Syndrome hémophagocytaire réactionnel : une cause probablement sous-estimée de thrombopénie en réanimation

Thrombocytopenia is a common feature in ICU patients which occurs usually in case of infection or septic shock. Its mechanisms, which are often unclear, include the haemophagocytic syndrome initially linked with histiocytic proliferation but probably also associated with infectious diseases. This syndrome is characterized by a phagocytosis of medullar blood cells. Reactive haemophagocytic syndrome can probably lead to thrombocytopenia in ICU patients as in this case report of a E. Coli infection.     

Hématome sous-arachnoïdien et rachianesthésie

Two cases of spinal subarachnoid haematoma occurring after spinal anaesthesia are reported. In the first case, lumbar puncture was attempted three times in a 81-year-old man ; spinal anaesthesia trial was than abandonned, and the patient given a general anaesthetic. He was given prophylactic calcium heparinate soon after surgery. On the fourth day, the patient became paraparetic. Radiculography revealed a blockage between T₁₀ and L₃. Laminectomy was performed to remove the haematoma, but the patient recovered motor activity only very partially. The second case was a 67-year-old man, in whom spinal anaesthesia was easily carried out. He was also given prophylactic calcium heparinate soon after surgery. On the fourth postoperative day, pulmonary embolism was suspected. Heparin treatment was then started. Twelve hours later, lumbar and bilateral buttock pain occurred, which later spread to the neck. On the eighth day, the patient had neck stiffness and two seizures. Emergency laminectomy was carried out, which revealed a subarachnoid haematoma spreading to a level higher than T₆ and below L₁, with no flow of cerebrospinal fluid, and a non pulsatile spinal cord. Surgery was stopped. The patient died on the following day. Both these cases are similar to those previously reported and point out the role played by anticoagulants. Because early diagnosis of spinal cord compression is difficult, the prognosis is poor, especially in case of paraplegia.     

Hématomes des surrénales et héparine

The diagnosis of adrenal haemorrhage complicating heparin therapy is often delayed, despite computed tomography (CT). Moreover, its pathogenesis is not clear. Adrenal haemorrhages are often seen in cases where there is no unduly excessive anticoagulation, and can be accompanied by a paradoxical thrombosis of the central adrenal vein. Symptoms usually occur within the first 8 to 12 days after starting heparin. The difficulty in establishing the diagnosis stems from the fact that symptoms are rather nonspecific: abdominal pain and backache, nausea, vomiting, lethargy, weakness, hypotension, hyperpyrexia. To confirm the diagnosis, both hormonal proof of adrenal failure and anatomic evidence of haemorrhage must be found. Early CT scans may show the haemorrhage. Several possible causes have been put forward to account for these adrenal haemorrhages. The degree of anticoagulation did not seem to be a prerequisite, 30 to 50% of patients showing no evidence of other bleeding or coagulation tests outside the therapeutic range. Capillary fragility of old age might be a factor. Stress would seem to be an important factor predisposing to adrenal haemorrhage. Many authors consider the paradoxical central vein thrombosis as a result of the haemorrhage rather than its cause, whereas other conclude the opposite. Unfortunately, to date coagulation studies are often incomplete; platelet counts were missing in most reports published before 1985. Since that date, a heparin induced thrombosis-thrombocytopaenia syndrome (HITTS), in which thrombosis may occur in any vascular bed, has been recognized with increasing frequency. Nine cases of adrenal haemorrhage associated with HITTS have been reported. It seems highly likely that a proportion of cases of heparin-related adrenal destruction are due to HITTS.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surveillance hémodynamique au cours de l''exérèse micro-neurochirurgicale par voie sous- et rétrosinusienne en position assise du neurinome de l''acoustique

Haemodynamic data (thermodilution Swan-Ganz catheter and radial artery cannula) were collected in 17 patients (52.4 +/- 8 yr) during retrosigmoid approach for removal of an acoustic tumour in the seated position. Measurements were made before stimulation of posterior fossa structures (period 1) and during tumour dissection along the brain stem (period 2). Significant increases in systolic, diastolic and mean blood pressures, in pulmonary capillary wedge pressure, in cardiac index and in stroke index were observed during period 2, whereas heart rate, right atrial pressure and systemic vascular resistances were unaffected. The greater the size of the tumour and the difficulties in dissection, the greater were these intraoperative haemodynamic changes. In addition, the pulmonary arterial blood temperature and the noradrenaline plasma concentrations (double isotope enzymatic assay) increased significantly during period 2. In conclusion, the prolonged microsurgical technique of acoustic tumour dissection through the retrosigmoid approach may modify left ventricular loading conditions and may lead to pulmonary oedema, even if intravascular volume expansion was minimal and ventricular function was near normal.     

Hémarthroses et hémophilie acquise : à propos de 2 observationsHémarthrosis in acquired hemophilia: 2 case-reports

The many causes of hemarthrosis include acquired hemophilia due to production of auto-antibodies to factor VIII. We report 2 very different cases.Case 1. – This woman experienced onset of juvenile idiopathic arthritis at 8 years of age. Her first child was born when she was 28-years-old. Three months after delivery, vaginal bleeding and recurrent hemarthrosis led to a diagnosis of acquired hemophilia (isolated APTT prolongation, 1% VIIIc activity, and 58 U of antifactor VIII antibody). Treatment included glucocorticoid therapy, prothrombin complex, and intravenous immunoglobulins. She achieved a full recovery within a year.Case 2. – In this 84-years-old woman, spontaneous recurrent hemarthrosis with hematomas revealed idiopathic acquired hemophilia. Treatment included prothrombin complex, factor VIII concentrates, and intravenous immunoglobulins, followed by cyclophosphamide and glucocorticoid therapy. Recovery was complete within a year. The diagnosis, etiology, prognosis, and treatment of acquired hemophilia are discussed.Conclusion. – Although rare, acquired hemophilia should be considered among the causes of hemarthrosis, particularly as a favorable outcome can be expected with early diagnosis and appropriate treatment.     

Carence en vitamine C: cause rare d'anémie grave mal tolérée

We report the case of a 82-year-old man, living in institution, hospitalized for a severe anaemia due to scurvy. Scurvy is rare in Occident. A multifactorial anaemia is usely associated with scurvy, but is rarely symptomatic. Alcoholism favours scurvy and anaemia. Treatment consisted of parenteral vitamin C supplementation associated with blood transfusion.     

Effets hémodynamiques de l''atracurium chez l''homme

Haemodynamic effects of atracurium at three doses (0.2, 0.6 and 1.2 mg . kg-1) were studied in thirty patients, anaesthetized with thiopentone (5 mg . kg-1) and fentanyl (0.2 microgram . kg-1 . min-1). No cardiovascular side-effects were observed with doses of 0.2 and 0.6 mg . kg-1. However, a 1.2 mg . kg-1 dose induced a transient but significant decrease in mean arterial pressure (-10%; p less than 0.001), maximal in the second minute, associated with an increase in heart rate (+10%; p less than 0.001) and cardiac index (+9%), and a decrease in systemic vascular resistance (-16%; p less than 0.001). The decrease in arterial pressure was constant in every patient and associated with a generalized flush in one of them. Histamine-release induced by atracurium may be one of the possible mechanisms involved in this hypotension.     

Surveillance de l'hémostase au cours de la transplantation hépatique : apport du thromboélastogramme

Monitoring of coagulation is mandatory during liver transplantation (LT). Standard coagulation tests may be routinely used. However, they give static information and may be inadequate in case of severe coagulation defect. Interest has been recently focused on thromboelastography (TEG) which could give more suitable and rapid information in these cases. Few studies have evaluated the clinical interest of TEG compared to conventionnal tests. This comparison was the aim of the present study, performed in 89 patients scheduled for LT. The anaesthetic management as well as procedure of transfusion were similar in all patients. Before unclamping, 5000 KUI · kg⁻¹ of aprotinin were injected. Routine tests and TEG were performed at the beginning and end of both preanhepatic and anhepatic phases, and 5, 30, 60, and 120 min after the revascularisation of the new liver. A phase of hypocoagulability was observed after unclamping. Biological signs included an increase in activated thromboplastin time, a reduction of α angle and maximum amplitude on TEG with a lengthening of its r + k component. A strong correlation existed between maximum amplitude and platelets, maximum amplitude and fibrinogen, α and fibrinogen at each time of the surgical procedure. Euglobulin lysis time decreased significantly after clamping, whereas fibrin degradation products increased at the same time. However, typical fibrinolysis with a clot lysis index (CLI) below 55 % was only observed in 15 patients. Twelve of them had a CLI value reaching 0 %, associated with severe generalized oozing. Aprotinin (200 000 to 600 000 KIU) corrected these abnormalities. These results show that TEG may not be very helpful to determine whether platelets or fibrinogen are involved in the phase of hypocoagulability detected after unclamping. However, TEG allows the actual diagnosis of fibrinolysis and guides therapy. Moreover, it may have a predictive value in some limited cases.     

Fracture apparemment spontanée de la pointe de l’omoplate. Rôle possible de la toux

We report a case of a fracture of the inferior angle of the scapula related to prolonged cough, without triggering trauma, sport or occupational activity. Bone insufficiency was present in this patient. Stress fractures of the scapula are rare; the fatigue type is the most frequent, associated with sports or occupational activity. We don’t find any published case report about scapula stress fracture related to cough, until rib fractures are frequent in this situation. Repetitive muscular activity of the serratus anterior and major rhomboid on the inferior angle of the scapula during cough may explain this avulsion fracture.     

Ostéomalacie révélatrice d'un syndrome de Gougerot Sjogren

Latent renal tubular diseases are common in Sjögren's syndrome but rarely complicated by osteomalacia. The authors report a 28 years old woman's case where osteomalacia reveal the disease. In the other hand, a pseudo-lymphoma is suspected from radiographic features. According to several studies, the authors review different types of renal diseases and describe different physiopathological hypotheses about bone involvement and pseudo-lymphomas.