A Belgian traveler who acquired yellow fever in the Gambia.

A 47-year-old Belgian woman acquired yellow fever during a 1-week vacation in The Gambia; she had never been vaccinated against yellow fever. She died of massive gastrointestinal bleeding 7 days after the onset of the first symptoms. This dramatic case demonstrates that it is important for persons to be vaccinated against yellow fever before they travel to countries where yellow fever is endemic, even if the country, like The Gambia, does not require travelers to be vaccinated.

Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock.

OBJECTIVE: To evaluate the effects of short-term, high-volume hemofiltration (STHVH) on hemodynamic and metabolic status and 28-day survival in patients with refractory septic shock. DESIGN: Prospective, interventional. SETTING: Intensive care unit (ICU), tertiary institution. PATIENTS: Twenty patients with intractable cardiocirculatory failure complicating septic shock, who had failed to respond to conventional therapy. INTERVENTIONS: STHVH, followed by conventional continuous venovenous hemofiltration. STHVH consisted of a 4-hr period during which 35 L of ultrafiltrate is removed and neutral fluid balance is maintained. Subsequent conventional continuous venovenous hemofiltration continued for at least 4 days. MEASUREMENTS AND MAIN RESULTS: Cardiac index, systemic vascular resistance, pulmonary vascular resistance, oxygen delivery, mixed venous oxygen saturation, arterial pH, and lactate were measured serially. Fluid and inotropic support were managed by protocol. Therapeutic endpoints were as follows during STHVH: a) by 2 hrs, a > or =50% increase in cardiac index; b) by 2 hrs, a > or =25% increase in mixed venous saturation; c) by 4 hrs, an increase in arterial pH to >7.3; d) by 4 hrs, a > or =50% reduction in epinephrine dose. Patients who attained all four goals (11 of 20) were considered hemodynamic "responders"; patients who did not (9 of 20) were considered hemodynamic "nonresponders." There were no differences in baseline hemodynamic, metabolic, and Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Scores between responders and nonresponders. Survival to 28 days was better among responders (9 of 11 patients) than among nonresponders (0 of 9). Factors associated with survival were hemodynamic-metabolic response status, time interval from ICU admission to initiation of STHVH, and body weight. CONCLUSIONS: These data suggest that STHVH may be of major therapeutic value in the treatment of intractable cardiocirculatory failure complicating septic shock. Early initiation of therapy and adequate dose may improve hemodynamic and metabolic responses and 28-day survival.

Isolation of the left coronary artery ostium by an aortic cusp attachment: a rare cause of myocardial ischemia.

A 34-year-old woman experienced a 3-month history of recurrent chest pain on exertion. Extensive investigation, including coronary angiography, revealed severe aortic incompetence with suspicion of single-vessel coronary disease. At operation the aortic valve was tricuspid but the left coronary cusp was adherent to the aortic wall, resulting in isolation of the left coronary artery with only a tiny communication with the aortic lumen. The three cusps were excised. An aortic valve replacement was performed with an aortic homograft. The postoperative course was uneventful and myocardial ischemia was totally relieved.

Basic components and patterns of acute ischemia recovery assessed from continuous ST monitoring in acute myocardial infarction treated by thrombolytic therapy.

Continuous ST monitoring of the lead showing the highest ST elevation on the admission 12-lead electrocardiogram was performed in patients with acute myocardial infarction of 6 hours or less enrolled in the OSIRIS and GUSTO trials. ST elevation measured at j + 50 ms was averaged from all normal beats every 20 seconds. ST trends were visually analyzed by two observers blinded from the thrombolytic treatment, its onset, and coronary angiograms performed 21 hours (median) after thrombolysis. Three basic and consecutive components were considered for analysis: the initial amplitude of ST elevation (A1), the maximal amplitude recovery (REC), and the minimal ST amplitude (A2). Prespecified patterns (PAT) were considered: PAT 1 integrated permanent A1 elevation followed by REC, PAT 2 intermittent A1 elevation, and REC. Prespecified pattern 3 was considered in absence of REC. Twenty-four-hour trends were recorded in 347 patients and judged adequate in 306 (88%) followed by angiography in 268 (77%). This group was not clinically different from the 79 patients without ST/angiography. Prespecified pattern 1 was identified in 81%, PAT 2 in 8%, and PAT 3 in 11% of the patients. The positive predictive value of PAT 1 + 2 for coronary patency was 94%, the negative predictive value 72%, sensitivity 96%, and specificity 60%. A salient feature was the occurrence of ST overshoot defined by a > or = 1 mm increase above A1 within the first minutes of REC. Overshoot occurred in 35% of PAT 1 and predicted subsequent patency in all but two patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypersensitivity interstitial pneumopathy and ulcero-hemorrhagic rectocolitis: role of methotrexate]. / Pneumopathie interstitielle d'hypersensibilité et rectocolite ulcéro-hémorragique: rôle du methotrexate.

The authors report the case of a 46-year-old man with refractory ulcerative colitis treated with methotrexate who was admitted in the hospital for asthenia, fever, cough and dyspnea. Owing to the development of adult respiratory distress syndrome despite broad spectrum antibiotherapy, the patient was transferred to the intensive care unit. A diagnosis of pneumonitis due to methotrexate was made. Patient's condition improved after discontinuation of the drug, mechanical ventilation, and corticosteroids. The increasing use of methotrexate in several gastroenterological diseases warrants further consideration of the potential devastating side effects of this drug, particularly on the lungs. A review of the literature on this topic is provided in the "discussion" section.

[The electrocardiogram and hypothermia. Apropos of a case]. / Electrocardiogramme et hypothermie. A propos d'un cas.

Hypothermia induces characteristic electrocardiographic changes (Osborn wave). They have been observed in the animal and in man, both in accidental hypothermia and in hypothermia induced during cardiac surgery. A case of accidental hypothermia, observed in an elderly woman found unconscious in her home, illustrates all of the electrocardiographic changes that have been described. This case report is accompanied by a brief review of the literature. The recognition of these clinical signs should enable the diagnosis of hypothermia to be made at an early stage and appropriate treatment instituted, as this is a condition which is generally associated with a high mortality rate.