Damien Contou

Golden Tracheal Secretions and Bronchoalveolar Fluid During Acute Chest Syndrome in Sickle Cell Disease

Acute chest syndrome (ACS) is the leading cause of ICU admission in patients with sickle cell disease and is characterized by golden sputum, which is commonly attributed to the presence of bilirubin. Three young consecutive patients with homozygous sickle cell disease were admitted for severe acute respiratory syndrome due to ACS. In all 3 patients, tracheal secretions and bronchoalveolar lavage fluid (BALF) showed a yellowish plasma-like stain. After normalization for the plasma-to-BAL urea ratio, BALF protein and lactate dehydrogenase levels were consistent with an exudative process. BALF bilirubin concentrations were very low, implying that the yellowish stain was not related to bilirubin content. The yellowish coloration of tracheal secretions and BALF observed during ACS appears to be related to an intense exudative process rather than to the presence of bilirubin.

Severe Ketoalkalosis as Initial Presentation of Imported Human Rabies in France

ABSTRACT We report a patient with an unusual initial metabolic presentation of imported human rabies who became symptomatic within 2 weeks of returning from Mali to France. This is the single case of imported human rabies identified in France within the past 11 years and the first report of viral RNA in bronchial secretions.

Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study

BackgroundThe lack of a patent source of infection after 24 hours of management of shock considered septic is a common and disturbing scenario. We aimed to determine the prevalence and the causes of shock with no diagnosis 24 hours after its onset, and to compare the outcomes of patients with early-confirmed septic shock to those of others.MethodsWe conducted a pragmatic, prospective, multicenter observational cohort study in ten intensive care units (ICU) in France. We included all consecutive patients admitted to the ICU with suspected septic shock defined by clinical suspicion of infection leading to antibiotic prescription plus acute circulatory failure requiring vasopressor support.ResultsA total of 508 patients were admitted with suspected septic shock. Among them, 374 (74 %) had early-confirmed septic shock, while the 134 others (26 %) had no source of infection identified nor microbiological documentation retrieved 24 hours after shock onset. Among these, 37/134 (28 %) had late-confirmed septic shock diagnosed after 24 hours, 59/134 (44 %) had a condition mimicking septic (septic shock mimicker, mainly related to adverse drug reactions, acute mesenteric ischemia and malignancies) and 38/134 (28 %) had shock of unknown origin by the end of the ICU stay. There were no differences between patients with early-confirmed septic shock and the remainder in ICU mortality and the median duration of ICU stay, of tracheal intubation and of vasopressor support. The multivariable Cox model showed that the risk of day-60 mortality did not differ between patients with or without early-confirmed septic shock. A sensitivity analysis was performed in the subgroup (n = 369/508) of patients meeting the Sepsis-3 definition criteria and displayed consistent results.ConclusionsOne quarter of the patients admitted in the ICU with suspected septic shock had no infection identified 24 hours after its onset and almost half of them were eventually diagnosed with a septic shock mimicker. Outcome did not differ between patients with early-confirmed septic shock and other patients.

Middle age exacerbates acute respiratory distress syndrome in a double hit murine model

Rationale In a recent systematic review, aging has been identified as the only factor independently associated with mortality during human acute respiratory distress syndrome (ARDS). We explored this age‐dependent severity in a clinically relevant double hit murine ARDS model. Methods Young adult (Y, 10–12 weeks) and middle‐old (O, 12–13 months) male C57BL6 mice underwent an aspiration of Escherichia coli lipopolysaccharide (LPS) or control saline vehicle. Twenty hours later, four groups of mice were sacrificed [Y(control), O(control), Y(LPS) and O(LPS)]. Four other groups of mice underwent 3 h of low tidal volume (8 mL/kg) mechanical ventilation (MV) [Y(MV), O(MV), Y(LPS + MV) and O(LPS + MV)]. Lung mechanics were assessed hourly during MV. Right ventricular pressure and cardiac output were measured at the end of the MV. After sacrifice, lung inflammation, edema and injury were explored with bronchoalveolar lavage (BAL) and histology. Results After saline aspiration, middle‐old mice had a higher respiratory system compliance than young adult mice. LPS aspiration dramatically altered the baseline compliance in middle‐old (O(LPS)), but not in young adult (Y(LPS)) mice. Middle‐old mice had a more pronounced alteration in lungs mechanics during MV as compared to young adult mice. Lung inflammation (as assessed by the total cell count, IL‐6, TNF&agr; and MIP‐2 concentrations in BAL fluid), systemic inflammation (as assessed by plasma IL‐6 concentration) and alveolocapillary leak (as assessed by the total protein concentration of BAL fluid) were higher in O(LPS) and O(LPS + MV) mice as compared to Y(LPS) and Y(LPS + MV) mice, respectively. The combination of LPS + MV induced a higher lung injury as compared to LPS alone in middle‐old mice but not in young adult mice. Hemodynamics (systemic blood pressure, cardiac output and pulmonary vascular resistances) were similar between Y(MV) and O(MV) on the one hand and between Y(LPS + MV) and O(LPS + MV) on the other hand. Conclusion Middle‐old mice were more susceptible to both LPS alone and the combination of LPS and low tidal volume MV as compared to their young adult counterparts. The synergism between LPS and MV was amplified in middle‐old mice. HighlightsA clinically relevant double hit murine model of ARDS is used.LPS aspiration and low tidal volume mechanical ventilation are combined.An aged‐dependent severity is observed.Middle‐old mice are more susceptible to LPS aspiration than young adult mice.Synergism between LPS and mechanical ventilation is amplified in middle‐old mice.

Earlobe Crease in Patient With Chest Pain

A 69-year-old man with a history of coronary artery disease was admitted to the emergency department for acute chest pain. A few minutes after admission, cardiac arrest occurred. Return of spontaneous circulation was obtained after defibrillation and intravenous amiodarone. Post–cardiac arrest ECG revealed a left bundle branch block. Emergency coronary angiography revealed an acute occlusion of the middle segment of the right coronary artery, with successful recanalization after thrombectomy and angioplasty. On ICU admission, an attentive physical examination showed a bilateral marked diagonal earlobe crease (Figure).

Long-term quality of life in adult patients surviving purpura fulminans: an exposed-unexposed multicenter cohort study

Background Long-term Health-related Quality of Life (HR-QOL) of patients surviving the acute phase of purpura fulminans (PF) has not been evaluated. Methods A French multicenter exposed-unexposed cohort study enrolling patients admitted in 55 ICUs for a PF from 2010 to 2016. Adult patients surviving the acute phase of PF (exposed group) were matched 1:1 for age, SAPS II and gender with septic shock survivors (unexposed group). HR-QOL was assessed during a phone-interview using the SF-36 questionnaire, the Hospital Anxiety and Depression (HAD) scale, the Impact of Event Scale-Revised (IES-R) and the Activity of Daily Living (ADL) and Instrumental ADL (IADL) scales. The primary outcome measure was the physical component summary (PCS) of the SF-36 questionnaire. Results Thirty-seven survivors of PF and 37 of septic shock were phone-interviewed at 55 [35-83] and 44 [35-72] months of ICU discharge, respectively (p=0.23). The PCS of the SF-36 was not significantly different between exposed and unexposed patients (median [quartile1-quartile3]=47 [36-53] vs. 54 [36-57]; p=0.18). There was also no significant difference between groups regarding the mental component summary of the SF-36, and the HAD, IES-R, ADL and IADL scales. Among the 37 exposed patients, those who required limb amputation (n=12/37, 32%) exhibited lower PCS (34 [24-38] vs. 52 [42-56]; p=0.001) and IADL scores (7 [4-8] vs. 8 [7-8]; p=0.021) as compared to non-amputated patients. Conclusion Long-term HR-QOL does not differ between patients surviving PF and those surviving septic shock unrelated to PF. Amputated patients have an impaired physical HR-QOL but a preserved mental health. Clinical Trials NCT03216577.

Perivalvular Mitral Abscess Fistulised to the Pericardial Cavity Revealing Staphylococcal Endocarditis

BACKGROUND Fistula to the pericardial cavity is a very rare complication of perivalvular abscess during infective endocarditis, with Staphylococcus aureus being the most commonly associated microorganism. METHODS We report a fatal septic shock due to a mitral endocarditis revealed by a myocardial abscess fistulised toward the pericardial cavity. RESULTS A 66-year-old female without previous valvular disease was admitted to intensive care for severe sepsis. A few hours after admission, an unexpected cardiac arrest occurred. Chest computed tomographic-scan and transoesophageal echocardiography revealed a pericardial effusion due to a perivalvular mitral abscess fistulised toward the pericardial cavity. Despite prompt management including surgical debridement and appropriate antibiotics, death occurred 36hours after intensive care admission. All blood cultures as well as native mitral valve and pericardial fluid grew methicillin-sensitive Staphylococcus aureus. CONCLUSIONS Intensivists should consider this rare complication in patients with staphylococcal infective endocarditis and perivalvular abscess.