Syndrome inflammatoire inexpliqué révélant une thyroïdite de De Quervain : à propos de 2 cas

Le syndrome inflammatoire d'origine inexpliqué est une situation fréquente en médecine. Nous rapportons le cas de deux patients chez qui les investigations devant ce syndrome ont permis de conclure à une thyroïdite subaiguë de De Quervain. Cas numéro 1 : une femme de 61 ans consultait pour une fébricule vespérale depuis 3 semaines, accompagnée de sueurs nocturnes et de vagues cervicalgies droites difficiles à caractériser. L'examen clinique ne retrouvait que deux adénopathies sensibles cervicales droites centimétriques. On notait une bronchite aiguë quelques semaines avant, totalement guérie. La biologie retrouvait une CRP oscillant autour de 150 mg/L et un hémogramme normal. Le scanner corps entier était décrit normal. La persistance de l'inflammation la 4e semaine (CRP 200 mg/L, fibrinogène 12 g/L) se sanctionna d'une hospitalisation à visée diagnostique. Les prélèvements infectieux étaient stériles et l'endoscopie ORL, l'échographie cardiaque et la biopsie temporale normales. Finalement, le TEP scanner rapportait un hypermétabolisme intense et diffus de la thyroïde (SUV 10). Un contrôle échographique retrouvait une glande de taille normale franchement hypo-échogène et sans hyper-vascularisation au doppler. Le bilan thyroïdien était dans les normes (TSH 0,86 mUi/L [0,27–4,2], T4 libre 17,4 pmol/L [11,4–22,6], T3 libre 6,93 pmol/L [3,54–6,47]). Les anticorps anti-thyroïdes n'étaient pas détectés. La fièvre et le syndrome inflammatoire s'amendaient à la 6e semaine pour laisser apparaître une hypothyroïdie d'allure périphérique (TSH 6,7 mUi/L, T4 libre 11 pmol/L), qui sera surveillée jusqu'à la totale rémission biologique quelques mois plus tard. Cas numéro 2 : un technicien EDF de 56 ans était adressé d'un centre périphérique pour une fièvre quotidienne, une tachycardie et syndrome inflammatoire depuis deux semaines. Un large bilan de fièvre inexpliquée réalisé en amont de l'admission était resté non contributif. La réévaluation clinique retrouvait une odynophagie (sans pharyngite), un lobe thyroïdien droit sensible à la palpation, une adénopathie cervicale droite. Dans un second temps, on objectivait un rash urticarien généralisé le matin et rapidement réversible. La biologie retrouvait un syndrome inflammatoire majeur en plateau (CRP 130 mg/L, fibrinogène 9 g/L). Le bilan thyroïdien retrouvait une hyperthyroïdie d'allure périphérique (TSH < 0,01 mUi/L, T4 libre 44 pm/L, T3 libre 11,8 pm/L). Les anticorps anti-récepteur de la TSH n'étaient pas détectés mais les anti-thyroglobulines l'étaient. L'échographie retrouvait un parenchyme de taille normal hétérogène et anormalement avasculaire avec deux adénopathies centrimétriques non supectes. Le TEP scanner retrouvait un hypermétabolisme diffus, intense (SUV 24) et isolé de la glande thyroïde. L'évolution était spectaculairement favorable en 48 h d'une corticothérapie à 0,5 mg/kg. La thyroïdite subaiguë (de De Quervain) est une thyroïdite douloureuse granulomateuse qui fait souvent suite à une virose ORL (infection à SARS-CoV-2 comprise) [1] chez des patients génétiquement prédisposés (HLA-Bw35, HLA-B67, HLA-Drw8) [2]. Elle semble plus fréquente chez les femmes entre 40 et 50 ans. Les signes généraux ou pseudo-grippaux peuvent être au premier plan, parfois associés de signes de thyrotoxicose. Les cervicalgies plutôt antérieures, peuvent irradier dans la mâchoire ou les oreilles (simulant une pharyngite). La palpation de la thyroïdite peut être sensible. La biologie retrouve un syndrome inflammatoire, une TSH basse, une augmentation de la T4 libre (pouvant entraîner une thyréotoxicose) et l'absence d'anticorps anti-thyroïde (hormis les anti-thyroglobulines). L'échographie peut montrer un goitre hétérogène, hypoéchogène, sans hypervascularisation avec des adénopathies. La scintigraphie montre que la fixation du radio-isotope dans la glande thyroïde est nettement réduite ou absente. L'hypothyroïdie peut succéder transitoirement (ou définitive ent) à l'hyperthyroïdie. Les traitements anti-inflammatoires (AINS, corticothérapie) avec décroissance sur quelques semaines sont suffisants pour contrôler les symptômes. À long terme, il y a un surrisque d'hypothyroïdie auto-immune [3]. La thyroïdite subaiguë (de De Quervain) est une cause de syndrome inflammatoire inexpliqué. Elle peut compliquer les infections à SARS-Cov-2. (French) [ FROM AUTHOR]

Assessment of Task Demand and Usability of a Virtual Reality-Based Rehabilitation Protocol for Combat Related Traumatic Brain Injury From the Perspective of Veterans Affairs Healthcare Providers: A Pilot Study

The risk of traumatic brain injury (TBI) is significantly higher among Veterans compared to non- Veterans. Access to treatment for TBI and post concussive symptoms is sometimes difficult, because of barriers related to distance, finances, and public safety (i.e., COVID-19 infection). Virtual reality rehabilitation (VRR) offers an opportunity to incorporate a virtual space into a rehabilitation environment. To our knowledge, VRR has not been used to assist Veterans with TBI and related health problems with Instrumental Activities of Daily Living (iADLs). The purpose of this study is to investigate the usability of a novel VRR ADL and iADL training protocols, developed by the Gaming Research Integration for Learning Laboratory (GRILL®) at the Air Force Research Laboratory, for cognitive rehabilitation for Veterans with a TBI. We deployed a prototype protocol among healthcare providers (n = 20) to obtain feedback on usability, task demand, and recommended adjustments. Our preliminary analysis shows that providers found the VRR protocol involved low physical demand and would likely recommend it to their patients. Although they had some concerns with vertigo-like symptoms from using a digital technology, they believed the protocol would improve iADL functioning and was a good addition to pre-existing rehabilitation protocols. These outcomes provide justification for more impactful studies investigating the effectiveness of this protocol among Veterans with TBI. Copyright © 2021 Greenhalgh, Fitzpatrick, Rodabaugh, Madrigal, Timmerman, Chung, Ahuja, Kennedy, Harris and Adamson.

The Association Between Screening Tools Used to Assess Nutrition Status in an Acute Care Setting

Background: Screening tools to assess both the risk of malnutrition (such as the Malnutrition Screening Tool, MST) and wound development (Braden scale) are frequently utilized in the hospital setting. Hospital-acquired pressure injuries (HAPIs) result in considerable patient harm, including expensive treatments, increased length of stays, and increased mortality. Malnutrition is a significant risk factor in the development and progression of HAPIs. Therefore, identifying malnutrition risk and prevalence is an important step in preventing HAPIs. However, processes which involve multiple screening steps consume resources such as staff and time which have become scarce during the COVID-19 pandemic. While the Braden scale contains a nutrition component as a sub-score, little is known about the validity of this sub-scale to capture malnutrition risk. We aimed to explore the association between a validated malnutrition screening tool (MST) and the Braden nutrition scale to determine their use in generating nutrition consults. Methods: We conducted a retrospective chart review of adult patients who developed a HAPI during hospital admission. Baseline MST scores (0-6) and Braden nutrition sub-scale score (1-4) were collected. Higher MST scores represent increased risk of malnutrition, while lower Braden nutrition sub-scores represent poor nutrition status. Documentation of a malnutrition diagnosis using the ASPEN guidelines (yes/no) was also collected for each patient. Pearson correlation coefficients and linear regression were used to assess the association between the MST and Braden nutrition sub-score in the entire cohort. A sub-analysis was conducted in the patients with a diagnosis of malnutrition. Logistic regression was performed to evaluate the association between the Braden nutrition sub-scores and a malnutrition diagnosis. Results: The cohort included 133 patients with a mean age of 69.3 years, with 69.9% being male. 77 patients had malnutrition status recorded, with 64.9% diagnosed with malnutrition. There was a significant correlation between Braden nutrition sub-score and MST (R = -0.28;p < 0.001) in the overall cohort and in subjects with malnutrition (R = -0.35;p = 0.01). Linear regression confirmed that low Braden scale nutrition subscores (poor nutrition status) were predicted by high MST scores (risk for malnutrition) (p = < 0.001). Logistic regression modeling showed a higher Braden nutrition sub-score (better nutrition status) was associated with a diagnosis of malnutrition (OR: 0.45;p=0.057). Conclusion: The results of this study demonstrate that the MST and the Braden nutrition sub-scores are correlated in a cohort of hospitalized patients who developed a HAPI. Use of both screening tools may not be necessary for identifying those that warrant further assessment and interventions for malnutrition.

Jejunal closed-loop obstruction without prior abdominal surgery during COVID-19 ICU admittance: A case report.

INTRODUCTION: and importance: Closed-loop obstruction is a specific case of small bowel obstruction in which two sites of the bowel obstruct at one adjacent location. This can result in strangulation with high mortality. This condition is most often observed after abdominal surgery. The exact underlying pathology in patients without prior abdominal surgery is still largely unclear, and only scarce literature on the role of COVID-19 or long-term prone position is available. CASE PRESENTATION: A 74-year-old male patient without prior abdominal surgery was presented to the emergency department with pulmonary and gastro-intestinal symptoms of COVID-19. The patient was known to have diverticulosis of colon and sigmoid. After a complicated ICU course, the patient developed a jejunal closed loop obstruction, and a diagnostic laparoscopy was performed. Fixation of the omentum to the retroperitoneum was released, without observation of further adhesions, bowel torsion or ischemic bowel. Further abdominal course was uncomplicated, however, unfortunately the patient died following pulmonary deterioration. CLINICAL DISCUSSION: The differential diagnosis of small bowel obstruction is extensive; however, adhesions are most often observed. In patients without prior surgery, also adhesions are observed, mainly caused by earlier infections. There might be a role for abdominal COVID-19 infection and prolonged prone position in the emergence of adhesions; however, literature is lacking. Alternatively, asymptomatic diverticulitis might have led to adhesion formation. CONCLUSION: Closed loop obstructions in patients without prior abdominal surgery are uncommon and post-infectious abdominal status might cause adhesions. It is unclear whether abdominal manifestations of COVID-19 and prolonged prone position can also cause adhesions and, thereby, small bowel obstructions.