinib. Une hypofibrinogenemie aggravee par les EP est eliminee. Une 4e seance d’EP permettra une reponse hematologique transitoire. L’EER est sevree devant l’amelioration de l’insuffisance renale liee a la probable necrose tubulaire aigue. Sur une periode d’un mois, le patient aura recu 19 CGR et 3 PFC. L’evolution sera marquee par le caractere refractaire de la cytopenie et le deces du patient de choc septique deux mois plus tard malgre les traitements anti-infectieux prophylactiques. Discussion L’hemolyse hyperaigue dans le contexte de MAF est exceptionnelle mais engendre une morbidite importante surtout quand elle s’accompagne de defaillance aigue d’organe. La therapie medicamenteuse consiste en du RTX et son association avec une chimiotherapie du lymphome. La corticotherapie et la splenectomie sont inefficaces. Le recours aux EP se justifie dans les cas d’hemolyse fulminante, relevant de support transfusionnel et/ou dans l’attente d’une efficacite des traitements immunosuppresseurs. Cette logique repose sur la clairance des auto-anticorps, complexes immuns et fractions du complement circulants. Dans la MAF, l’hemolyse chronique est surtout intratissulaire. L’utilisation des EP porte ainsi sur l’activite hemolytique des IgM circulantes. L’amplitude thermique des auto-IgM peut etre telle que l’agglutination dans le circuit extra-corporel impose le recours aux EP, chez des patients necessitant une EER comme cela a ete le cas pour notre patient. Les etudes sur l’utilisation des EP dans les AHAI severes se limitent a des petites series retrospectives et d’etudes de cas. Il semble important de distinguer l’efficacite aleatoire des EP rapportee dans les AHAI a anticorps chauds (mais mieux decrites), des cas de defaillances d’organe dans la MAF qui pourraient beneficier de la reponse, certes transitoire, de cette technique. Par ailleurs, on privilegiera des anti-neoplasiques d’action rapide en limitant les produits induisant des saignements. La perfusion de plasma doit etre tres limitee car elle pourrait, en theorie, entretenir l’hemolyse par l’apport de C3 et C4. Les traitements tels que le bortezomib ou eculizumab ne sont que de recours exceptionnel et mis en balance avec le risque infectieux majeur preexistant. Conclusion Les EP constituent un choix therapeutique interessant dans la gestion de l’hemolyse hyperaigue et de defaillance d’organe de ces formes exceptionnelles de MAF fulminantes. Une meilleure comprehension de leur place dans cette pathologie pourra etre apportee par le recours a un appel a observations.

Introduction Les anticorps anticytoplasme des polynucleaires neutrophiles ou ANCA ont permis, par leur association, de caracteriser des vascularites necrosantes de petits vaisseaux. Ils sont toutefois aussi retrouves dans des maladies non vascularitiques. L’objectif est de decrire ces entites non vascularitiques associees aux ANCA positifs et identifier leur significativite en termes pronostics. Materiels et methodes Cette etude observationnelle, realisee dans un centre hospitalier tertiaire, s’est interessee retrospectivement au registre de patients adultes (> 18 ans) identifies via leur positivite pour les ANCA sur une periode de 01/01/2010 au 31/12/2018. Ces patients etaient classes en fonction de leur diagnostic de vascularite (ANCA/V + ) ou l’absence de manifestation vascularitique au diagnostic (ANCA/V-), et a 3 mois du dosage initial d’ANCA. Les caracteristiques demographiques entre ces 2 groupes etaient comparees. Pour le groupe ANCA/V-, les caracteristiques cliniques et diagnostics associes etaient decrits. On recherchait aussi l’evolution vers une vascularite, les modifications du taux d’ANCA, la survie jusqu’a 5 ans et les formes de connectivites associees. Resultats Deux cent quatre-vingt dix-neuf patients etaient etudies sur une cohorte de 321 patients au moment de la soumission. Il n’y avait pas de difference des sexe-ratios entre les 2 groupes, mais les sujets ANCA/V- etaient plus jeunes (55,0 ± 1,2 vs. 66,3 ± 1,8 ans, p Conclusion Une positivite des ANCA, notamment de specificite anti-PR3, accompagnant des presentations cliniques non vascularitiques ne semble pas etre un marqueur d’evolutivite vers une vascularite necrosante. Les ANCA/V- sont grevees d’une mortalite de moins de 5 % a 5 ans et la recherche de maladie associee amene a identifier une connectivite dans moins de 15 % des cas.

Background Although oversedation has been associated with increased morbidity in ventilated critically ill patients, it is unclear whether prevention of oversedation improves mortality. We aimed to assess 90-day mortality in patients receiving a bundle of interventions to prevent oversedation as compared to usual care. Methods In this randomized multicentre trial, all adult patients requiring mechanical ventilation for more than 48 h were included. Two groups were compared: patients managed according to usual sedation practices (control), and patients receiving sedation according to an algorithm which provided a gradual multilevel response to pain, agitation, and ventilator dyssynchrony with no specific target to alter consciousness and no use of sedation scale and promoted the use of alternatives to continuous infusion of midazolam or propofol (intervention). Results Inclusions were stopped before reaching the planned enrolment. Between 2012 and 2014, 584 patients were included in the intervention group and 590 in the control group. Baseline characteristics were well balanced between groups. Although the use of midazolam and propofol was significantly lower in the intervention group, 90-day mortality was not significantly lower (39.4 vs. 44.2% in the control group, p = 0.09). There were no significant differences in 1-year mortality between the two groups. The time to first spontaneous breathing trial and time to successful extubation were significantly shorter in the intervention group than in the control group. These last results should be interpreted with precaution regarding the several limitations of the trial including the early termination. Conclusions This underpowered study of severely ill patients was unable to show that a strategy to prevent oversedation could significantly reduce mortality. Trial registration NCT01617265

La Presse Medicale - In Press.Proof corrected by the author Available online since mercredi 2 mars 2016

We recently published a comparison of two hydrocortisone dosage regimens in patients with septic shock. We compare the results conferred by the two regimens as a function of the response to cosyntropin stimulation test (CST). Patients with septic shock were treated by one of two hydrocortisone regimens: either a 50-mg intravenous bolus every 6 h during 7 days (200 mg group; n = 49), or a 100-mg initial bolus followed by a continuous infusion of 300 mg daily for 5 days (300 mg group; n = 50). Nonresponders was defined as a CST response of 9 μg/dL or less. Nonresponders had more severe septic shock, greater fluid resuscitation needs, and greater vasopressor dependence than responders. When analyzed only as a function of CST results, there was no difference in survival between responders and nonresponders. However, analyses crossing CST results and the treatment regimens showed that patients who were responders and in the 300 mg group had significantly less intensive care unit mortality compared with responders in the 200 mg group (respective mortality of 24% vs. 55% [relative risk 0.43, 95% confidence interval, 0.20 to 0.94, P = 0.018]). Multivariate analysis identified baseline blood cortisol as an independent prognostic factor for 28-day mortality in all groups (hazard ratio 1.002, 95% confidence interval, 1.001 to 1.002, P ≤ 0.0001). The results suggest that in patients who respond to CST, hydrocortisone can provide a dose-dependent benefit. In contrast, nonresponse may indicate corticosteroid resistance. This heterogeneity of response to hydrocortisone may explain the difficulties encountered when trying to demonstrate its benefit in septic shock.

International audience; Background: Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts.Methods: An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest).Results: A total of 698 patients were included during the study period. At the time of death, 84% had one or more organ failures (mainly hemodynamic) and 89% required at least one organ support (mainly mechanical ventilation). Deaths were considered unexpected and anticipated in 225 and 473 cases, respectively. Compared to its anticipated counterpart, unexpected death occurred earlier (1 day vs. 5 days; P< 0.001) and had fewer organ failures (1 [1 to 2] vs. 1 [1 to 3]; P< 0.01) and more organ supports (2 [2 to 3] vs. 1 [1 to 2]; P< 0.01). Withdrawal or withholding of treatments accounted for half of the deaths.Conclusions: In a general intensive care unit population, the majority of patients present with at least one organ failure at the time of death. Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms.

Aims Lactate reflects hypoxic insult in many conditions and is considered as a prognosis factor. But, after cardiac arrest, its interest is still debated. Our study aimed to assess the prognosis value of lactate in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia. Methods This retrospective observational study included out-of-hospital cardiac arrest patients treated with therapeutic hypothermia in four ICUs. Lactate levels were compared at different times during the first 24 hours according to outcome at ICU discharge and to the type of death (multiorgan or neurologic failure). Results Two hundred and seventy-two patients were included, 89 good outcome and 183 poor outcome. In the latter group, 171 patients died, from multiorgan failure in 30% and neurologic failure in 70%. Lactate levels were higher in the poor compared to the good outcome patients at admission (5.4 (3.3–9.4) vs. 2.2 (1.5–3.6) mmol/L; p

Introduction Le purpura thrombotique thrombocytopenique (PTT) est une microangiopathie thrombotique (MAT) grave responsable de defaillance multi-organe en l’absence de therapeutique. Il peut etre associe a des connectivites dont le syndrome Sjogren primitif (SSp). Nous rapportons le cas d’une patiente suivie pour un SSp et presentant une rechute precoce de PTT malgre un traitement optimal au diagnostic. Observation Une femme de 49 ans, sans antecedent particulier en dehors d’un SSp sans facteur d’evolutivite depuis 20 ans, s’est presentee aux urgences pour des troubles neurologiques, arthralgies et un syndrome hemorragique depuis 24 heures. On ne note pas d’episode infectieux ou de nouveau traitement introduit. La fonction renale n’est pas alteree et le dosage de la troponine Ic est normal. L’IRM cerebrale montre l’absence d’anomalie. Le diagnostic de MAT amene a une prise en charge en secteur de reanimation et a l’initiation d’echanges plasmatiques (EP) quotidiens avec 1,5 de volume plasmatique total substitue a chaque seance. On caracterisera le PTT par l’effondrement de l’activite ADAMTS13 et le dosage d’anticorps anti-ADAMTS13 supra-seuil (> 100 UI/mL). Le SSp repondait aux criteres de classification et ne relevait jusqu’a l’episode de MAT d’aucun traitement. On precise la positivite des facteurs antinucleaires avec la presence d’anti-SSA. La patiente recoit une corticotherapie a 1 mg/kg/j et de l’hydroxychloroquine a 6,5 mg/kg/j y est associee. Au vu de l’association de SSp au PTT, un traitement par rituximab est administre a 375 mg/m2 selon un schema j1, j4, j8, j15 (PTT-RTX 1) sans intervalle libre depuis le debut des EP. L’examen clinique se normalise a j2 de prise en charge. La thrombopenie et les LDH se corrigent a j4 chez une patiente restant asymptomatique. Les EP sont ainsi arretes sur les criteres de reponse biologique classique. A j7 de prise en charge, la thrombopenie reapparait et l’anemie s’aggrave avec la reapparition de schizocytes. Les EP quotidiens sont reinities et progressivement espaces (au total 16 EP) suite a une reponse biologique. La remission est maintenue apres un recul de 2 mois. Discussion Le SSp est la connectivite la plus frequemment associee au PTT (SSp-PTT) apres le lupus erythemateux systemique (LES). Tres peu d’etudes se sont interessees a caracteriser les patients avec SSp et MAT [1] , [2] . Les quelques donnees disponibles montrent l’absence de manifestation extraglandulaire ou de facteurs de risque d’evolution vers une maladie lymphomateuse [1] . Si le risque de maladie auto-immune a bien ete decrit et correle a la presence d’anti-SSA et anti-ADN natif au diagnostic de PTT, les donnees de la litterature sont insuffisantes pour caracteriser la reponse therapeutique dans les SSp-PTT. Certaines etudes ont evoque un pronostic plus sombre dans les PTT satellites de LES [3] . Les strategies therapeutiques n’ont pas ete etudiees et sont classiquement adaptees a la reponse therapeutique initiale. L’hydroxychloroquine ne semble pas prevenir le PTT [1] , [3] . Il existe une tendance a l’augmentation du taux de reevolutivite precoce dans les SSp-PTT comparee au PTT idiopathique seul [2] . Le traitement par rituximab, ayant deja prouve son efficacite dans les PTT auto-immuns refractaires par une action de depletion des lymphocytes B auto-reactifs producteurs d’anticorps anti-ADAMTS13, semble justifie dans la prise en charge precoce des SSp-PTT. Conclusion Le SSp-PTT est un evenement rare dans le cadre d’un SSp et releve d’une therapeutique precoce par rituximab au vu du potentiel evolutif potentiellement plus important que les formes de PTT non associees aux connectivites. De futures etudes sur les MAT permettront de mieux caracteriser l’histoire naturelle du SSp-PTT.

Diffuse alveolar haemorrhage (DAH) complicating primary catastrophic anti-phospholipid syndrome (CAPS) was diagnosed in a 50-year-old female patient. Treatment strategies are limited for this often life-threatening autoimmune disease that requires aggressive immunosuppression. In the absence of clinically validated treatment strategies, high-dose steroids associated with plasma exchange and eventually intravenous immunoglobulins were used to manage the disease. Its severity prompted the initiation of rituximab that was administered weekly for four consecutive weeks. Anticoagulation therapy, on the other hand, needed to be discontinued due to the major haemorrhagic episodes. This combination treatment provided an effective control of the CAPS-associated DAH and helped achieve clinical remission.

The Surviving Sepsis Campaign guidelines recommend hydrocortisone in septic shock only when fluid resuscitation and vasopressors fail to restore hemodynamic stability. Hydrocortisone administration modalities are supported only by low-grade recommendations. Our main objective here was to determine differences in 28-day mortality between two low-dose hydrocortisone regimens for the treatment of septic shock.We performed a multicenter, prospective, randomized, double-blind, pilot study in four adult medical intensive care units. Patients presenting septic shock were rapidly administered one of two regimens of hydrocortisone, either a 50-mg intravenous bolus every 6 h during 7 days (200-mg group; n = 59) or a 100-mg initial bolus followed by a continuous infusion of 300 mg daily for 5 days (300-mg group; n = 63). Hydrocortisone was stopped abruptly at the end of treatment.There were no significant differences between the 200-mg and 300-mg groups as concerns 28-day mortality (respectively 52.5% vs. 44.4% [RR 0.84, 95% CI, 0.58-1.22, P = 0.47]), refractory shock incidence or delay from shock to vasopressor cessation. There were also no differences in adverse events between the groups. Shock relapse after hydrocortisone cessation was independent of hydrocortisone regimens, but it was associated with the persistence of infection and the use of etomidate. The resumption of hydrocortisone due to shock relapse was significantly more frequent in the 300-mg group.We found no differences in mortality or adverse events between the two hydrocortisone administration regimens. Shock relapse was significantly associated with the persistence of infection and the use of etomidate.

T cell activation as well as unresponsiveness has been described in separate studies in sepsis. Our aim was to establish the coexistence of both T cell fate in human sepsis.This is a cross-sectional study of 48 patients presenting with severe sepsis or septic shock and 15 healthy controls. Cytofluorometric techniques were used to quantify T cell activation, apoptosis, proliferation, expression of costimulatory molecules, and cytokine secretion.Patients with sepsis were characterized by a significant increase in the percentage of activated T cell subsets, as measured using CD69 marker, compared with healthy controls (P.05). T cell proliferation as measured through Ki67 expression was obvious in infected patients for both CD4 and CD8 T cell subsets compared with controls (P ≤.006). T cell subset apoptosis as measured using Hoechst dye was also increased in infected patients compared with controls (P ≤.002). CD4 T cell proliferation was correlated with interleukin 2 secretion (R(2)=0.84, P.001), whereas up-regulation of CD4 T cell apoptosis was correlated with CTLA-4 expression (R(2)=0.24, P=.001). No such similar relationship was observed for CD8(+) T cells.Concomitant T cell proliferation and T cell apoptosis are observed in human sepsis, being related to a different pathway.

To describe the clinical spectrum of infective endocarditis in critically ill patients and assess the impact of neurologic complications on outcomes.Prospective multicenter observational study conducted from April 2007 to October 2008.Thirty-three intensive care units in 23 university-affiliated and 10 general French hospitals.Two hundred twenty-five patients with definite IE were studied. Factors associated with neurologic complications and predictors of 3-month mortality were identified by logistic regression analysis. Functional outcomes of patients with neurologic complications were evaluated with the modified Rankin Scale.None.Among 198 patients with definite left-sided infective endocarditis, 108 (55%) experienced at least one neurologic complication. These complications were ischemic stroke (n = 79), cerebral hemorrhage (n = 53), meningitis or meningeal reaction (n = 41), brain abscess (n = 14), and mycotic aneurysm (n = 10). Factors independently associated with neurologic complications were (subhazard ratio [95% confidence interval]): Staphylococcus aureus infective endocarditis (1.45 [1.02-2.05]), mitral valve infective endocarditis (1.54 [1.07-2.21]), and nonneurologic embolic events (1.51 [1.09-2.09]). In contrast, health care-associated infective endocarditis had a protective effect (0.46 [0.27-0.77]). Multivariate analysis identified three variables associated with 3-month mortality (odds ratio [95% confidence interval]): neurologic failure, as defined as a Glasgow Coma Scale10 (7.41 [2.89-18.96]), S. aureus infective endocarditis (3.26 [1.53-6.94]), and severe comorbidities before admission as defined as a Charlson score2 (3.16 [1.47-6.77]). Among the 106 patients with neurologic complications assessed at follow-up (3.9 [3-8.5] months), 31 (29%) had a modified Rankin Scale score ≤3 (ability to walk without assistance), nine (9%) a modified Rankin Scale score of 4 or 5 (severe disability), and 66 (62%) a modified Rankin Scale score of 6 (death).Neurologic events are the most frequent complications in infective endocarditis patients requiring intensive care unit admission. They contribute to a severe prognosis, leaving less than one-third of patients alive with functional independence. Neurologic failure at intensive care unit admission represents a major determinant of mortality regardless of the underlying neurologic complication.

Results: A total of 381 consultations for 195 patients were recorded, 244 (64%) in ward A and 137 (36%) in ward B. The median SAPS score was 45 and the mortality rate was 23%. Infections accounted for 220 (58%) admissions. A diagnostic discrepancy between ID and intensive care specialists was noted in 125 (33%) cases. The ID specialist advised continuation of the same antibiotic therapy in 138 (36%) cases, a change in 154 (41%) and withdrawal in 89 (23%). Adherence to ID therapeutic advice was recorded for 326 (86%) cases. Multivariate analysis identified two factors independently associated with adherence: ward B [odds ratio (OR), 4.9; 95% confidence interval (CI), 2.0–12.1] and proposition to pursue the same therapy (OR, 4.8; 95% CI, 1.6–14.5). Conclusions: Patients’ characteristics and antibiotic therapy modalities do not influence adherence to ID consultation. In contrast, the ward and its characteristics play a major role in adherence to ID advice.

Although the demographic characteristics of patients who develop infective endocarditis (IE) have changed over the last few decades, Enterobacteriaceae remain rarely responsible. We report the clinical and epidemiological characteristics of 9 patients with native-valve Enterobacteriaceae IE from 6 French medical intensive care units over a 10-y period and have identified 29 additional cases in the literature. Nearly a third of the 38 patients were immunocompromised and/or had previously known valvular heart disease. Salmonella spp. and Yersinia spp. were the most frequently isolated microorganisms reported in the literature. The overall mortality rate was 24% (9/38) and was lower for operated patients (10% (1/10)) compared to those who did not undergo valve surgery (31% (8/26)). Our results confirmed the rarity of native-valve endocarditis caused by Enterobacteriaceae, pathogens frequently responsible for nosocomial and community-acquired bacteraemias. This paradox may be explained by susceptibility to the bactericidal action of serum and the inability of these bacteria to colonize the endocardium.

Resume Propos. – Le syndrome de Lemierre est une pathologie rare mais grave qui associe fievre, douleur cervicale et symptomatologie pulmonaire dans les suites d’une infection oropharyngee, le plus souvent une angine. La large utilisation des antibiotiques dans les infections oropharyngees n’a pas permis une disparition de cette infection. Nous avons voulu, a travers ces 6 observations originales faire partager notre experience. Methodes. – Il s’agit d’une etude descriptive retrospective menee entre 1995 et 2000 dans deux services (maladies infectieuses et tropicales et reanimation medicale) du centre hospitalier universitaire de Nice. Resultats. – Nous presentons une serie de 6 cas de ce syndrome, tous de sexe feminin et âges de 27 ans en moyenne. Il s’agissait de sujets anterieurement sains et la symptomatologie oropharyngee initiale etait une angine. Ces patientes presentaient dans la majorite des cas des signes de sepsis severe et une patiente est decedee des suites d’un choc septique. Dans les autres cas, l’evolution a ete favorable sous traitement. Le delai entre l’angine et l’apparition du syndrome infectieux etait de 7 jours en moyenne. Le traitement a consiste en une association betalactamine et metronidazole dans 4 cas, amoxicilline–acide clavulanique pour les autres cas. Une anticoagulation a ete systematiquement debutee en cas de thrombose jugulaire interne documentee. Conclusions. – Le diagnostic peut etre fortement suspecte sur la clinique et confirme secondairement par les examens complementaires. Le pronostic depend etroitement de la rapidite et de la qualite de la prise en charge. Nous avons donc souhaite familiariser nos confreres avec cette pathologie en rapportant notre experience personnelle.

Since 1996, we have a common protocol in the Infectious Diseases Department and the Intensive Care Unit for the administration of quinine in case of Plasmodium falciparum malaria. Patients were classified as uncomplicated form of malaria (UFM) or severe form of malaria (SFM) according to WHO criteria, adding parasitemia >5% as a criteria of SFM. Treatment of SFM should consist of a 4 h infusion of 16 mg/kg quinine-base loading dose, followed by 8 mg/kg every 8 h. Patients with UFM receive quinine-base, 8 mg/kg every 8 h. A therapeutic index of 10-15 mg/l was considered adequate. Hypoglycemia and cardiotoxicity were the two main adverse effects of quinine to be investigated. In order to verify that these modalities for quinine administration are associated with adequate quinine blood concentrations, we have reviewed the pharmacological data and the occurrence of adverse effects. Between April 1996 and December 2000, 95 patients were hospitalised: 25 with SFM and 70 with UFM: 78/95 patients (82%) received adequate treatment and 26/95 (28%) of the patients presented an overdosage of quinine. Six severe adverse effects were observed, even in case of adequate quinine administration. Consensual treatment of malaria does not confer adequate quinine blood concentrations, and toxic effects are still common.

International audience; Early antifungal therapeutic strategies are proposed during invasive fungal infection (IFI), but antifungal stewardship programs should institute a systematic reevaluation of prescriptions, particularly in the context of empirical treatment. Here, we aimed to evaluate the performances and particularly the negative predictive value (NPV) of diagnostic strategies, including a whole blood panfungal quantitative PCR assay (PF-qPCR) in a high risk population for IFI. The first step was to standardize and optimize a new PF- rtPCR targeting ITS2 region. Then, this method was evaluated in a multicenter prospective study including 313 patients with suspected IFI for whom an early antifungal treatment was prescribed. All patients enrolled at day 0 of their treatment benefited from serum Aspergillus galactomannan (GM) antigen detection twice a week, weekly PF-qPCR assay, and when indicated and feasible, CT-scan and mycological sampling. In total, 125 of 313 patients were diagnosed with IFI: 68 invasive aspergillosis (eight proven, 48 probable and 12 possible), one fusariosis, 47 candidemia, three disseminated candidiasis and six cryptococcosis. Globally, the sensitivity of the PF-qPCR assay was only 40%, but the specificity, PPV and NPV were 96%, 88% and 69%, respectively. In the population of patients at high risk for invasive aspergillosis who also benefited from Aspergillus GM detection, the sensitivity and the NPV of the combined detection reached to 78% and 84%, respectively. Even higher NPV were obtained when combining negative PF-qPCR and CT scan (95%) as well as negative GM and CT scan (93%), thus allowing to rationalize and re-evaluate the prescription of empirical treatment in such highly selected population.

International audience

To assess long-term outcomes and the management of critical left-sided infective endocarditis (IE) and evaluate the impact of surgery.Among the 198 patients included prospectively for IE across 33 adult intensive care units (ICU) in France from 1 April 2007 to 1 October 2008, 137 (69%) were dead at a median follow-up time of 59.5 months. Characteristics significantly associated with mortality were: Sepsis-related Organ-Failure Assessment (SOFA) score at ICU admission [Hazard ratio (HR), 95% Confidence Interval (CI) of 1.43 (0.79-2.59) for SOFA 5-9; 2.01 (1.05-3.85) for SOFA 10-14; 3.53 (1.75-7.11) for SOFA 15-20; reference category SOFA 0-4; P = 0.003]; prosthetic mechanical valve IE [HR 2.01; 95% CI 1.09-3.69, P = 0.025]; vegetation size ≥15 mm [HR 1.64; 95% CI 1.03-2.63, P = 0.038]; and cardiac surgery [HR (95%CI), 0.33 (0.16-0.67) for surgery ≤1 day after IE diagnosis; 0.61 (0.29-1.26) for surgery 2-7 days after IE diagnosis; 0.42 (0.21-0.83) for surgery7 days after IE diagnosis; reference category no surgery; P = 0.005]. One hundred and three (52%) patients underwent cardiac surgery after a median time of 6 (16) days. Independent predictors of surgical intervention on multivariate analysis were: age ≤60 years [Odds ratio (OR) 5.30; 95% CI (2.46-11.41), P0.01], heart failure [OR 3.27; 95% CI (1.03-10.35), P = 0.04], cardiogenic shock [OR 3.31; 95% CI (1.47-7.46), P = 0.004], septic shock [OR 0.25; 95% CI (0.11-0.59), P = 0.002], immunosuppression [OR 0.15; 95% CI (0.04-0.55), P = 0.004], and diagnosis before or within 24 h of ICU admission [OR 2.81; 95% CI (1.14-6.95), P = 0.025]. SOFA score calculated the day of surgery was the only independently associated factor with long-term mortality [HR (95% CI) 1.59 (0.77-3.28) for SOFA 5-9; 3.56 (1.71-7.38) for SOFA 10-14; 11.58 (4.02-33.35) for SOFA 15-20; reference category SOFA 0-4; P0.0001]. Surgical timing was not associated with post-operative outcomes. Of the 158 patients with a theoretical indication for surgery, the 58 deemed not fit had a 95% mortality rate.Mortality in patients with critical IE remains unacceptably high. Factors associated with long-term outcomes are the severity of multiorgan failure, prosthetic mechanical valve IE, vegetation size ≥15 mm, and surgical treatment. Up to one-third of potential candidates do not undergo surgery and these patients experience extremely high mortality rates. The strongest independent predictor of post-operative mortality is the pre-operative multiorgan failure score while surgical timing does not seem to impact on outcomes.

Introduction La crise renale sclerodermique (CRS) est une complication rare et grave de la sclerodermie. Nous rapportons 11 cas de CRS au sein d’une cohorte de 110 sclerodermies suivies dans un service universitaire. Patients et methodes Il s’agit d’une etude retrospective de 2006 a 2016 portant sur les patients presentant une CRS. L’objectif principal etait de decrire la population avec CRS : presentation clinique et biologique, prise de corticotherapie, participation au programme d’education therapeutique, survie globale, survie renale et recours eventuel a la transplantation. Les patients presentant les criteres diagnostiques de CRS ont ete selectionnes a partir d’une cohorte de patients sclerodermiques prevalents suivis dans un centre de competence. Resultats Onze patients ont presente une CRS. Il s’agissait de 9 femmes et 2 hommes d’âge median 62 ans. Neuf patients avaient une forme diffuse. La duree mediane d’evolution entre le premier signe hors Raynaud et la CRS etait de 11,4 ans. Au moment de la CRS, 2 patients avaient une fibrose pulmonaire, 3 avaient eu au moins une ulceration digitale, 3 patients avaient un Rodnan > 30 et un patient presentait une HTAP. La duree moyenne d’evolution entre le diagnostic de SSc et la CRS etait de 2,98 ans. Les CRS etaient inaugurales chez 45 % des patients (n = 5). Tous les patients avaient des anticorps antinucleaires (4 antinucleolaires, 3 anti-scl70, 2 PmScl et 2 anti-SSA). Les anti-ARN polymerase III etaient positifs chez une seule patiente (sur 4 recherches). Huit patients avaient recu des corticoides avant la CRS dont 6 a plus de 15 mg/j. Tous les patients etaient hypertendus au diagnostic de CRS, les œdemes etaient presents chez 4 patients, 7 presentaient une alteration de l’etat general. La creatininemie mediane etait de 418 μmol/L, les taux medians d’hemoglobine et de plaquettes etaient respectivement de 8,9 g/dL et 97 000/mm3. Dix patients avaient les LDH elevees et 9 avaient des schizocytes. Tous les patients ont recu un IEC. Le recours a la dialyse etait necessaire chez 7 patients. La duree mediane de dialyse etait de 3,5 mois. Une patiente etait encore dependante de l’hemodialyse a la fin du suivi. Un patient a ete greffe. Aucun patient n’a recupere une fonction renale normale. Une patiente a ete mise sous Bosentan dans le cadre d’un protocole. Deux patients ont eu des echanges plasmatiques par meconnaissance du diagnostic. A la fin du suivi, 5 patients sont decedes (a 1,91 ans du diagnostic de CRS). Les causes de deces etaient : 2 cancers, 2 defaillances cardiaques, une radionecrose postradique d’un meningiome. Une seule patiente avait beneficie du programme d’education therapeutique avant l’apparition de la crise mais n’etait pas venue a la seance concernant la CRS. Discussion Notre serie de patients avec CRS est interessante car elle correspond a l’activite d’un centre de competence sur une duree de 10 ans. Les resultats sont comparables aux donnees de la litterature [1] , [2] en ce qui concerne la prevalence, la duree d’evolution, la presentation clinique et biologique des CRS. La corticotherapie est retrouvee comme facteur favorisant dans 75 % des cas. Tous les patients ont recu le traitement de reference. Par contre, dans notre serie, la CRS est inaugurale dans presque la moitie des cas. Dans notre serie, aucun patient n’est decede de la CRS, par contre, le suivi montre que les deces sont lies a la presence d’un cancer ou secondaire a une defaillance cardiaque, temoignant pour cette derniere de presentations severes de la sclerodermie. Cependant, cette etude est retrospective, avec neanmoins peu de donnees manquantes, la recherche d’anti-ARN polymerase III n’a pu etre realisee que dans les cas les plus recents. L’etude des facteurs pronostiques de morbidite au sein de la cohorte sera realisee. Conclusion Les CRS surviennent chez les patients presentant une forme severe de SSc. Si la mortalite n’est plus un enjeu, les CRS ont une morbidite importante malgre l’utilisation des IEC, en particulier en terme de maladie renale. Les formes inaugurales de CRS sont difficiles a prevenir, d’ou l’importance de la formation des medecins a cette pathologie, et la prise en charge collaborative, en particulier avec les reanimateurs. La mise en place de courriers avertissant patients et medecins des facteurs de risques evitables de CRS, et les programmes d’education therapeutique sont des moyens d’optimiser la prevention des CRS chez un patient connu pour avoir une SSc.

Introduction L’arret cardiaque extra-hospitalier (ACREH) est un probleme majeur de sante publique dont le pronostic neurologique est incertain. L’hypothermie therapeutique a ameliore le devenir de ces patients mais aussi modifie la valeur de divers facteurs pronostiques [1] , [2] . Le lactate est un marqueur pronostique controverse dans l’ACREH [3] . Le but de notre etude etait d’evaluer le caractere pronostique de la lactatemie apres ACREH traite par hypothermie therapeutique. Materiel et methodes Nous avons mene une etude retrospective incluant des patients adultes admis dans 4 services de reanimation pour ACREH beneficiant d’une hypothermie therapeutique. Nous avons collecte les donnees demographiques, les circonstances de l’arret cardiaque ainsi que les lactatemies arterielles durant les 2 premiers jours. Le pronostic neurologique etait etabli sur le score CPC : 1–2 bon devenir et 3–5 mauvais devenir. Les donnees sont exprimees en mediane et intervalle interquartile. Les comparaisons entre groupes ont fait appel a un test de Mann-Whitney ou du Chi2 quand approprie. Une regression logistique a estime les odds-ratio associes au devenir. Un p Resultats Deux cent soixante-douze patients ont ete inclus avec 89 bons et 183 mauvais devenirs. Les patients ayant une bonne evolution presentaient un âge inferieur, des durees de no-flow et low-flow inferieures et plus de rythmes choquables. La lactatemie aux differents temps est rapportee dans le Tableau 1 . En analyse multivariee, la lactatemie initiale (OR 1,304 [1,146–1,483] p Fig. 1 ). Discussion Notre etude semble confirmer l’association de la lactatemie au devenir apres ACREH traite par hypothermie. Cependant, les performances statistiques de lactatemie seule ne sont pas suffisantes pour etablir avec certitude le pronostic neurologique. Des etudes prospectives evaluant les associations de plusieurs parametres pronostiques sont necessaires pour ameliorer la fiabilite de l’evaluation pronostique.

Resume Les moules bronchiques sont des formations qui moulent et obstruent les bronches. Ils peuvent entrainer des detresses respiratoires, parfois fatales. Ils se rencontrent essentiellement au cours d’affections respiratoires chroniques comme l’asthme, l’aspergillose broncho-pulmonaire allergique ou la mucoviscidose. Chez l’enfant, ils peuvent aussi se developper au cours d’une cardiopathie cyanogene. La survenue de moules bronchiques chez un patient sans pathologie respiratoire chronique est exceptionnelle.

IMPORTANCE Despite advances in care, mortality and morbidity remain high in adults with acute bacterial meningitis, particularly when due to Streptococcus pneumoniae. Induced hypothermia is beneficial in other conditions with global cerebral hypoxia. OBJECTIVE To test the hypothesis that induced hypothermia improves outcome in patients with severe bacterial meningitis. DESIGN, SETTING, AND PATIENTS An open-label, multicenter, randomized clinical trial in 49 intensive care units in France, February 2009-November 2011. In total, 130 patients were assessed for eligibility and 98 comatose adults (Glasgow Coma Scale [GCS] score of

Introduction Les maladies inflammatoires systemiques peuvent entrainer des defaillances d’organes secondaires soit a une poussee de la maladie soit a des complications des traitements, ainsi elles peuvent necessiter un sejour en reanimation. Peu d’etudes ont ete consacrees a ce sujet. L’arsenal therapeutique s’est elargi depuis les annees 2000, nous disposons maintenant de traitements plus immunosuppresseurs. Nous proposons de decrire les types de maladies inflammatoires systemiques en reanimation, d’identifier les raisons d’admission, les traitements recus, l’evolution et la mortalite. Patients et methodes Etude observationnelle retrospective a partir du tableau de bord d’un service de 10 lits de reanimation medicale d’un CHU de juin 2004 a juin 2015. Les criteres d’inclusion etaient les suivants : patients majeurs, hospitalises dans le service de reanimation, maladies inflammatoires systemiques selon les criteres de classification en cours ; et les criteres d’exclusion : patients avec greffe d’organe solide ou transplantes de mœlle, manque de donnees, criteres diagnostiques incomplets. Une analyse groupee des donnees a ete realisee pour des sejours multiples en reanimation au cours d’une meme hospitalisation. Les donnees demographiques et cliniques ont ete extraites du dossier medical informatise. Resultats Sur 6053 sejours en reanimation, 98 patients correspondaient aux criteres d’inclusions avec 108 sejours (2 %). La population etait a predominance feminine 58 % ( n = 63) et avait un âge moyen de 55 ± 19 ans [extremes : 19–82]. Les pathologies les plus representees etaient le lupus erythemateux systemique pour 25 % (27 sejours chez 21 patients), les vascularites a ANCA pour 15 % (16 sejours chez 15 patients), le syndrome des antiphospholipides pour 12 % (13 sejours chez 11 patients), puis venaient les myosites inflammatoires pour 11 %, les polyarthrites rhumatoides pour 10 %, les cryoglobulinemies mixtes pour 6 %, les sclerodermies pour 5 %, le syndrome de Gougerot-Sjogren pour 5 %, la maladie de Behcet pour 3 %, les periarterites noueuses pour 3 %, les purpuras vasculaires pour 2 %, la maladie de Goodpasture pour 1 %, la maladie de Horton pour 1 %, et la maladie de Still de l’adulte pour 1 %. La duree d’evolution de la maladie etait en moyenne de 55 ± 93 mois [extremes : 0 a 554 mois]. Les 3 causes principales d’admission etaient : une poussee de la maladie (43 %), une infection (43 %) ou les deux associees (15 %). Dans 26 % des cas, la maladie inflammatoire systemique etait decouverte en reanimation. Les defaillances d’organes responsables d’une admission etaient respiratoires dans 72 % des cas, hemodynamiques dans 56 % des cas, renales dans 30 % des cas et neurologiques dans 24 % des cas. Le score IGS2 a l’admission etait a 41,6 ± 18,6 points et le LOD a 6,1 ± 3,6 points. Le taux de mortalite etait respectivement de 29 % ( n = 31) en reanimation et de 32 % ( n = 35) a J28. Discussion Notre etude porte sur un nombre important de patients. Il est cependant difficile de degager des idees claires en raison du caractere tres heterogene des pathologies. Notre etude montre que les maladies inflammatoires systemiques peuvent conduire les patients en reanimation. Elles representent 2 % de la population d’un service de reanimation medicale. La mortalite est alors tres elevee. La population de notre etude est comparable a celle retrouvee dans d’autres etudes en termes d’âge et de sexe ratio. Les syndromes des antiphospholipides sont plus nombreux avec comme presentation principale un CAPS ; 1 patiente recidive 3 fois a distance ce qui augmente leur nombre total de CAPS. Les polyarthrites rhumatoides sont au contraire, moins nombreuses car plus de la moitie des patients ont du etre exclus en raison de manque de donnees. Comme dans l’etude de Quintero et al., la detresse respiratoire, quelle qu’en soit l’origine, est le motif d’hospitalisation le plus courant [1] . Schematiquement la moitie des patients vient pour une poussee de leur maladie et l’autre moitie pour une infection. Le nombre important d’infections chez ces patients immunodeprimes souligne l’importance de la prophylaxie antibiotique et des vaccinations. Conclusions Les maladies inflammatoires systemiques sont un challenge en reanimation car rares et graves. Les 2 motifs principaux d’hospitalisation sont une poussee de la maladie et une infection. Une collaboration etroite entre reanimateur et interniste est indispensable pour permettre un diagnostic precoce et une prise en charge la plus adaptee.

The last name of the second author in the Hopital de Limoges collaborators in the SIMA study group was misspelled. The correct spelling is: D.Ajzenberg.

A 52-year-old woman with a history of Crohn's disease was admitted due to peritonitis which followed an intestinal perforation. After transitory treatment with voriconazole, resolution of the infection was complicated by recurring peritonitis resulting from necrosis and perforation of the left colon which ultimately lead to the death of the patient. Microscopic examination of the peritoneal fluid revealed the presence of broad, irregular hyphae and culture of the fluid yielded Rhizopus microsporus. The identification of the fungus was confirmed by its characteristic microscopic morphology and sequencing of the ITS region of the rDNA. The histopathologic examination of the colon tissue demonstrated the presence of broad, non-septate hyphae and the same fungus was again isolated in culture.

We present 2 cases of community acquired S. aureus pneumonia carrying Panton Valentine leucocidin (PVL). These cases illustrate this clinical entity characterized by a younger and healthier population than usual staphylococcal pneumonias and complicated by a 75% mortality rate. We also discuss the diagnosis and therapeutic difficulties.

Acute obstructive kidney failure can occur during sulfadiazine treatment of cerebral toxoplasmosis in immunocompromised patients.Six days after the patient began sulfadiazine treatment for toxoplasmosis, he developed low back pain radiating into the abdomen and kidney failure with obstructive uropathy, followed by anuria. Abdominal computed tomography found bilateral pyelocaliceal distention. Six hours after a hemodialysis session, the pain stopped abruptly and abundant diuresis resumed.During acute renal failure due to sulfadiazine, simply stopping the drug treatment does not suffice. The massive alkalinization induced by hemodialysis, however, is effective.

To assess the prevalence of relative adrenal insufficiency in patients successfully resuscitated after cardiac arrest, and its prognostic role in post-resuscitation disease.A prospective observational single-center study in a medical intensive care unit.64 patients hospitalised in the intensive care unit after successful resuscitation for out-of-hospital cardiac arrest.A corticotropin-stimulation test was performed between 12 and 24 h following admission: serum cortisol level was measured before and 60 min after administration of tetracosactide 250 microg. Patients with an incremental response less than 9 microg/dl were considered to have relative adrenal insufficiency (non-responders). Variables were expressed as medians and interquartile ranges. 33 patients (52%) had relative adrenal insufficiency. Baseline cortisol level was higher in non-responders than in responders (41 [27.2-55.5] vs. 22.8 [15.7-35.1] microg/dl respectively, P=0.001). A long interval before initiation of cardiopulmonary resuscitation was associated with relative adrenal insufficiency (5 [3-10] vs. 3 [3-5] min, P=0.03). Of the 38 patients with post-resuscitation shock, 13 died of irreversible multiorgan failure. The presence of relative adrenal insufficiency was identified as a poor prognostic factor of shock-related mortality (log-rank P=0.02). A trend towards higher mortality in non-responders was identified in a multivariate logistic regression analysis (odds ratio 6.77, CI 95% 0.94-48.99, P=0.058).Relative adrenal insufficiency occurs frequently after successful resuscitation of out-of-hospital cardiac arrest, and appears to be associated with a poor prognosis in cases of post-resuscitation shock. The role of corticosteroid supplementation should be evaluated in this setting.

Resume Introduction Une insuffisance renale aigue obstructive peut survenir lors d’un traitement d’une toxoplasmose cerebrale par sulfadiazine chez un patient immunodeprime. Observation Six jours apres l’instauration d’un traitement antitoxoplasmique par sulfadiazine sont survenues des lombalgies a irradiation abdominale et une insuffisance renale a diurese conservee puis une anurie. Une tomodensitometrie abdominale trouvait une distension pyelocalicielle bilaterale. Six heures apres une seance d’hemodialyse, les douleurs cedaient brutalement avec reprise d’une diurese abondante. Commentaires Lors d’une insuffisance renale aigue a la sulfadiazine, l’arret isole de cette derniere ne suffit pas. En revanche, l’hemodialyse est efficace par un effet d’alcalinisation massive.

A 28-year-old male patient, treated with prednisone for bronchitis with sibilant rales, developed fever with abdominal pain and generalized vesicular rash after coming in contact with varicella-infected children. He was hospitalized after having a seizure. Laboratory values revealed hepatitis and rapidly fulminant hepatic insufficiency with disseminated intravascular coagulation. Despite acyclovir treatment, the patient died 4 days after admission. Clinical presentation could evoke a Reye's syndrome, but liver biopsy showed massive coagulative necrosis. This report demonstrates the increased risk of complicated varicella associated with the use of corticosteroids, even for a short period of time.

Introduction There is growing evidence to suggest that transthoracic echocardiography (TTE) should be used to identify the cardiac origin of respiratory weaning failure. The aims of our study were: first, to evaluate the ability of transthoracic echocardiography, with mitral Doppler inflow E velocity to annular tissue Doppler Ea wave velocity (E/Ea) ratio measurement, to predict weaning failure from mechanical ventilation in patients, including those with atrial fibrillation; and second, to determine whether the depressed left ejection fraction and/or diastolic dysfunction participate in weaning outcome. Methods The sample included patients on mechanical ventilation for over 48 hours. A complete echocardiography was performed just before the spontaneous breathing trial (SBT) and 10 minutes after starting the SBT. Systolic dysfunction was defined by a left ventricle ejection fraction under 50% and relaxation impairment by a protodiastolic annulus mitral velocity Ea under or equal to 8 cm/second. Results A total of 68 patients were included. Twenty failed the weaning process and the other 48 patients succeeded. Before the SBT, the E/Ea ratio was higher in the failed group than in the successful group. The E/Ea measured during the SBT was also higher in the failed group. The cut-off value, obtained from receiver operating characteristics (ROC) curve analysis, to predict weaning failure gave an E/Ea ratio during the SBT of 14.5 with a sensitivity of 75% and a specificity of 95.8%. The left ventricular ejection fraction did not differ between the two groups whereas Ea was lower in the failed group. Ea increased during SBT in the successful group while no change occurred in the failed group. Conclusions Measurement of the E/Ea ratio with TTE could predict weaning failure. Diastolic dysfunction with relaxation impairment is strongly associated with weaning failure. Moreover, the impossibility of enhancing the left ventricle relaxation rate during the SBT seems to be the key factor of weaning failure. In contrast, the systolic dysfunction was not associated with weaning outcome.