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

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.

Dopamine versus norepinephrine: is one better?

Dopamine and norepinephrine are widely used as first line agents to correct hypotension in patients with acute circulatory failure. There has been considerable debate in recent years as to whether one is better than the other. Both drugs can increase blood pressure in shock states, although norepinephrine is more powerful. Dopamine can increase cardiac output more than norepinephrine, and in addition to the increase in global blood flow, has the potential advantage of increasing renal and hepatosplanchnic blood flow. However, dopamine has potentially detrimental effects on the release of pituitary hormones and especially prolactin, although the clinical relevance of these effects is unclear. Observational studies have provided conflicting results regarding the effects of these two drugs on outcomes, and results from a recently completed randomized controlled trial are eagerly waited.

Use of a temperature gradient measuring device in monitoring of diabetic and critically ill patients.

A device realizing the simultaneous measure of the central body temperature (Tc), the superficial one (Ts) and their difference (Dt), was proposed for permanent energetic balance evaluation in humans. A program was elaborated to command the intravenous delivery of insulin by a pump depending on the value and trends of Dt. The use of this device for monitoring of decompensated diabetic patients allowed their easier stabilization. In critically ill patients (post transplantation, myocardium infarction) it had a diagnostic and prognostic value, and was helpful for optimization of conventional and insulin therapy.

A previously undescribed side effect of icodextrin: overestimation of glycemia by glucose analyzer.

OBJECTIVE: Serious discrepancies between glycemia measurements obtained with an Accutrend Sensor (Boehringer Mannheim GmbH, Mannheim, Germany) type analyzer (based on a glucose dehydrogenase enzymatic reaction) and measurements obtained in the laboratory by a reference method (hexokinase) have been found in an insulin-requiring, diabetic, continuous ambulatory peritoneal dialysis (CAPD) patient treated with icodextrin 7.5% (Extraneal; Baxter Healthcare SA, Castlebar, Ireland), a new osmotic agent for peritoneal dialysis. We therefore investigated the respective role of the Analyzer and of the glucose polymer in this hitherto undescribed problem. DESIGN: Glycemia was measured simultaneously on venous blood using a reference laboratory technique, and on capillary blood using the Accutrend Sensor glucose analyzer in three groups of CAPD patients: 6 patients on Extraneal for at least 1 week, 6 patients receiving their first Extraneal exchange, and 8 patients never exposed to Extraneal. In the first group of patients, glycemia was also measured with another analyzer (Glucocard; Menarini Diagnostics, Firenze, Italy) using a different enzymatic reaction (glucose oxidase). In a separate study, whole blood of a normal subject was spiked with concentrated solutions of glucose and icodextrin and some of its metabolites (maltose, maltotriose, maltopentaose). Once again, comparative measurements of glycemia were performed with the Accutrend Sensor, with two other kits using a glucose dehydrogenase enzyme reaction, and with the hexokinase reference method. RESULTS: In 6 CAPD patients treated with once-daily exchanges with Extraneal for a minimum of 7 consecutive days, we confirmed overestimation of glycemia by the Accutrend Sensor of 65 +/- 26 mg/dL compared to reference values (p < 0.01), and of 69 +/- 25 mg/dL (p < 0.001) compared to measurements obtained with the Glucocard monitor. In 6 other CAPD patients studied at the end of one single icodextrin exchange, overestimation of 61 +/- 11 mg/dL was already present (p < 0.001). On the other hand, in 8 CAPD patients never treated with icodextrin, there was no discrepancy between the Accutrend Sensor readings and reference values. The measurements in spiked blood confirmed that only the Accutrend Sensor overestimates glycemia in the presence of maltose and glucose polymers. The overestimation decreased as the molecular size of the saccharides added to blood increased. There was no overestimation when other kits using a dehydrogenase enzyme were tested. CONCLUSION: The overestimation observed is probably related to the presence of oligosaccharides (mainly maltose), derivatives of glucose polymers present in Extraneal and absorbed via the peritoneal route, in the blood of patients treated with icodextrin. The glucose dehydrogenase characterizing the Accutrend Sensor, an enzyme of the pyrroloquinolinequinone class, very likely reacts with the free reducing group of the glucose molecule located at the end of each saccharide chain. This would not be the case for the Glucocard monitor using glucose oxidase, for other kits using glucose dehydrogenase, and for the reference method based on hexokinase. The Accutrend Sensor type of analyzers are therefore not suitable for regular monitoring of glycemia in diabetic PD patients treated with icodextrin.

[Biliary ileus]. / Ileus biliaire.

A case of gallstone ileus in an elderly woman is described and attention is drawn to the insidious clinical presentation and the significance of the often subtle radiological signs. The data from the literature specifies these aspects and allows a more complete review of this relatively rare pathology in order to remind its importance in differential diagnosis to emergency clinicians and radiologists.

[Isolated respiratory insufficiency in Arnold-Chiari malformation]. / Insuffisance respiratoire isolée sur malformation d'Arnold-Chiari.

We report on a 45-year old woman with daytime sleepiness, polycythemia, hypoxemia and hypercapnia, admitted to hospital on three occasions in a 10 month period for acute respiratory failure. Polysomnography demonstrated apneas of central type, testing of the respiratory drive suggested central alveolar hypoventilation and magnetic resonance imaging showed an Arnold-Chiari malformation with syringomyelia. The originality of this case is the absence of any neurologic sign, respiratory failure being the sole manifestation of the Arnold-Chiari malformation.

Legionellosis and "torsades de pointes".

Myocarditis, pericarditis and endocarditis are rare manifestations of Legionella pneumophila infection. We describe a case of myocarditis complicated with a potentially fatal arrhythmia: "torsades de pointes".

Acute nonlymphocytic leukemia following chemotherapy with cisplatin and etoposide for non-small-cell carcinoma of the lung: case report.

A case of acute nonlymphocytic leukemia (ANLL) following chemotherapy with cisplatin (CDDP) and etoposide (VP16) for non-small-cell lung cancer (NSCLC) diagnosed 24 months before is reported. Although the fortuitous occurrence of two unrelated malignancies cannot be excluded, the hypothesis of secondary leukemia must be taken into account. The clinical and experimental data implying these agents, generally considered to be noncarcinogenic in man, in the occurrence of secondary malignancies are briefly discussed.

Leaflet escape of a mitral Duromedics prosthesis. Case report.

This article reports a case of leaflet embolization of a mitral Edwards-Duromedics prosthesis. The patient had abrupt onset of acute pulmonary edema and was initially treated medically for 3 days. Fluoroscopy showed only one freely moving leaflet and the other was (incorrectly) assumed to be blocked in the closed position. The patient received IV thrombolysis for another 3 days and was finally operated. He died 8 days later from sepsis and the leaflet was recovered at autopsy in the abdominal aorta. Leaflet escape of a mitral Edwards-Duromedics prosthesis is a rare, potentially curable mode of valve failure. Correct interpretation of clinical signs and symptoms and of fluoroscopy should allow early diagnosis and surgical therapy.