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Purpose: Star fruit intoxications have been reported mainly in uremic patients, leading to various degrees of neurological symptoms and potentially fatal outcomes. Nephrotoxicity has been reported in few patients with normal renal function or moderate chronic renal impairment (CRI). The present report describes clinical course, management, and outcome of six patients with moderate CRI admitted to ICU for severe star fruit intoxication., Methods: Over a 1-year period we observed six cases of star fruit intoxication. All but two patients were prospectively monitored. For each case we collected clinical characteristics, management, and outcome., Results: On admission, all patients presented acute renal failure with underlying moderate CRI and required intubation for coma. The most common symptoms were hiccups, mental confusion, seizures, and coma. Status epilepticus was authenticated in three patients. Management consisted of several methods of renal replacement therapy (RRT) and supportive measures. Four patients survived without sequelae and two patients died., Conclusions: Severe star fruit intoxication can occur in patients with moderate CRI with a potentially fatal outcome. Prompt continuous RRT should be instituted.

Background: The practice of platelet (PLT) transfusions has been adopted into the standard clinical practice in many dengue-endemic countries. Because many patients were found to have received unnecessary PLT transfusions, the development of guidelines for the management of dengue patients with thrombocytopenia has become a necessity., Study Design and Methods: An emergency department-based prospective observational study was conducted in Martinique during a dengue outbreak in adult patients presenting with an acute febrile illness. Patients with severe bleeding and/or who underwent invasive intensive care procedures or emergency surgery were given PLT transfusion to achieve PLT counts of more than 50 x 10(9)/L. PLT transfusion was also considered for patients with PLT counts of less than 5 x 10(9)/L and for those with associated risk factors and PLT counts of less than 20 x 10(9)/L., Results: A total of 350 patients were admitted with confirmed dengue infections. Most of them had secondary serotype-2 infections. PLT counts of less than 50 x 10(9)/L were recorded in 165 patients (47.1%). PLT transfusion was administered to 9 patients with thrombocytopenia. The indications included severe bleeding (5 cases), invasive procedures (3 cases), emergency surgery (1 case), and/or associated risk factors (2 cases). The median time duration from the onset of fever to PLT transfusion was 6 days (range, 4-10 days). The median amount of PLTs transfused was 3.66 x 10(11) (range, 2.8 x 10(11)-13.2 x 10(11)). The median PLT yield was +12.4% (range, -3.9% to +67.1%). Three patients died. All other patients recovered during the second week after the onset of fever., Conclusion: A restrictive strategy for PLT transfusion based on clinical features and low PLT count thresholds proved to be feasible and safe for adult dengue patients.

We report two cases of community-acquired Acinetobacter baumannii pneumonia. Although most infections occur in hospitalized patients, a few cases of community-acquired pneumonia have been described. This disease occurs predominantly in men, and is often associated with underlying conditions such as cigarette smoking, alcohol abuse, diabetes mellitus, and chronic pulmonary diseases. Community-acquired Acinetobacter baumannii pneumonia cases are generally reported from tropical areas, especially during wet season. Microbiological identification in blood or sputum can be difficult because of frequent misinterpretation and possible confusion with Staphylococcus or Haemophilus infuenzae or neisseriae. Early antibiotherapy is required because of the fulminant clinical course, with approximatively 50% fatality rate.

Background: Acute pulmonary edema may be induced by beta 2-mimetics used for tocolysis., Case Report: A 41-year-old patient, admitted for preterm labor, presented acute pulmonary edema after parenteral tocolysis using salbutamol in combination with corticosteroid therapy to improve fetal pulmonary maturation., Discussion: The pathogenic mechanism is essentially non-cardiologic. Fluid retention is probably the main cause, potentially worsened by corticosteroid administration. If detected early, pulmonary edema is usually and adequately treated by cessation of beta 2-sympathomimetic therapy, oxygen administration and diuretics. Mechanical ventilation can be required. Cardiac function must be assessed after this complication. In preterm labor, the duration of tocolysis with beta 2-sympatomimetics should be reduced.

Case report of a 30-year-old patient, admitted one hour after an intentional ingestion of paraquat (60 g). The initial treatment included gastric washing, parenteral n-acetylcysteine and forced diuresis. Considering the severity of the intoxication, conventional haemodialysis was started four hours after the ingestion. Plasma concentrations of paraquat, in the lethal range at admission, decreased rapidly and significantly after haemodialysis. This case raises the question of the part played by n-acetylcysteine and haemodialysis respectively in a favourable outcome. As the determination of paraquat blood concentrations requires some delay, these data are of no help for therapeutic decisions. Therefore, in cases of massive poisoning or uncertainty of the ingested dose, a technique of blood purification in indicated. Charcoal haemoperfusion is the most efficient, however conventional haemodialysis, which is more widespread, should be considered if the former is not available.

Introduction: Side-effects of immunoglobulins administered via the intravenous route are usually minor. However, acute renal failure and more rarely thrombotic events, including ischemic stroke, have been reported in association with immunoglobulin infusion. To our knowledge, no case of both acute failure and stroke following immunoglobulin has been described until now., Exegesis: Two days after immunoglobulin infusion (2 g/kg), a patient who presented with autoimmune thrombocytopenia suffered severe acute renal failure associated with an ischemic stroke in the right anterior choroid artery territory. Moreover, the stroke worsened immediately following a second infusion (1 g/kg). Clinical and neuroradiological examinations were conducted., Conclusion: Results indicate the need for both close monitoring of serum creatinine and diuresis before starting immunoglobulin therapy, and limiting the total dose to prevent thrombotic events such as stroke.

Unlabelled: Tracheal intubation may pose problems in patients with cervical spine injury (CSI). In patients without CSI, the success rate of blind nasotracheal intubation is increased by endotracheal tube (ETT) cuff inflation in the pharynx. The purpose of this study was to assess the efficacy of ETT cuff inflation in the pharynx as an aid to blind nasotracheal intubation in patients with an immobilized cervical spine. The technique was compared with fiberoptic bronchoscopy. Twenty ASA physical status I and II patients undergoing elective surgery in which the trachea was to be intubated nasally were enrolled in this prospective, randomized study. The cervical spine of each patient was immobilized. The trachea of each patient was intubated twice, once using fiberoptic bronchoscopy and once blindly using the technique of ETT cuff inflation in the pharynx. A maximum of three attempts was allowed for intubation using ETT cuff inflation. A maximum of 3 min was allowed for intubation using fiberoptic bronchoscopy. When ETT cuff inflation was used, intubation was successful in 19 of 20 patients (95%); the first attempt at intubation was successful in 14 of 20 patients (70%). Intubation was successful in 19 of 20 patients (95%) when using fiberoptic bronchoscopy. Mean times to intubate were 20.8 +/- 23 s when the ETT cuff was inflated in the pharynx and 60.1 +/- 56 s when using fiberoptic laryngoscopy (P < 0.01). We conclude that both ETT cuff inflation in the pharynx and fiberoptic bronchoscopy are valuable for nasotracheal intubation in patients with an immobilized cervical spine and that ETT cuff inflation can be used as an alternative to fiberoptic bronchoscopy in patients with CSI., Implications: We compared the technique of endotracheal tube cuff inflation in the pharynx for blind nasotracheal intubation in patients with an immobilized cervical spine with fiberoptic bronchoscopy. There was no significant difference between the success rates of the techniques.

A 24-year-old woman developed hyperemesis gravidarum, complicated by Wernicke's encephalopathy and central pontine myelinolysis. The first-was due to a deficiency of thiamine, and was hastened by intravenous dextrose without thiamine supplements. However, no changes in serum sodium or phosphorus values were observed. In this case, the pathophysiology of central pontine myelinolysis remained obscure.

A 37 year-old man had headaches for 10 days, then a single tonic-clonic seizure and coma due to an extensive cerebral venous thrombosis. In spite of full-dose heparin treatment for 7 days, the clinical picture worsened along with increasing edema on CT-Scan. Direct thrombolytic treatment was then performed using transvenous catheterization and instillation of Urokinase (2.6 MU over 4 days). A near complete repermeabilization of the sinuses was obtained and the patient improved dramatically in a few days. The only adverse effect of Urokinase was hematuria. Based on our experience and review of the literature which includes 26 previous cases, direct thrombolytic therapy appears to be a relatively safe procedure. This treatment should be considered in a patient with extensive dural sinus thrombosis which fails to respond to heparin treatment.

We report a case of retinal vein occlusion after breath-holding diving. After one hour of diving at a maximal depth of eight meters, each apnea no longer than one minute, the patient complained of a diminution of the visual acuity in the left eye. Ophthalmological examination revealed an occlusion of the superior branch of the central vein of the retina in the left eye. This could be considered as a decompression sickness even if the occlusion could happen fortuitously in water. Secondary to the multiple descents, a bubble would have appeared in the vein leading to an obstruction. The purpose of this paper is to discuss a possible link between the breath-holding diving and this kind of accident. We also report the different ophthalmological features that may occur while diving.

Since mid 95, many Caribbean islands and America's countries suffer from a new outbreak of an epidemic of dengue fever and dengue haemorrhagic fever. Until today, no case of dengue haemorrhagic fever was reported in Martinique (FWI) in spite of the high prevalence of dengue fever in the island. The first identified case asserts the severity of illness. In Martinique, these arbovirosis is often underestimated. Nowadays, the disease prevention must become one of the principal targets of the medical corporation and the Public Health Authorities. Consequently, epidemiologic survey and principally vector's control must be reinforced.

Objectives: To determine the oxygen supply (DO2) and uptake (VO2) responses to a 60-min dobutamine infusion in critically ill septic patients without circulatory shock and with normal blood lactate concentrations. Also, to determine whether these responses would predict outcome., Design: Prospective, cohort study., Setting: Five intensive care units in university-affiliated, city hospitals., Patients: Fifty critically ill patients with sepsis syndrome were studied from April 1990 to August 1991., Interventions: Pulmonary artery catheterization; fluid loading if pulmonary artery occlusion pressure was < 10 mm Hg; and 10 micrograms/min/kg dobutamine infusion for 60 mins., Measurements and Main Results: Cardiac index, DO2, VO2, and oxygen extraction ratio were determined immediately before and 1 hr after the onset of the dobutamine test. Using receiver operating characteristic curves, responders to the dobutamine infusion were identified by a > 15% increase in VO2 from the time immediately before to 1 hr after the onset of the dobutamine test. We identified 23 responders and 27 nonresponders. Groups differed significantly in age (responders 46 yrs vs. nonresponders 55 yrs) and associated chronic disease (responders one cancer vs. nonresponders six cancers). Significant changes in responders were: a) cardiac index increased 42.9%; b) systemic vascular resistance decreased 20.7%; and c) DO2 increased 39.1% while VO2 increased 40.8%, with no changes in oxygen extraction or blood lactate concentration. Significant changes in nonresponders were: a) cardiac index increased 14.2%; b) DO2 increased 13.2% and c) oxygen extraction decreased from 0.26 to 0.22. Lactate concentration increased significantly by 25.1% in nonresponders. The mortality rate in responders (8.7%) was significantly less than that rate in nonresponders (44.4%)., Conclusions: Most of these septic patients without shock or hyperlactatemia responded to dobutamine infusion in one of two ways: with little increase in DO2 and no increase in VO2, or with significant increases in both DO2 and VO2. The latter response is typical of healthy volunteers given dobutamine. Because of the calorigenic effect of dobutamine, our results imply nothing about the presence or absence of oxygen supply limitation. Still, patients who had increases in DO2 and VO2 had a much higher survival rate than patients who did not. We speculate that the inability of some patients to respond to dobutamine and the associated higher mortality rate may be related to beta-adrenoreceptor dysfunction.

From previous studies it has been hypothesized that multiple organ failure and high level of mortality, seen in critically ill septic patients, may be due to defective oxygen extraction and tissue hypoxia occurring early in the course of sepsis. Oxygen flux test has been proposed as a method of revealing an occult oxygen debt. We used a one hour dobutamine infusion test, in septic patients, without increase in blood lactate. Fifty patients with sepsis syndrome entered a multicentric prospective study. After fluid loading to increase pulmonary artery occlusion pressure (Paop) to a minimum value of 10 mmHg, all the patients were given 10 mcg/kg.min of dobutamine for one hour. Hemodynamic and metabolic variables were recorded before, HO, and after the test, H1 (cardiac index, Paop, oxygen deliver, DO2, and consumption, VO2, oxygen extraction ratio, (OER), blood lactate). The dobutamine test allowed to identify responders (R) who increased VO2 by more than 15% and non-responders. R and NR differed significantly in mortality (8.5% vs 44.4%). The test has a good predictive value for surviving. Without respect of the result of the test, the patients were randomized in two groups. The group D+ was given conventional therapy and dobutamine at the same rate of infusion for 9 consecutive days and the D- group received only conventional therapy. The RD+ patients improved more rapidly when compared with RD-, NRD+, NRD-. We concluded that a one hour dobutamine test is able to identify R and NR critically ill septic patients. The response is associated with significant difference in outcome.(ABSTRACT TRUNCATED AT 250 WORDS)