Right ventricular infarction: epidemiological, clinical, and angiographic characteristics and the outcomes through the experience of a Moroccan cardiology department.

Background: Acute myocardial infarction (MI) is a major cause of cardiovascular mortality, which is the leading cause of death in the world. Our objective in this study was to evaluate the epidemiological, clinical, and angiographic features of right ventricular infarction (RVI), as well as its complications and its therapeutic approaches. Patients and methods: It is a single-centered retrospective descriptive study conducted over a period of 2 years from November 2018 to October 2020. The authors included 82 patients with RVI hospitalized in the cardiovascular ICU during the initial phase of acute coronary syndrome with persistent ST segment elevation. Patients who were diagnosed with RVI at electrocardiogram and echocardiography were recruited. Results: The authors included 500 patients hospitalized for STEMI, 82 had MI extended to the RV, reflecting a rate of 16.4%. The mean age in our study was 64±12.3 years. Dyslipidemia, diabetes mellitus, and hypertension were the most common cardiovascular risk factors among these patients. RVI co-existed with inferior MI in 62.2 of cases and in 37.8% of anterior MI, while isolated RVI was seen in only one patient. Transthoracic echocardiography showed right ventricular (RV) systolic dysfunction in 24.39% of cases, while RV dilatation was seen in only 10.9% of patients. Therapeutic approach was based essentially on revascularization with thrombolysis and coronary angiography +/- PCI. The percentage of mortality was 2.4%. Conclusion: RVI is relatively rare and is mostly related to an extension of an inferior MI. Early diagnosis, prompt treatment, and appropriate are the keys to improve prognosis, and reduce complications.

Effectiveness of Primary Coronary Intervention for Patients With Delayed ST-Segment Elevation Myocardial Infarction: Insights from Moroccan Cardiology Intensive Care Units.

The benefits of myocardial revascularization in ST-segment elevation acute coronary syndrome after 12 to 24 hours from symptom onset remain a topic of debate, especially in patients who are stable and asymptomatic. We analyzed the benefit of late revascularization by primary coronary intervention in patients admitted to Moroccan cardiac intensive care units (CICUs) with ST-segment elevation myocardial infarction after 12 hours of symptom onset. We included a total of 406 patients who met the inclusion criteria: 262 patients in the invasive strategy group and 144 patients in the conservative strategy group. A total of 74.6% were men, and 25.4% were women. For the primary outcome, 46 all-cause deaths were observed at 1 year, with 33 patients in the conservative strategy arm and 13 patients in the invasive strategy group, with a significant difference between the 2 groups (p <0.001). For secondary outcomes, there was no difference in readmission for acute coronary syndrome or acute heart failure between the 2 groups (p = 0.277, p = 0.205). For in-CICU cardiogenic shock and ejection fraction <35% at discharge, more events are observed in the conservative strategy, with a significant difference for both (p <0.001). In multivariable analysis, 1-year all-cause mortality was independently associated with revascularization between 12 and 48 hours (hazard ratio [HR] 0.372, 95% confidence interval [CI] 0.182 to 0.762, p = 0.007), ejection fraction <35% at discharge (HR 1.92, 95% CI 1.22 to 2.54, p = 0.04), and cardiogenic shock in-CICU (HR 2.69, 95% CI 1.82 to 3.78, p = 0.005).Although no evidence exists to date on the true benefit of late primary coronary intervention revascularization in patients with ST-segment elevation myocardial infarction, this practice remains common, as indicated by the results of most registries.

Is There a Causal Link Between Acute Myocarditis and COVID-19 Vaccination: An Umbrella Review of Published Systematic Reviews and Meta-Analyses.

Introduction: A few months after the beginning of the coronavirus disease of 2019 (COVID-19) vaccination, several reports of myocarditis secondary to the vaccines were published, sometimes with fulminant cases, but until today there is no proven causal link between these 2 events, but with many hypotheses proposed. Methods: A systematic review of current evidence regarding myocarditis after COVID-19 vaccination was performed by searching several databases including PubMed/Medline and Web of Science. The quality of Meta-analysis was assessed using the AMSTAR-2 tool as well as other qualitative criteria. Results: Our umbrella review appraised 4 Meta-analysis of retrospective studies (range: 5-12), The number of vaccine doses included ranged from 12 to 179 million, with the number of myocarditis cases observed ranging from 343 to 1489. All types of vaccines were evaluated, with no exclusions. The overall incidence ranged from 0.89 to 2.36 cases of myocarditis per 100 000 doses of vaccine received. Heterogeny was assessed in 3 of the Meta-analysis, and was highly significant (>75%) in all included studies, and with a significant P-value (P < .05). Regarding publication bias, 3 of the Meta-analysis conducted the egger and begg regression, with a significant result in only 1. Regarding the assessment of the methodology by the AMSTAR-2 scale indicating that the quality was very critical in 1, low in 2, and moderate in 1 Meta-analysis. Conclusion: The quality of current non-randomized evidence on real causality and incidence of myocarditis after COVID-19 vaccine is still low.

The Benefit of an Extensive Cancer Screening Strategy After the First Episode of Unprovoked Pulmonary Embolism.

INTRODUCTION: The etiological assessment after an acute unprovoked pulmonary embolism (PE) represents an essential step in the overall management of the patient, with the aim of adapting the duration and type of anticoagulant to be used, avoiding recurrence and thus improving overall morbidity and mortality, but this is not such a simple question to answer. PURPOSE: The main objective of this work is to know the benefit of a limited etiology strategy versus an extensive strategy after a first episode of acute non-provoked PE, first on all-cause mortality, and then the superiority of one strategy over another on the diagnosis of cancer at 1 year in patients admitted to a cardiac intensive care unit. METHODS: This is a single-center, retrospective study from 2014 to 2021, which includes all patients, admitted to a cardiac intensive care unit for a first episode, at high or high intermediate risk of mortality at day 30. The included patients were divided into 2 groups: those who received a limited cancer screening strategy, and those who received, in addition to the latter, an injected cerebral and cervical-thoracic-abdominal scan, and the determination of tumor markers. All data were extracted from the medical hospital files. RESULTS: In total, we included 130 patients. The mean age of our patients was 87.19 (SD = 6.1), with a female predominance with a percentage of 55.4%. Eighty-seven patients benefited from an extensive cancer screening strategy, versus 43 patients who benefited from a limited strategy. First, for mortality at 1 year, 27 deaths were found between the 2 groups but without significant difference (hazard ratio; 0.53; P = 0.16), and for the mean duration from embolic episode to death, there was a mean of 20 weeks for the limited strategy group and 24 weeks for the extensive strategy group, with a nonsignificant difference ( P = 0.106). For the diagnosis of cancer at 1 year, 28 patients were diagnosed with cancer: 13 patients in the limited strategy group versus 15 in the extensive strategy group, with no significant difference (hazard ratio, 1.983; P = 0.082). The mean time to diagnosis was 22 weeks in the limited strategy group and 20 weeks in the extensive strategy, with no significant difference ( P = 0.729). CONCLUSION: To date, no scientific evidence has been established for the extensive versus the limited strategy, therefore, a minimal etiological workup is also effective in the detection of cancer after unprovoked PE.

Cardiac intensive care unit: where we are in 2023.

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023.

Usefulness of the Quick-Sepsis Organ Failure Assessment Score in Cardiovascular Intensive Care Unit to Predict Prognosis in Acute Coronary Syndrome.

Triage of patients with acute coronary syndrome (ACS) at high risk of in-hospital complications is essential. In this study, we evaluated the quick sepsis organ failure assessment (qSOFA) score as a tool for predicting the prognosis of 964 patients admitted to the cardiovascular intensive care unit (CICU) with ACS over a 4-year period. In total, out of 964 patients included, with a percentage of 4.6% for 30-day mortality. The risk of 30-day mortality was independently associated with qSOFA ≥ 2 at admission (hazard ratio = 2.76, 95% CI 1.32-5.74, p = 0.007). For MACEs, qSOFA ≥ 2 at admission was a predictive factor with (odds ratio = 2.42, 95% CI 1.37-4.36, p = .002). A qSOFA ≥ 2 on admission had an AUC of 0.729 (95% CI [0.694, 0.762]), with a good specificity of 91.6%. For 30-day mortality, an AUC of 0.759 (95%CI [0.726, 0.792]) for cardiogenic shock with specificity of 92.5%. For MACEs, an AUC of 0.702 (95% CI [0.64, 0.700] with a specificity of 95%. Concerning the different scores tested, we found no significant difference between the Zwolle score and the qSOFA score for predicting prognosis, whereas the CADILLAC score was better than qSOFA for predicting 30-day mortality (AUC = 0.829 and De long test = 0.03). However, there was no difference between qSOFA and CADILLAC scores for predicting cardiogenic shock (De Long test at 0.08). This is the first study to evaluate qSOFA as a predictive score for 30-day mortality and MACEs, and the results are very encouraging, particularly for cardiogenic shock.

Pharmaco-invasive Therapy: A Continued Role for Fibrinolysis in the Primary PCI era.

INTRODUCTION: Early Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion therapy for most patients with ST-segment elevation myocardial infarction (STEMI), and the European guidelines recommend pPCI to occur within 120 min of first medical contact. However, this is not always available. METHODS: We performed a retrospective study of patients admitted for STEMI to a level I cardiac intensive care unit in a developing country, to analyze the efficacy of the pharmaco-invasive (PI) strategy versus late PCI over a 2-year follow-up. RESULTS: Four hundred and thirty-nine STEMI patients presented within the first 12 h of symptom onset, pPCI was performed in 154 patients, PI-strategy in 185 patients, and finally Late PCI in 100 patients. All-cause mortality at 2-year risk was statistically significant associated with cardiogenic shock during initial hospitalization, LM and ostio-proximal left anterior descending artery as the culprit artery, severe conductance disorders requiring the use of a temporary pacemaker, and acute kidney disease with glomerular filtration rate < 30 ml/min/1.72 m2 . For the revascularization strategy, there as a well-demonstrated benefit of the pPCI versus Late PCI strategy with (hazard ratio (HR) = 0.293; 95% confidence interval (CI) 0.11-0.737; P = 0.009), as well as a benefit of the PI-strategy versus Late PCI strategy with (HR = 0.433; 95%CI 0.21-0.87; P = 0.02). However, there was no difference between the pPCI and PI-strategy. CONCLUSION: The PI-strategy remains a reasonable alternative for pPCI when the latter is not available, with a prognosis almost identical to pPCI in the long term whenever patients are treated early after the onset of symptoms.

The Efficacy and Safety of Prolonged Oral Anticoagulation for the Prevention of Thromboembolic Events in Patients Recovered From COVID-19 1 Year After Hospital Discharge: The SARCOV-19 Prospective Registry.

Our objective in this study is to know the predictors of thromboembolic events 1 year after hospitalization for severe COVID-19 and the benefit of preventive oral anticoagulation for 1 month to placebo after release. We conducted a prospective study to determine the benefit of preventive anticoagulation upon discharge from the hospital and to determine the predictive factors of thromboembolic events. We included 720 patients in the SARCOV-19 Registry, with a mean age of 62.07 (±18.11), and 61.1% male. After 1 year, 60 thromboembolic events were observed, 45 in patients on a placebo, and 15 in patients on a direct oral anticoagulant. The predictive factors determined for these events were the presence of cardiac disease, elevation of D-dimer during hospitalization, myocardial damage defined by elevation of troponins more than 6 times normal, and the use of mechanical ventilation. However, the use of preventive anticoagulation protects against thrombotic events and reduces the risk of a thromboembolic event at 1 year with a relative risk of 0.49 compared to a placebo. The prolongation of the preventive anticoagulation at the exit will protect with a decrease of almost 50% of the risk against thrombotic events and this without increasing the risk of bleeding.

The Impact of Prior Antithrombotic use on Thromboembolic Events in Patients with Cardiovascular Disease and Severe COVID-19 Infection.

OBJECTIVE: Our objective in this study was to determine the predictive factors of thromboembolic complications in patients with previous heart disease and severe covid-19 infection and the impact of previous use of antithrombotics on protection against these complications. METHODS: We conducted a single-center retrospective study of 158 patients with heart disease admitted to an intensive care unit for severe SARS-COV-2 infection. In order to determine the predictive factors, we used logistic regression analysis. RESULTS: Out of 158 patients, 22 were complicated by a thrombo-embolic event (13.9%), mean age of our population 64.03 (SD = 15.27), with a male predominance of 98 (62%). For the predictive factors of thromboembolic complications, and after multivariate analysis, we find the short duration of hospitalization (OR = 0.92; 95%CI (0.863-0.983), P = .014, previous use of antithrombotic drugs ((OR = 0.288, 95%CI (0.091-0.911), P = .034 for antiplatelet agents) and (OR = 0.322, 95% CI (0, 131-0.851), P = .021) for anticoagulants) as protective factors, and admission thrombocytosis as a risk factor (OR = 4.58, 95%CI (1.2-10.627), P = .021). D-dimer was not detected as a risk factor, and this can be explained by the characteristics of our population. Although prior use of antithrombotic drugs protects against thromboembolic complications during severe infection, there was no benefit in mortality. CONCLUSION: Prior use of antithrombotic drugs is a protective factor against thromboembolic complications in patients with a history of heart disease but without effect on mortality.

Acute coronary syndrome complicating infective endocarditis: A case report with an etiological review.

Introduction: Acute coronary syndrome (ACS) is an uncommon complication associated with high mortality in patients with endocarditis. It requires prompt and appropriate management to cure the patient. Cases presentation: We report the case of a 52-year-old patient, initially admitted for an acute non-ST-segment elevation coronary syndrome at very high ischemic risk, in whom coronary exploration was negative, and whose echocardiography showed a mobile image on the aortic valve, suggesting infective endocarditis. The patient benefited from an aortic valve replacement because of the size and the embolic complications he presented, with a favorable evolution. Discussion: Acute coronary syndrome during infective endocarditis is a rare complication with a high mortality rate. Several mechanisms are possible: the embolic mechanism, coronary extraluminal compression due to coronary mycotic aneurysm and obstruction of the coronary ostium by a large vegetation. The management remains multidisciplinary and personalized according to the phenotype of the patient, with the need to have the endocarditis team to be able to take the best therapeutic choice. Conclusion: Infective endocarditis must be evoked in any patient without usual cardiovascular risk factors who presents with an ACS that is accompanied by fever and elevated inflammatory markers, and a thorough clinical examination as well as the performance of additional tests.

Pulmonary embolism with junctional tachycardia: A serious complication after COVID-19 vaccination.

Introduction: the association between the development of a thromboembolic event following COVID-19 vaccination is very rare, it represents less than 0.1% of vaccinated cases. Until now this association remains to be discussed. Case presentation: A 49-year-old man presented to the Emergency Department a 7-day after receiving her second dose of BNT162b2 mRNA COVID-19 (Pfizer-BioNTech), and he was diagnosed with pulmonary embolism (PE) with junctional tachycardia on ECG. The biological workup showed an increase in CRP with elevated D-dimer, but no abnormalities in cardiac markers, including troponin and BNP, the COVID-19 testing was negative and absence of thrombocytopenia. The patient was put under curative anticoagulation by rivaroxabon. Discussion: Studies have reported the association of venous thrombosis after administration of the COVID-19 vaccine with negative FP4 antibodies and normal platelet count which is similar with our patient. Moreover, spike proteins generated by mRNA vaccines can produce a pro-inflammatory state, a cascade of events guiding to endothelial dysfunction and afterwards to the development of venous thrombosis. Conclusion: All the same that some studies association COVID-19 immunizations to the development of VTE, we nevertheless recommend COVID-19 vaccination, due to the rarity of these events, compared to the hypercoagulable effects and other serious complications of COVID-19 infection.

Factors influencing the length of stay in the moroccan intensive care unit in patients surviving critical COVID-19 infection.

Introduction: our objective is to determine the factors that influence the length of hospitalization of patients admitted to an intensive care unit. Methods: We have conducted a mono-centric retrospective cohort of 417 patients admitted in intensive care unit for a critical infection by COVID-19, for this purpose we have realized an analytical study using the linear regression model. Results: In our study, the average length of hospitalization for a critical infection with COVID-19 is 6 days (SD = 7Days), regarding the factors that influence the length of hospitalization, the length of time between the consultation and the onset of symptoms higher thann 8 days affects the length of hospitalization (coefficient = 1.2 days; CI = 0.769; 2.102 and pValue = 0.009), the presence of obesity which also affects the length of hospitalization (Coefficient = 1.6 days CI ((0.009; 3.265), and pValue = 0.049). During hospitalization, the use of mechanical ventilation, the use of tocilizumab, having a billateral nosocomial pneumonia are all factors that impact the length of hospitalization. Conclusion: It is recommended to emphasize the importance of early consultation after the onset of respiratory symptoms in the patients who are admitted to the intensive care unit in order to improve the length of their stay.

Cannabis-induced myocardial infarction in a 27-year-old man: Case report.

Cannabis smoking has been reported as one of the risk factors for coronary heart disease, which can trigger in rare cases, an acute coronary syndrome (ACS). In this report, we present a case of a 27-year-old man presented with acute myocardial infarction (AMI) following cannabis consumption. The patient developed ST-segment elevation on the anterior and inferior leads. Coronary angiogram demonstrated a significant stenosis of the left anterior descending coronary artery (LAD). A Percutaneous Coronary Intervention (PCI) of the LAD, was realized with the implantation of a new generation-stent with good clinical evolution status. Healthcare professionals should consider cannabis consumption as a possible etiology of acute myocardial infarction, particularly in young patients with a susceptible social profile (drug-using patients with coronary heredity as a cardiovascular risk factor), and should educate patients regarding this emerging public health issue.

A very rare case of chylomicronemia revealed by cerebral thrombophlebitis in a 4-month-old infant.

INTRODUCTION: Hyperchylomicronemia is a disorder of lipid's metabolism that can present fatal complications such us such venous or arterial thrombosis, pancreatitis, and cardiovascular incidents. CASE PRESENTATION: In this report case we report a 4months old patient who was admitted in the emergency room for hypotonia and during the blood sampling we were surprised by the macroscopic latescent aspect of the blood. During the investigations we found that the patient had a fatty cerebral venous thrombosis that revealed hyperchylomicronemia. Furthermore, the patient presented tuberculosis cerebral abscess and stage A pancreatitis and was successfully treated. DISCUSSION: Primary hypertriglyceridemia results from the accumulation of genes polymorphisms encoding for proteins involved in the triglycerides metabolism but before thinking about primary origin a secondary one should be pushed aside. Biological investigations should test lipoprotein lipase activity that can be absent or reduced to confirm a lipid disorder, then lipoprotein electrophoresis and genetic study can deliver the diagnosis. The management of this disease is based on low fat diet that should not be over than 25-30g per day, also statin, fibrate, omega 3 acid, heparin and insulin can be used. CONCLSUION: Adequate treatment and exploration permits to obtain the optimum care to avoid any complications.

Capillary hyperpermeability syndrome: A fatal complication of acute leukaemia: Case report and review.

INTRODUCTION: The capillary hyperpermeability syndrome is a rare disease that should be suspected in the presence of recurrent generalized edema without obvious cause, which may be idiopathic or secondary. CASE PRESENTATION: In this case, we report a Clarkson syndrome secondary to an acute leukemia affecting a 4-year-old child admitted to the emergency room in respiratory and hemodynamic distress with a generalized oedematous syndrome and a bone marrow failure syndrome. Laboratory tests concluded that the patient was suffering from an acute lymphoblastic leukemia, hypoalbuminemia, pericardial effusion, and the absence of any other cause that is in favor of a capillary leak syndrome.In spite of the filling and the introduction of drugs, the cardio respiratory arrest could not be recovered and the child died 24h after his admission. DISCUSSION: It is a rare pathology described for the first time in 1960, generally secondary to a pathological state and more rarely idiopathic, to be evoked in front of clinical and biological parameters which are hypoalbuminemia, hemiconcentration and hypoperfusion, after having eliminated a sepsis in the first place.The treatment is based on the management of the acute phase by filling with crystalloids, drugs or even steroids, and as a preventive treatment of relapses immunoglobulins or theophylline are used. CONCLUSION: The evolution can be quickly fatal, that's why it is necessary to know how to evoke this syndrome in front of a similar clinical presentation.

Special case of a patient in the blast phase of chronic myeloid leukemia successfully treated with tocilizumab during critical SARS-CoV-2 infection.

The medical care of patients with hematological malignancies who develop coronavirus disease 2019 (COVID-19) has been a major challenge during the current pandemic. We herein describe a patient in the blast phase of chronic myeloid leukemia who was hospitalized for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The patient was successfully treated with tocilizumab, and intubation was avoided. The severity of SARS-CoV-2 infection is mostly related to a severe acute respiratory distress syndrome that develops secondary to cytokine release syndrome, and interleukin 6 is the main cytokine involved in cytokine release syndrome. Very few reports have described the use of tocilizumab in patients with hematologic malignancies who develop SARS-CoV-2 infection, although a few cases of patients with multiple myeloma have been reported. To our knowledge, however, this is the first report of a SARS-CoV-2-infected patient in the blast phase of chronic myeloid leukemia who had a favorable response to treatment with tocilizumab. The management of patients with hematological malignancies who become infected with SARS-CoV-2 is a major challenge for practitioners, necessitating more specific research in this direction.

Post Myocardial Infarction Ventricular Septal Rupture Revealed By Acute Liver Failure Symptoms: A Case Report.

INTRODUCTION: The mechanical complications of acute myocardial infarction (AMI) still kill despite the evolution of medicine. Early diagnosis and adequate management are necessary to improve the prognosis, and this requires first, a good clinical examination that should raise the suspicion of a mechanical complication, then the echocardiography is performed to confirm the diagnosis. CASE PRESENTATION: We present a case of a 64-year-old patient admitted to the emergency room for jaundice with delayed ST-segment elevation myocardial infarction (STEMI). Physical examination revealed signs of right heart failure, which led us to associate jaundice with signs of acute liver failure secondary to right heart failure. Echocardiography confirmed the diagnosis of a ventricular septal rupture (VSR) with left-right shunt, and a significant dilation of the right ventricle. The patient underwent surgical closure of the VSR with fatal evolution. DISCUSSION: VSR is a rare life-threatening mechanical complication of AMI. The clinical signs depend on the left-right shunt and the onset of heart failure, which are 2 major determinants of the therapeutic strategy and the timing of the surgery. Despite surgical closure of the VSR, the mortality remains high, but the prognosis is better in patients treated with surgery than in patients who are treated medically only. CONCLUSION: The clinical presentation of VSR may differ from a patient to another. Good clinical sense and echocardiography are essential to set early diagnosis, and thus decide on the adequate management at the right time.

Purpura as a late complication of covid-19 infection that should not be ignored: Case report and brief review.

INTRODUCTION AND IMPORTANCE: The SARS COV2 infection is a challenging pandemic that has affected millions of people with a very high mortality rate. In addition to the typical respiratory symptoms, it can also cause variable skin lesions, such as vascular purpura in some exceptional cases. CASE PRESENTATION: We report the case of a 60-year-old woman who was admitted for a SARS COV2 infection, the evolution was marked by the appearance of a vascular purpura at D20 after the beginning of the symptoms. DISCUSSION: The cutaneous manifestations associated with the SARS COV2 infection are polymorphic. Vascular purpura is one of them. Its diagnosis is retained in the light of a combination of arguments, which makes it a real challenge for the physician to diagnose it. The management of the disease is based on a symptomatic treatment. The clinical evolution is, in general, favorable. CONCLUSION: Although rare and still not fully explained, skin involvement during SARS COV2 infection has been described. It should not be neglected and it should be diagnosed early and treated appropriately, especially in asymptomatic patients.

Cerebral Salt Wasting Syndrome (CSW): An unusual cause of hypovolemia after spontaneous cerebral hemorrhage successfully treated with fludrocortisone.

Our objective is to demonstrate the interest of thinking about Cerebral salt wasting syndrome (CSW) in front of hyponatremia with severe hypovolemia after a brain injury, and at the same time the interest to differentiate between Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and Cerebral salt wasting syndrome (CSW) as two etiologies to be evoked in front of a hyponatremia with brain injury. Case report: We report the case of a 63-year-old patient with a recent history of hemorrhagic stroke admitted for severe hypovolemic shock in whom the investigations find a very deep hypotonic hyponatremia secondary to a cerebral salt wasting syndrome successfully treated with fludrocortisone. Discussion: CWS is characterized by hypotonic hyponatremia associated with cerebral associated with hypovolemia, the difficulty of the diagnosis is explained by the points of convergences with SIADH which is also presented with hyponatremia. The treatment is based on filling with saline, if the symptoms are severe, hypertonic saline has its place. Fludrocortisone has proven its effectiveness in the correction of refractory hyponatremia in CWS. Conclusion: It is essential to differentiate between hyponatremia in CWS and hyponatremia in SIADH because the medical care is categorically different.

SARS-CoV-2 infection presenting as rhabdomyolysis: case report and review.

Coronavirus disease 2019 (COVID-19) is the health crisis of our time and a great challenge we face, requiring the implementation of worldwide general containment. The symptoms and complications of COVID-19 are diverse, and rhabdomyolysis is an atypical manifestation. We report a case of a 63-year-old patient, admitted to the emergency room for myalgia and fever evolving over 5 days, in whom laboratory and other examinations indicated rhabdomyolysis complicated by renal insufficiency. During the diagnostic workup, the real-time polymerase chain reaction (RT-PCR) test result for COVID-19 was positive, revealing infection with sudden acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although the severity of COVID-19 infection relates mainly to acute respiratory syndrome, other complications can be prognostic, and these complications make the management of this disease difficult. Rhabdomyolysis is one of the fatal complications; first, because the pathophysiological mechanism is not yet understood, and second, because rhabdomyolysis, itself, is usually complicated by acute renal failure. This complication makes the disease management difficult, especially in patients with SARS. Rhabdomyolysis during COVID-19 infection represents a significant challenge, given the few reported cases, and further research is required to develop a therapeutic consensus.