David De Bels

Torsade de pointes in Kearns–Sayre syndrome

A 47-year-old woman with Kearns–Sayre syndrome (KSS) and an implanted pacemaker for complete heart block was admitted to the intensive care unit following a cardiac arrest due to ventricular tachycardia (torsade de pointes) in the setting of QT prolongation. Complete heart blocks and ventricular tachycardia are implicated as mechanisms of sudden deaths in KSS; such patients may require pacemaker implantation and implantation of an automatic implantable cardioverter–defibrillator.

First Epileptic Seizure Induced by Occupational Nickel Poisoning

Summary:  Toxic causes of seizures are numerous: alcohol and other substances of abuse, drugs, and industrial and household products. However, in the absence of a clearly suggestive history and/or associated symptoms and signs, identification of the toxic origin of new‐onset seizures may be extremely difficult. We report here the case of a patient admitted in our hospital after a single generalized tonic–clonic seizure. The remarkable coincidence that a colleague of his, with whom he was working to clean the same workshop, had been admitted 1 week earlier for respiratory distress, coma, and de novo nonconvulsive focal status epilepticus, led us to consider a possible toxicologic etiology. Urine analysis revealed a high nickel concentration, suggestive of acute nickel poisoning.

Late onset of Aspergillus aortitis presenting as femoral artery embolism following coronary artery bypass graft surgery.

Aspergillus sp. are ubiquitous mould infections and in most patients, the source is presumed to be air-borne infections during surgical procedures. Prevention of these infections requires special attention of ventilation systems in operating rooms. Post-operative aspergillosis occurs mainly in immunocompromised patients as well as those who receive corticosteroids temporarily. We report a case of a 71-year-old immunocompromised patient who developed multiple lower limb embolisms due to Aspergillus niger originating from an aortitis of the ascending aorta nine months following coronary artery bypass graft (CABG) surgery.

Rhabdomyolysis-induced acute renal failure due to itraconazole and simvastatin association.

Abstract We present the case of an 82-year-old man admitted to our hospital for muscle weakness. He was under simvastatin 20 mg per day and was given pulse itraconazole therapy 8 days before the onset of symptoms for onychomycosis. He developed severe rhabdomyolysis inducing an acute renal failure necessitating renal replacement therapy. He eventually fully recovered. Given the possible concurrent use of simvastatin and itraconazole, awareness of this potential interaction is clinically important.

Influence of bedside blood insulin measurement on acute coronary syndrome pathways.

BACKGROUND The aim of the study was to evaluate the influence of blood insulin measurements on acute coronary syndrome (ACS) pathways. METHODS All patients admitted to the emergency department within 12 months for acute, retrosternal, constrictive chest pain lasting for more than 30 minutes; cardiogenic pulmonary edema; electrocardiogram ST changes; and echographic alterations were included. The study parameters were clinical (age, sex, blood pressure, presence of pulmonary rales and gallop), including classic laboratory tests associated with troponin T, blood insulin levels, and hemoglobin A1C, and echographic values. These were taken on admission and throughout hospital stay. All patients underwent a coronary angiography for ACS diagnosis confirmation as well as treatment intention. RESULTS Sixty patients were included in the study. Abnormal blood insulin levels were present on admission in 47% of the population. Blood insulin level was significantly correlated to thrombolysis in myocardial infarction coronary perfusion score (Spearman Rank, 0.55, P < 0.0001). Abnormal insulinemia was normalized with reperfusion. Insulin was administered essentially to the 16 patients with hypoinsulinemia. Patients with hypoinsulinemia seem to have the most severe coronary lesions and highest Killip score. CONCLUSIONS In ACS, insulin levels are altered in half of the patients. After the investigators noted its tight correlation with the thrombolysis in myocardial infarction coronary flow score, its determination could be important in ACS for triggering emergency coronary angiography for percutaneous coronary intervention. This could modify the critical pathways of ACS patients in the emergency department.

Upper gastrointestinal bleeding related to emphysematous cholecystitis due to Clostridium perfringens

We describe the case of a 46-year-old man admitted for upper gastrointestinal bleeding in the context of cirrhosis. A deep bleeding duodenal ulcer was treated by sclerotherapy. Abdominal pain and fever lead us to perform an abdominal computed tomography, which demonstrated emphysematous cholecystitis. An emergency cholecystectomy was performed and antimicrobial therapy initiated. The patient recovered uneventfully. Links between ulcers and emphysematous cholecystitis are discussed.

Fatal multiple coronary involvements in a young woman with systemic lupus erythematosus

Abstract We report a rare case of fulminant congestive heart failure with fatal outcome in a 21-year-old girl with systemic lupus erythematosus (SLE). A young woman was admitted in the intensive care unit for pericardial tamponade associated with disseminated coagulopathy and refractory shock secondary to multiple coronary aneurysms. Post-mortem examination revealed significant multiple coronary lesions with aneurysms of the interventricular and right coronary arteries, responsible of muscular necrosis, thrombosis of the coronary sinus, and significant pericardial infiltration with hemorrhagic fluid. We describe a refractory cardiac failure with extensive coronary artery involvements, which is very uncommon in young patients with SLE: few cases have been previously described in the literature. We report a rare case of fulminant congestive heart failure with fatal outcome in a young woman with SLE related to extensive coronary involvements.

Cardiogenic shock after nifedipine administration in a pregnant patient: A case report and review of the literature

Abstract We present a case of a 21-year-old Caucasian woman at 27 weeks of pregnancy who was admitted to the obstetric department for pre-term labor. She received 10 mg of nifedipine 4 times in 1 h, according to the internal protocol. Shortly after, she brutally deteriorated with pulmonary edema and hypoxemia requiring transfer to the intensive care unit (ICU) for mechanical ventilation. She finally improved and was successfully extubated after undergoing a percutaneous valvuloplasty of the mitral valve. This case illustrates a severe cardiogenic shock after administration of nifedipine for premature labor in a context of unknown rheumatic mitral stenosis. Nifedipine induces a reflex tachycardia that reduces the diastolic period and thereby precipitates pulmonary edema in case of mitral stenosis. This case emphasizes the fact that this drug may be severely harmful and should never be used before a careful physical examination and echocardiography if valvular heart disease is suspected.

Citrate: How to get started and what, when, and how to monitor?

Abstract In most of the case, regional citrate anticoagulation is using diluted citrate around 1% depending on the types used in clinical practice. Diluted citrate is much more safer when compared to highly concentrated citrate around 4% or even more. In clinical practice, trisodium citrate is used in high concentration (around 30%) as a bactericidal agent with anticoagulant properties for locking deep venous catheters used in hemodialysis (HD; close to 25–30% of citrate). In this review article, buffer and anticoagulant potential of citrate are discussed during renal replacement therapy in critically ill patients with particular focus on the practical approach at the bedside.

Adjuvant vitamin C in cardiac arrest patients undergoing renal replacement therapy: an appeal for a higher high-dose

We read with interest the excellent review of Spoelstra-de Man et al. which focused on the potential benefit of adjuvant vitamin C (vit C) therapy in ischemia-reperfusion injury [1]. Following an exhaustive in-depth analysis of the impressive experimental, clinical, and safety record of vit C, the authors plead for a randomized controlled clinical trial assessing the effect of early, high-dose (i.e., at least 3 g/day), intravenous vit C administration in post-cardiac arrest patients. About half of the patients may develop acute kidney injury stage ≥ 1 within 2 days after cardiac arrest and 20 to 60% will require renal replacement therapy (RRT) [2]. Vit C has a molecular weight of 176 Dalton and is thus exposed to significant clearance during RRT. Intermittent hemodialysis as well as continuous RRT (CRRT) are indeed associated with a 50% reduction of plasma ascorbate and vit C levels [3–5]. Diffusion and convection account for two-thirds and one-third, respectively, of the vit C loss [3]. A 3 g daily vit C dose, therefore, is by no means guaranteed to cover the acute need in post-cardiac arrest patients initiated on (C)RRT. Vasopressor-dependent subjects in particular may benefit from increased dosing because vit C has been shown to support endogenous vasoactive catecholamine synthesis. Awaiting solid pharmacological data, we propose to supplement post-cardiac arrest patients not treated with CRRT with 6 g vit C daily. If CRRT is running, the dose should be increased to 12 g. We fully agree with Spoelstra-de Man et al. to administer vit C as early as possible (i.e., before intensive care admission) and to continue treatment for a short period of time.