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Resume Objectifs . – Fournir a la communaute medicale, ainsi qu’a l’ensemble des personnes impliquees dans le management du sport, un guide de reference sur les aspects medicaux et sur la prevention du coup de chaleur d’exercice. Actualites . – Parmi les accidents hyperthermiques survenant a l’occasion d’activites physiques ou sportives, il faut distinguer : • le coup de chaleur d’exercice qui touche un sujet jeune, en bonne sante, au cours d’un exercice physique tres intense de duree intermediaire ; • l’epuisement hyperthermique qui survient plus souvent chez un sujet deshydrate pendant un exercice d’intensite moderee a elevee, de longue duree ; • et enfin le coup de chaleur mixte observe par temps tres lourd au cours d’activites de la vie courante. L’importante variabilite clinique du coup de chaleur d’exercice reflete aussi la diversite des mecanismes physiopathologiques qui contribuent a son developpement. Ceux-ci, discutes dans le second article de ce dossier, aident a systematiser les nombreux facteurs favorisants de cette affection en facteurs extrinseques (conditions climatiques), intrinseques (propres a l’individu et permanents) et circonstanciels. Perspectives et projets . – Cette demarche qui permet aux differents acteurs intervenant dans ce domaine de mieux se comprendre doit aussi les aider a mieux apprehender les facteurs susceptibles de favoriser la survenue du coup de chaleur d’exercice donc de mieux prevenir cet accident. Conclusion . – Le demantelement en cours de l’ensemble « fourre-tout » des accidents hyperthermiques survenant a l’occasion d’activites physiques ou sportives permet d’isoler le cas specifique du coup de chaleur d’exercice, decrit dans ses aspects medicaux et operationnels dans cet article.

Resume Objectif. – Discuter les elements pathogeniques recents susceptibles d’associer leurs effets pour induire le coup de chaleur d’exercice et proposer un processus global faisant intervenir le tissu musculaire, la sphere hepatosplanchnique et le systeme nerveux central. Actualites. – Depuis longtemps, on pense que le facteur hyperthermie est le principal element pathogenique du coup de chaleur d’exercice, une hypothese renforcee par la demonstration recente qu’un certain nombre de sujets victimes d’un CCE sont porteurs d’anomalies musculaires infracliniques du type de celle rencontree dans l’hyperthermie maligne peranesthesique. Pourtant l’analyse des cas rapportes et des facteurs favorisants demontrent : • que l’effet de l’hyperthermie ne resulte pas lineairement de son niveau ; • et que l’activation du systeme immuno-inflammatoire est un autre facteur d’importance majeure, aussi bien localement au niveau du systeme nerveux central, du systeme hepato-enterocolique et peut-etre des fibres musculaires striees qu’au niveau de l’organisme entier. Conclusion et perspectives. – La description d’un phenomene general pouvant intervenir a differents niveaux, ou son action peut etre modulee en plus ou en moins, permet d’envisager un cheminement pathogenique specifique pour un individu donne et donc des pistes therapeutiques precoces de nature etiologique.

Oesophagus perforation, despite an often-loud symptomatology, is lately diagnosed. A similar course is illustrated by the observation of a patient who presented a Candida albicans-induced empyema. The oesophagus rupture was diagnosed by thoracoscopy made because of extensive hydropneumothorax on the thoracic CT 3 days after ablation of the thoracic drain. Temporary oesophagus exclusion and pleural drainage in close proximity of the perforation were performed. A nosocomial pneumonia complicated the development but the patient could endly issue from ICU. This mode of revelation was unusual and the authors recommend thinking of the diagnosis of oesophagus rupture when a patient is admitted for a candidosis empyema.

Heatstroke is a potentially fatal disorder caused by an extreme increase in body temperature. It can result in widespread damage to the cardiovascular system, liver, kidney and blood clotting function. Classical heatstroke can occur during heat waves or as a result of intense environmental heat in persons in whom the thermoregulatory functions fail to adapt to a sudden increase in temperature, as during a heat wave, or to a high regional temperature. Exertional heatstroke can occur as a result of strenuous exercise, especially in hot, humid conditions, and may affect young, healthy individuals such as athletes during severe physical exertion and military recruits during training. A significant number of the histopathological and clinical characteristics described in persons with heatstroke indicate that these changes are a consequence of hyperthermia per se. A new hypothesis is that splanchnic vasoconstriction following heat stress leads to an increase in epithelial permeability and endotoxic translocation. The inflammatory factors involved could be similar to those observed in sepsis. Classical heatstroke is characterized by the following triad: rectal temperature 0≥40.6°C (> 105° F); neurological dysfunction with coma; and anhydrosis. Exertional heatstroke is characterized by a sudden collapse and loss of consciousness during exercise. The internal body temperature often exceeds 40.6 °C at the time of collapse, but hyperthermia is not indispensable to the diagnosis. Following heatstroke, rhabdomyolysis, renal damage, hepatic disorders and blood clotting dysfunction rapidly occur. An early diagnosis, the prompt institution of body cooling, and the rapid transportation of patients to an intensive care unit are essential for a favorable outcome. The mortality rate in these patients can be as low as 5% or less in centers where appropriate facilities for whole body cooling and emergency treatment are available.

Total intravenous anesthesia (TIVA) is a useful technique in precarious situations in which anesthesia ventilators and medical gas can be difficult to obtain. The aim of the study is to compare TIVA technique using a simplified infusion scheme for propofol and alfentanil mixed together (45 ml of propofol 1% and 2,500 micrograms of alfentanil in a 50-ml syringe) with an inhalational anesthetic technique (isoflurane/N2O, sufentanil). Thirty-two American Society of Anesthesiologists physical status I patients undergoing orthopedic surgery were studied. Intubation conditions and hemodynamic responses to intubation were comparable in the two groups. Only patients receiving TIVA had responses to surgery. In the TIVA group, time to extubation was shorter (16 +/- 5 vs. 25 +/- 7 minutes) and postoperative requirement for morphine was lower (6.2% vs. 25%) than in the inhalation group (p < 0.05). TIVA using a mixture of propofol and alfentanil is a reliable technique of anesthesia in patients without multiple injuries.

A 22-year-old man treated with ceftazidime-amikacine for a Pseudomonas aeruginosa pneumonia, experienced two days later allergic symptoms, acute renal failure and urinary sediment abnormalities. The renal biopsy showed an acute interstitial nephritis. Basophils stimulation test was positive for ceftazidime. Early diagnosis and discontinuation of the suspected agent is essential to allow rapid and complete recovery of renal function.

Two cases of severe complications due to injection of hydrogen peroxide under pressure into areas of muscular attrition in war wounds are reported. In both cases the administration of hydrogen peroxide was associated with tachypnoea, with major arterial desaturation and a precordial "mill-wheel" murmur was heard. In one case, these symptoms were followed by hemiplegia caused by paradoxical arterial gas embolism, and in the other case by a pulmonary oedema confirmed by computerized tomography. Both patients recovered under hyperbaric oxygen therapy. The release of gaseous oxygen under the effect of tissue catalase and the membrane peroxydasic activity of hydrogen peroxide initiate such complications. The injection of hydrogen peroxide under pressure into a closed or partially closed cavity should therefore be strictly prohibited.

Severe malaria is characterized by the presence of asexual forms of Plasmodium falciparum in the blood and the presence of one or more OMS 2000 criterion. Imported malaria is defined as malarial infection acquired in an endemic country (often in sub-Saharan Africa) and treated in France. The largest patient group includes African patients, long-term residents in France, coming back from a vacation in their native country. In non-immunized adults, severe malaria causes multiple organe failure such as severe Gram-negative sepsis, with variable degrees of altered mental status. Severe sepsis is treated in an intensive care unit (mechanically assisted ventilation, kidney dialysis, vasoconstrictors...). Intravenous quinine is the reference treatment, but artemisinin derivatives (arthemeter and artesunate) are the most rapidly acting antimalarial drugs.

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Malaria requiring intensive care is characterized by failure of one or more organ systems and/or development of several metabolic disorders secondary to the presence of Plasmodium faliciparum in the blood. Severe imported malaria in non-immunized adults causes multiple organ failure with variable degrees of altered mental status. Acute pulmonary edema is frequent, jaundice associated with mild disturbance of liver function is consistent, arterial hypertension due to hypovolemia is usual, and acute renal insufficiency is uncommon. Coagulation disorders are generally low-grade, acidosis is an unfavorable prognostic factor, severe hypoglycemia can occur after the beginning of quinine treatment, and anemia is an consistent but discrete symptom. In endemic areas emphasis should be placed on the complications of severe malaria in pregnant women due to the high incidence of hypoglycemia and pulmonary edema. Severe malaria can develop early in children in endemic zones. Presenting signs include cerebral malaria in older children and severe anemia in young children. Quinine is the reference treatment with a bolus of 17 mg/kg followed by a daily maintenance dose of 24 mg/kg. Use of artemether should be restricted to quinine-resistant forms. Total blood exchange transfusion is not recommended. Supportive symptomatic treatment, e.g. mechanically assisted ventilation and kidney dialysis, is required. In endemic zones over 90% of deaths involve children without access to intensive care facilities. Mortality rates associated with management of severe imported malaria in intensive care range from 10 to 30%.

Oesophagus perforation, despite an often-loud symptomatology, is lately diagnosed. A similar course is illustrated by the observation of a patient who presented a Candida albicans-induced empyema. The oesophagus rupture was diagnosed by thoracoscopy made because of extensive hydropneumothorax on the thoracic CT 3 days after ablation of the thoracic drain. Temporary oesophagus exclusion and pleural drainage in close proximity of the perforation were performed. A nosocomial pneumonia complicated the development but the patient could endly issue from ICU. This mode of revelation was unusual and the authors recommend thinking of the diagnosis of oesophagus rupture when a patient is admitted for a candidosis empyema.

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Total intravenous anesthesia (TIVA) is a useful technique in precarious situations in which anesthesia ventilators and medical gas can be difficult to obtain. The aim of the study is to compare TIVA technique using a simplified infusion scheme for propofol and alfentanil mixed together (45 ml of propofol 1% and 2,500 micrograms of alfentanil in a 50-ml syringe) with an inhalational anesthetic technique (isoflurane/N2O, sufentanil). Thirty-two American Society of Anesthesiologists physical status I patients undergoing orthopedic surgery were studied. Intubation conditions and hemodynamic responses to intubation were comparable in the two groups. Only patients receiving TIVA had responses to surgery. In the TIVA group, time to extubation was shorter (16 +/- 5 vs. 25 +/- 7 minutes) and postoperative requirement for morphine was lower (6.2% vs. 25%) than in the inhalation group (p0.05). TIVA using a mixture of propofol and alfentanil is a reliable technique of anesthesia in patients without multiple injuries.

Tropical pyomyositis (TP) is a microbial infection involving one or more skeletal muscles that rapidly leads to abscess. The most common infectious agent is Staphylococcus aureus. Since muscle tissue is highly resistant to infection, occurrence of TP is contingent upon one or more compromising factors such as trauma, skin lesions, parasitosis, or malnutrition. HIV infection is currently a major factor in the occurrence of TP. While Staphylococcus aureus accounts for 80% of cases, other microbial agents have been identified including gram-positive cocci and gram-negative bacilli. TP is endemic in intertropical zones of Africa and Latin America and in island areas of the Pacific Ocean. However a growing number of non-tropical cases have been reported in association with AIDS. The most frequent presentation is single-muscle involvement in the thighs, calves, and buttocks. The symptomatic phase or suppurative phase is almost always associated with hyperthermia. The infected muscle indurates prior to development of characteristic fluctuance. Hemocultures are seldom positive but needle aspiration may confirm diagnosis. Ultrasound imaging can allow early detection. Severe sepsis or cardiovascular, renal, or pleuropulmonary complications are observed in 10% of cases. Treatment is antibiotic therapy with penicillin M and surgical drainage or needle puncture of abscess cavities. Prognosis is generally favorable even in HIV-infected patients.

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Describe the course of fulminant liver failure after exertional heat stroke.A 30-year-old man acclimated to the tropical climate, collapsed and became comatose with hyperthermia during a commando march in Gabon. Thirty-six hours later, the biological examination revealed moderate rhabdomyolysis and fulminant liver failure. An orthotoptic liver transplantation was performed at the 48th hour. Acute renal failure with severe rhabdomyolysis developed on the 4th day post-surgery while the patient was perfectly alert. His condition thereafter deteriorated and he died of chronic rejection 11 months after liver transplantation.In its most serious forms exertional heat stroke is a multiple organ dysfunction syndrome of poorly understood pathogenesis. The reported case suggests that exertional heat stroke can cause fulminant liver failure, resulting either from the direct effect of heat on the hepatic parenchyma, or from acute hepatic ischemia due to blood redistribution made worse by the hypersecretion of antidiuretic hormone, a potent portal vasoconstrictor, which occurs in the heat acclimated subject.

A 22-year-old man treated with ceftazidime-amikacine for a Pseudomonas aeruginosa pneumonia, experienced two days later allergic symptoms, acute renal failure and urinary sediment abnormalities. The renal biopsy showed an acute interstitial nephritis. Basophils stimulation test was positive for ceftazidime. Early diagnosis and discontinuation of the suspected agent is essential to allow rapid and complete recovery of renal function.

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The present study was conducted in West Africa in a region where malaria exists as a seasonal endemic disease. The aim was to compare clinical and biological aspects of adult severe falciparum malaria with those found in children and to appreciate the role of cytokines a prognostic markers. Thirty-one patients fulfilling the WHO criteria of severe malaria were included.Fifteen children (8 boys and 7 girls; mean age: 7.9 +/- 3.7 years) were compared with an adult group of 16 patients (9 men and 7 women; mean age: 31.1 +/- 14.5 years). The number of severe criteria and most of the biological features (glycaemia, parasitaemia, haemoglobin levels, platelet count) were similar in both groups. As regards immunological findings, serum levels of IgM and IgG were significantly increased in the adult group. Serum levels of TNF alpha, IL-6 and IL-2SR were similar (255.2 +/- 375.3 versus 298.4 +/- 254.1 pg/ml for TNF alpha, 534.6 +/- 642.7 versus 609.5 +/- 1217.0 pg/ml for IL-6, 253.1 +/- 120.5 versus 297.6 +/- 142.2 pg/ml for IL-2SR). Each of these cytokines correlated with the others and were also correlated to parasitaemia. Three children and two adults died during the course of the study. At admission a significant died during the course of the study. At admission a significant difference was observed between serum levels of TNF alpha (p0.01), IL-6 (p0.001) and IL-2SR (p0.05) in patients who were later survivors or non-survivors.This study confirms the prognostic significance of serum levels of TNF alpha, IL-6 and IL-2SR in severe malaria.

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Two cases of severe complications due to injection of hydrogen peroxide under pressure into areas of muscular attrition in war wounds are reported. In both cases the administration of hydrogen peroxide was associated with tachypnoea, with major arterial desaturation and a precordial "mill-wheel" murmur was heard. In one case, these symptoms were followed by hemiplegia caused by paradoxical arterial gas embolism, and in the other case by a pulmonary oedema confirmed by computerized tomography. Both patients recovered under hyperbaric oxygen therapy. The release of gaseous oxygen under the effect of tissue catalase and the membrane peroxydasic activity of hydrogen peroxide initiate such complications. The injection of hydrogen peroxide under pressure into a closed or partially closed cavity should therefore be strictly prohibited.

International audience

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