Immune surveillance for six vaccinable pathogens using paired plasma and dried blood spots in HIV infected and uninfected children in Kinshasa.

Child vaccination reduces infant mortality rates. HIV-infected children present higher risk of diseases than non-infected. We report the protection coverage rates for 6 vaccine-preventable diseases in a paediatric population from the Democratic Republic of the Congo (DRC) and the impact of HIV infection, providing the first data on the validity of dried blood samples (DBS) to monitor the immune protection. During 2016-2018 DBS from 143 children/adolescents were collected in Kinshasa (DRC), being 52 HIV-infected. Forty-two had a paired plasma sample. Protective IgG was quantified (VirClia-IgG,VIRCELL) to obtain the optimal cut-off in IgG detection in DBS. ROC curves were generated with R software and statistical analyses with Stata. Protective IgG levels varied across pathogens, not reaching herd immunity. HIV-infected presented lower vaccine protection than uninfected for all analyzed pathogens, except rubella, with statistically significant differences for measles (30.8% vs. 53.8%; p = 0.008) and tetanus (3.8% vs. 22%; p = 0.0034). New cut-offs were calculated when using DBS to improve test performance. We reinforce the necessity to increase pediatric vaccination coverage in Kinshasa, especially in HIV seropositive, with less capacity to maintain adequate antibody levels. DBS were useful to monitor vaccination coverage in seroprevalence studies in resource-limited settings, after optimizing the cut-off value for each pathogen.

[Accidental spinal anesthesia in obstetrics. Limits of epidural test-dose]. / Rachianesthésies accidentelles en milieu obstétrical. Limites de la dose-test péridurale.

Two cases of accidental spinal anaesthesia occurring in obstetrical patients are reported and discussed. Epidural anaesthesia had been asked for by the women, both being free from any significant medical history. A Tuohy needle was inserted in the midline between L3 and L4 with the patient sitting. The extradural space was identified by the loss of resistance using saline. The test-dose (2 ml and 4 ml of 1% lignocaine respectively) was administered five minutes before changing the patient to the supine position. In the first case, after a test-dose had remained without any effect, 8 ml of 0.25% bupivacaine were injected, about one hour later. The patient rapidly complained of paralysis of her legs and difficulties in breathing. Her blood pressure decreased from 120/80 mmHg to 90/60 mmHg. The upper level of analgesia reached T4. She improved after infusion of 1.51 of lactated Ringer's solution. Endotracheal intubation was not required. Delivery was assisted with a vacuum extractor. In the other patient, when the extradural space had been located, there was a small reflux of clear fluid which did not contain any glucose. As the test-dose did not result in any effect. 2 ml of 2% lignocaine with adrenaline were injected. This was followed by an immediate sensory loss in the legs, extending up to T10. Caesarean section was decided on, without any further injections (foetal macrosomia, breech presentation). Both patients totally recovered without any sequela. Both children had an Apgar score of 10 at 1 and 5 minutes. The type of test-dose is discussed. Smaller volumes of more concentrated solutions are recommended.

[Worsening of chronic disseminated intravascular coagulation after embolization of the renal artery]. / Aggravation d'une coagulation intravasculaire disséminée chronique après embolisation d'une artère rénale.

A case is reported of a 60 year-old patient with chronic disseminated intravascular coagulation (DIC) which was increased by the therapeutic embolization of a renal tumour. The patient had 2 primary carcinomas (renal and prostatic) with vertebral metastases, severe chronic anaemia (due to haematuria), and chronic DIC, with thrombocytopaenia, soluble complexes, and fibrinogen and fibrin degradation products. Therapeutic embolization of the renal artery was carried out with fragments of dura mater. Although the result was anatomically very satisfactory, the patient's condition worsened, with continuing haematuria, and development of an haematoma in the lumbar fossa. Coagulation factors and antithrombin III (AT III) concentrations decreased, whereas the activated partial thromboplastin, thrombin and reptilase times increased. The patient also suffered from acute renal failure (creatinine: 690 mumol.l-1). Treatment consisted in fluid replacement, red blood cell and platelet transfusions, 150 IU.kg-1.d-1 heparin and 20 IU.kg-1.d-1 AT III. Haematological tests returned to pre-embolization values on the ninth day. The sudden worsening in the patient's condition was probably due to the sudden massive release of tissue thromboplastins related to the renal necrosis induced by the therapeutic embolization. The use of heparin AT III in the management of this patient is discussed.