Causes of acute respiratory failure in patients with small-vessel vasculitis admitted to intensive care units: a multicenter retrospective study

Rationale Acute respiratory failure (ARF) in patients admitted to the intensive care unit (ICU) with known or de novo small-vessel vasculitis (Svv) may be secondary to the underlying immune disease or to other causes. Early identification of the cause of ARF is essential to initiate the most appropriate treatment in a timely fashion. Methods A retrospective multicenter study in 10 French ICUs from January 2007 to January 2018 to assess the clinical presentation, main causes and outcome of ARF associated with Svv, and to identify variables associated with non-immune etiology of ARF in patients with known Svv. Results During the study period, 121 patients [62 (50–75) years; 62% male; median SAPSII and SOFA scores 39 (27–52) and 6 (4–8), respectively] were analyzed. An immune cause was identified in 67 (55%), and a non-immune cause in 54 (45%) patients. ARF was associated with several causes in 43% (n = 52) of cases. The main immune cause was diffuse alveolar hemorrhage (DAH) (n = 47, 39%), whereas the main non-immune cause was pulmonary infection (n = 35, 29%). The crude 90-day and 1-year mortality were higher in patients with non-immune ARF, as compared with their counterparts (32% and 38% vs. 15% and 20%, respectively; both p = 0.03), but was marginally significantly higher after adjusted analysis in a Cox model (p = 0.053). Among patients with a known Svv (n = 70), immunosuppression [OR 9.41 (1.52–58.3); p = 0.016], and a low vasculitis activity score [0.84 (0.77–0.93)] were independently associated with a non-immune cause, after adjustment for the time from disease onset to ARF, time from respiratory symptoms to ICU admission, and severe renal failure. Conclusions An extensive diagnosis workup is mandatory in ARF revealing or complicating Svv. Non-immune causes are involved in 43% of cases, and their short and mid-term prognosis may be poorer than those of immune ARF. Readily identified predictive factors of a non-immune cause could help avoiding unnecessary immunosuppressive therapies.

Acute infrarenal abdominal aortic occlusion in a patient with COVID-19

A high rate of thrombotic complications have been observed in patients infected with COVID-19. These complications are related to increased blood hypercoagulabity, which can cause both venous and arterial thrombosis. We report a case of a 60-year-old man with COVID-19 pneumonia and thrombotic occlusion of the infrarenal abdominal aorta at the time of admission to the hospital. A CT scan showed a crazy-paving pattern in the lungs, consistent with COVID-19. A clinical suspicion of aortic thrombosis was confirmed by CT angiography. Embolectomy was undertaken a few hours later. At the end of the procedure, the patient was taken to the intensive care unit while intubated. The patient then worsened, developing severe renal failure, and died on day 1 after admission to the hospital. A CT scan, which is necessary for diagnosis of COVID-19, and a CT angiography, can be used to diagnose thrombotic events. It should be kept in mind that arterial thrombosis can be present not only in hospitalized COVID-19 patients but also at the time of admission. SIMILAR CASES PUBLSHED: 1

P064 Henoch-Schonlein Purpura: experience of a general pediatric center

Background Henoch-Schonlein purpura (HSP) is the most classic dysimmune vasculitis in children, related to an abnormal response of an immature immune system following an external antigen attack. Digestive involvement in HSP conditions the immediate vital prognosis and severe renal failure conditions the long-term functional prognosis. The Objective is to identify the epidemiological, clinical, disease course and therapeutic particularities of patients with HSP with a review of the literature. Material and method The authors reported the results of a retrospective study of cases of patients with HSP hospitalized and treated in the 02 pediatric departments of the wilaya of Annaba in Algeria (Clinique Sainte Thérèse, Annaba hospital university center and EHS El Bouni) over a period of 02 years. Information was obtained from hospital records. Results 24 cases of HSP were identified with a sex ratio of 1.4 (14 boys and 10 girls) and a hospital incidence of 1.66%. The average age was 6.6 years. Half of patients was hospitalized during the autumn-winter period, 67% of whom had an ENT infection before their hospitalizations. 17% of cases have personal history of HSP (the oldest was 5 years ago and the most recent 10 days before hospitalization). 7 patients underwent surgeries prior to hospitalization. Skin lesions were found in all patients. Joint, digestive and renal involvement were recorded in 50%, 80% and 25% respectively. Gastrointestinal bleeding has been observed in one patient. Only 1 patient with renal impairment progressed to chronic renal failure and only 1 patient had confirmed hypertension. A rare association with viral hepatitis A has been noted in one patient. Conclusion HSP remains a benign condition, easy to recognize clinically. Its immediate prognosis depends on the digestive complications and its long-term on nephropathy which may expose to the risk of chronic renal failure.

Suicide by ethylene glycol/brake oil poisoning—a case report

Background Brake fluid is used for automobiles. It is a mixture of different glycol derivatives including ethylene glycol and diethylene glycol (DEG) which are metabolized into various toxic metabolites. Fatalities following brake fluid ingestion are rare in forensic practice. Here, we report a case of suicide by brake fluid ingestion complicated with severe renal failure and esophageal and gastric erosions. Case presentation A 52-year-old male, with a history of alcohol dependence and comorbid moderate depression, ingested a bottle of brake fluid (100ml) mixed with alcohol. He had defaulted psychiatric follow-up. He developed severe metabolic acidosis and acute renal failure which necessitated intensive care, other supportive management, and the antidote; ethyl alcohol. On the 2nd day of admission, he developed upper gastrointestinal bleeding with melena. He also had seizures and cardiovascular complications. He died 12 days after hospital admission, and the manner of death was concluded as suicidal. The autopsy revealed congested and edematous brain, flabby and pale heart without evidence of infarction, erythematous trachea, bilateral diffuse pulmonary edema, congested liver, ulcer over the lower 1/3 of the esophagus, and few ulcers in the stomach. Also, the kidneys were edematous, diffusely necrosed, and there were adrenal hemorrhages. Conclusions This case report highlights the severity of effects of brake fluid poisoning including the corrosive effect on gastrointestinal mucosa which is rarely encountered in clinical practice.

Safety and Effectiveness of High-Precision Hyperthermic Intraperitoneal Perfusion Chemotherapy in Peritoneal Carcinomatosis: A Real-World Study

BackgroundHyperthermic intraperitoneal chemotherapy (HIPEC) has been reported to effectively control peritoneal carcinomatosis (PC) in various patient populations, but there is a lack of real-world data. This study aimed to examine the safety and effectiveness of HIPEC in patients with PC in a real-world setting.MethodsThis was a retrospective study of patients with PC treated with the high-precision BR-TRG-I type HIPEC device between December 2006 and December 2016. Vital signs during HIPEC and adverse events were recorded. Effectiveness was evaluated by total objective remission rate (ORR), which was based on ascites’ remission 4 weeks after HIPEC.ResultsA total of 1,200 patients were included. There were 518 males and 682 females, with a mean age of 58.6 ± 6.5 years (range, 32–76 years). Among the patients, 93.6% of the patients (1123/1200) successfully received the three sessions of HIPEC, 158 had massive ascites. The changes of vital signs during HIPEC were within acceptable ranges, and patients only had a transient fever and abdominal distension. Regarding the HIPEC-related complications, hemorrhage was observed in seven (0.6%) patients, anastomotic leakage in four (0.5%), and intestinal obstruction in eight (0.7%). Nine (0.8%, 9/1200) patients had CTCAE grade IV bone marrow suppression, and three (0.3%, 3/1200) patients had severe renal failure (SRF), which were considered to be drug-related. The ORR of malignant ascites was 95.6% (151/158).ConclusionThis real-world study strongly suggests that HIPEC was safe in treating PC patients with a low rate of adverse events and leads to benefits in PC patients with massive malignant ascites.

Neonatal Atypical Hemolytic Uremic Syndrome in the Eculizumab Era

The atypical hemolytic uremic syndrome (aHUS) in the newborn is a rare disease, with high morbidity. Eculizumab, considered a first-line drug in older children, is not approved in neonates and in children weighing less than 5 kg. We present a 5-day-old female newborn, born at 36 weeks' twin gestation, by emergency cesarean section due to cord prolapse, with birth weight of 2,035 g and Apgar score of 7/7/7, who develops microangiopathic hemolytic anemia, thrombocytopenia, and progressive acute renal failure. In day 5, after diagnosis of aHUS, a daily infusion of fresh frozen plasma begins, with improvement of thrombocytopenia and very slight improvement in renal function. The etiologic study (congenital infection, Shiga toxin, ADAMTS13 activity, directed metabolic study) was normal. C3c was slightly decreased. On day 16 for maintenance of anemia and severe renal failure, she started 300 mg/dose eculizumab. Anemia resolves in 10 weeks and creatinine has normal values after 13 weeks of treatment. The genetic study was normal. In this case, eculizumab is effective in controlling microangiopathy and in the recovery of renal function. Diagnosis of neonatal aHUS can be challenging because of phenotypic heterogeneity and potential overlap with other manifestations that may confound it, such as perinatal asphyxia or sepsis/disseminated intravascular coagulation.