A Bronchopulmonary Onset of Candidemia Revealing a Granulomatosis with Polyangiitis

Candidemia is defined as being a yeast infection confirmed by the presence of at least one positive Candida blood culture. It is a life threatening infection causing high mortality. The clinical signs are generally compatible with the causative agent (whether there is a deep venous catheter or not). On the other hand and according to the 2012 Revised Chapel Hill Classification, granulomatosis with polyangiitis GPA is classified as a vasculitis associated with antineutrophil cytoplasmic antibodies ANCA. It is a systemic disease characterized by the anatomopathological aspect of granuloma. We report the case of a patient who presented an atypical and a very rare revealing mode of GPA which was a bronchopulmonary candidiasis complicated by candidemia. Despite its controversy, the combination in the acute phase of antifungal treatment based on intravenous voriconazole and glucocorticoid therapy has made it possible to control candidemia and calm vasculitis.

Fractional flow reserve and non-hyperemic indices:Essential tools for percutaneous coronary interventions

Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact.Fractional flow reserve(FFR)received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis.FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy,deferring unnecessary procedures for lesions with a FFR>0.8,improving patients'management and clinical outcome.Post intervention,an optimal FFR>0.9 post stenting should be reached and>0.8 post drug eluting balloons.Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89.They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated.FFR remains the gold standard reference for invasive assessment of ischemia.We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio.We conclude introducing a hybrid approach to intermediate lesions(DFR 0.85-0.95)potentially maximizing clinical decision from all measurements.

Administration of Nebulised Ketamine for Managing Pain in the Intensive Care Unit of Obstetrics and Gynaecology

Introduction: The use of inhaled ketamine to manage a variety of painful conditions has been endorsed by the American College of Emergency Physicians and the American Academy of Emergency Medicine. Nebulized analgesia has multiple benefits, including rapid, effective and titratable analgesic delivery. The aim of our study is to assess the efficacy and safety of intranasal analgesic-dose ketamine compared to multimodal analgesia in patients presenting with acute postoperative pain or headache after a spinal anaesthetic in the intensive care unit of obstetrics and gynaecology. Materials and Methods: This was a prospective descriptive study, with hospital Ethics Committee approval and written informed consent from study participants. We compared the effect of nebulized ketamine and multimodal analgesia postoperatively in 120 patients belonging to the physical status I - II of the American Society of Anesthesiologists, in the intensive care unit of obstetrics and gynaecology, at the Ibn Rochd University Hospital Center in Casablanca from June 2021 to June 2022. Results: We included 120 patients in our study divided into two groups of 60 patients: the average age was 35 years, with extremes ranging from 18 to 45 years, All patients were hospitalized for postoperative care: all women underwent locoregional anaesthesia with a standard dose according to the service protocol (10 mg of bupivacaine, 25γ of fentanyl, 100γ of morphine), where pain was the common denominator. Among these patients, 59 were admitted for management of postpartum haemorrhage, 43 for postoperative monitoring, 15 for post-spinal anaesthesia headache and 3 for pelviperitonitis. The results of the pain assessment 30 minutes after the ketamine nebulization were marked by a request for analgesia in 12 patients, which is 20% of group A, including 5 patients, whose visual analogue scale (VAS) on admission was between 5 and 7, and 7 patients whose VAS at admission was ≥8;all these patients received a second dose of ketamine by nebulization;the evaluation 30 min after the second dose was marked by a request for analgesia in 4 patients, which is 7% of Group A;in all these patients the VAS at admission was ≥8. Of the total number of patients of Group A, only 4 received morphine when they were requested for analgesia after the second dose of nebulized ketamine. Conclusion: The primary outcome of nebulized ketamine use is a significant reduction in VAS pain score. We believe that nebulized ketamine has a potential effect of reducing pain in the intensive care unit of obstetrics and gynaecology;this may be an additional analgesic modality for clinicians to provide rapid, effective and non-invasive pain relief.

Right Post-Traumatic Diaphragmatic Hernia with Liver Dislocation

Diaphragmatic hernia is a rare consequence of thoraco-abdominal trauma. It may be associated with high morbidity and mortality, particularly if surgical intervention is delayed. We report a case of a right diaphragmatic hernia in a 75-year-old woman. The patient was referred to our hospital with mild dyspnea. Chest radiograph showed an overtly elevated right hemi-diaphragm. Thoracic and abdominal computed tomographic scan was requested and showed a defect of the right diaphragmatic muscle wall with intrathoracic ascension of the liver. During the postoperative course, the patient was still on mechanical ventilation, hemodynamically unstable. She developped urinary peritonitis and an extensive bowel ischemia worsening. We report this case to show that the prognosis is related to associated injuries and possible complications. The possibility of a diaphragmatic rupture should be kept in mind and surgery is mandatory in order to avoid complications.

Cade Oil Poisoning: A Case Series

Objectives and Study: Cade oil is aromatic oil obtained from the branches and wood of Juniperus oxycedrus, common in the Mediterranean region and widely used in traditional medicine. This oil contains many chemical compounds with neurological, cardiac, renal, respiratory, hepatic, and gastrointestinal toxicity. Cade oil poisoning often requires intensive care admission due to the severity of the clinical picture. The objective of this study is to highlight the multiple manifestations found in the pediatric population due to cade oil exposure objectifying its significant toxicity. Methods: The authors report during this article a series of five cases of cade oil poisoning on pediatric patients hospitalized in the pediatric intensive care unit of El HARROUCHI hospital at the CHU Ibn Rochd in Casablanca during the period from 11/01/2022 to 12/07/2022. The patients have been exposed, a few hours before their admission, to an external cade oil application used by parents for therapeutic purposes. Main Findings: Our patients were aged from 1 month to 4 years, the average age was 1.5 years with a female predominance and a sex ratio of 1.5:1. The patients had no prior medical history, and the cade oil application was spontaneously declared by the parents of only 2 patients, 3 of them reported the use of it after the detection of the substance by the clinician. For all the cases, cade oil was applied to treat fever. All five (5) patients presented initial neurological signs. 3 of them were admitted to an acute consciousness disorder and the 2 other patients presented respectively a convulsive status epilepticus and generalized-onset seizure. We report respiratory symptoms in 4 cases ranging from a simple caught, rhinorrhea to severe respiratory distress. Three patients presented acute liver failure with very high transaminase levels associated with acute kidney failure. Two of them presented digestive symptoms such as abundant hematemesis, vomiting, and watery diarrhea. All patients received high doses of N acetylcysteine in their initial treatments. The evolution was unfavorable for 4 patients who developed a multiorgan failure, 3 of them died, with a good clinical improvement in the fifth patient after supportive and symptomatic treatment. Conclusion: Cade oil poisoning remains a very frequent situation in our context. Its toxicity is widely described in the literature. The increasing number of cases admitted, and the seriousness of the clinical picture require mass awareness among the population and the scientific community toward the use of medicinal plants.

Chronic permanent hypoxemia predisposes to mild elevation of liver stiffness

AIM:To evaluate the impact of long term permanent hypoxemia noticed in patients with non operated congenital cyanogenic cyanotic cardiopathy on liver stiffness.METHODS:We included ten adult patients with non operated inoperate cyanotic cardiopathy and ten matched patients for age and gender admitted to the gastroenterology department for proctologic diseases;Clinical and laboratory data were collected[age,gender,body mass index,oxygen saturation,glutamate oxaloacetate transaminase(GOT),glutamate pyruvate transaminase(GPT),glycemia and cholesterol].Measurement of hepatic stiffness by transient elastography was carried out in all patients using the Fibroscan device.All patients underwent an echocardiography to eliminate congestive heart failure.RESULTS:Among the patients with cyanotic cardiopathy,median liver stiffness 5.9±1.3 kPa was greater than control group(4.7±0.4 kPa)(P=0.008).Median levels of GOT,GPT,gamma-glutamyltransferase,glycemia and cholesterol were comparable in cardiopathy and control group.In regression analysis including age,gender,body mass index,oxygen saturation,GOT,GPT,glycemia,cholesterol showed that only oxygen saturation was related to liver stiffness(r=-0.63 P=0.002).CONCLUSION:Chronic permanent hypoxemia can induce mild increase of liver stiffness,but further studies are needed to explore the histological aspects of liver injury induced by chronic permanent hypoxemia.

Association between Overexpression of Her-2 and Other Clinicopathologic Prognostic Factors in Breast Cancer in Morocco

Background: Breast cancer is the leading cancer among women. The management depends largely on the knowledge of prognostic factors. The aim of our study is to evaluate the overexpression of Her-2/neu in patients with invasive breast carcinoma in Morocco, and to study the association between this overexpression and otherprognostic factors of breast cancer, such as age, tumor size, tumor grade, hormone receptors, vascular space invasion and lymph node status. Methods: This is a transversal study in which we included patients with invasive breast carcinomas treated at University Hospital Ibn Rochd of Casablanca in radiotherapy-oncology departement between January 2008 and December 2010, having had surgery first. Univariate analysis (Chi 2 test and Student’s test) and multivariate (logistic regression) were performed to study this association. Results: The overexpression of Her-2/neu was found in 29.2% of cases. In univariate analysis, Her-2 positive status was significantly correlated with high-grade tumors and large, to a lymph node, vascular space invasion and negative ER/PR. Age alone does not appear as a factor associated with positive Her-2/neu status. In multivariate analysis, the overexpression of Her 2 was significantly associated only with vascular space invasion, high tumor grade and the negativity of estrogen receptors. Conclusion: In our series, only the high grade, the vascular space invasion and the negative hormone receptors are independent factors associated with overexpression of Her 2/neu. Age does not appear as a factor associated with positive Her-2/neu status.

Antibacterial activity of plant methanolic extracts on a field isolate of <i>Pseudomonas syringae</i>pvtomato from the Casablanca region (Morocco)

A bacterial field isolate recovered from infected tomato plants in a green-house at Sidi Rehal, a region near Casablanca city (Morocco), was identified as the gammaproteobacterium Pseudomonas syringae pv. tomato DC3000 strain, the causal agent of bacterial speck. The bacterial isolate was characterized by morphological, biochemical and molecular biological tests, its growth curves carried out in various culture media, and its phytopathogenicity verified by infection tests. A screening was performed to evaluate the antibacterial activity of methanolic extracts of 12 selected Moroccan plants against the P. syringae pv. tomato DC3000 isolate, and Agar-well diffusion and Broth microdilution methods were used to determine minimum inhibitory and minimum bactericidal concentrations. Among the methanolic extracts tested, only those of Nigella sativa, Geranuim robertianum, Aizoon canariense and Rubia peregrine showed clear inhibitory and bactericidal activities, although the highest values were achieved with N. sativa, a plant used in Morocco as a spice, condiment and medicinal treatment.

Review Venous Thromboembolism Risk with Anti-Osteoporosis Drugs

Osteoporosis is the most common skeletal diseases, predisposing the patient to an increased risk of fractures. It is an important health issue linked to increased morbidity and mortality. Prevention and treatment strategies are now well defined and are always updating. Indeed, the therapeutic decision is based on the individual risk of fracture, efficiency and degree of therapeutic tolerance. However, some side effects, although rare can be attributed to drugs used. The benefit and risks of prescription drugs can be optimized by choosing the right time and the right treatment. The purpose of this article is the study of thromboembolic risk of various drugs recommended in osteoporosis. Furthermore we discuss preventive measures, and the different approaches after the first event.

Intramedullary Metastasis of Medulloblastoma: A Case Report

Medulloblastoma (MB) is a malignant brain tumor with a usual potential for leptomeningeal spread. Intramedullary metastases of MB are rare and there are very few cases reported in the literature. Here, we report the case of an 18-year-old man with intramedullary spinal cord metastasis of MB occurring 9 years after the first diagnosis. The patient presented a 2-month history of progressive weakness in both lower limbs associated with urinary incontinence. Magnetic resonance imaging (MRI) demonstrated a large intramedullary spinal cord tumor extending from T10 to L1. The patient underwent surgical decompression and adjuvant therapy. Histological examination confirmed the diagnosis of classic MB metastasis. Postoperatively, the neurological status was stationary. Intramedullary metastasis of medulloblastoma is rare and difficult to manage with a poor prognosis. Comprehensive studies on the medulloblastoma dissemination mechanisms and clinical trials are needed to assess combined therapeutic approaches on metastases of MB.

Type IV Aggressive and Symptomatic Vertebral Hemangioma

Vertebral hemangiomas (VHs) are benign tumours with rich vasculature. They are the most common tumours of the spine with an estimated incidence of 10% - 12% of the population. Despite its high incidence, they are often asymptomatic and only 0.9% - 1.2% are symptomatic. They may also be aggressive and are characterised by bone expansion, extra osseous extension of the tumour, disturbance of local blood flow and, in rare cases, compression fractures. We report a 59-year-old woman, presented with back pain after falling from standing height. Magnetic resonance imaging revealed lumbar spine vertebral fractures and T12 osteolytic lesion with spinal canal extension, concurring to VH type IV, according to Tomita’s surgical classification of spinal. Embolization, posterior decompression and fixation were performed followed by postoperative radiotherapy. Her symptoms were resolved immediately without recurrence after 6 mouths.

Fahr’s Syndrome Discovered at Adulthood Revealing the Pseudohypoparathyroidism

Fahr’s syndrome is a rare clinicopathological entity, defined by the presence of intracerebral calcifications not arteriosclerotic, bilateral and symmetric at the level of the basal ganglia, whose main etiology is dysparathyroidism, rarely pseudohypoparathyroidism. Hypocalcemia and hyperphosphatemia despite normal or high levels of parathyroid hormone are the result of resistance to the action of parathyroid hormone. The clinical profile is not specific but dominated by neuropsychiatric symptoms. We report the case of a 30-year-old patient with type pseudohypoparathyroidism revealed one year ago by Fahr’s syndrom. The diagnosis made by convulsion history since the age of 5 years resistant to treatment, the disturbance of metabolism disorders, and the presence of intracerebral calcifications. The vitamin D and calcium supplementation have contributed to the stabilization of the disease.

Hypoglycemia Controlled by Prednisone in an Occult Insulinoma or a Nesidioblastosis

Insulinoma is a pancreatic endocrine tumor lower in size than 20 mm in 80% of the cases and his treatment is chirurgical. However, in certain circumstances such as an occult location or circumstances of metastases, medical treatment is called for. Observation: A 29 years old patient with no specific pathological antecedents has presented severe hypoglycemia mainly in the morning. A patient was in a generally good condition. The fasting test revealed an inappropriate secretion of insulin at a venous glycemia of 0.35 g/l;which was corroborated by Turner index and altered glucose insulin index that we calculated. Moreover, the 8 h cortisolemia was normal at 90.13 ng/l, the TSH was normal at 1.44 μui/l, anti-insulin antibodies were negative at 6.7 U/l;the search of hypoglycemic sulfonamides was negative. Morphologically, she had three pancreatic tomodensitometry these were normal. She also had echo-endoscopy which showed a normal pancreas. The surgical exploration with preoperative echo is advised only after surgeon’s assessment when the technical conditions are not put together. The diagnosis of the occult insulinoma or of nesidioblastosis was retained. The medical treatment was retained. Due to the unavailability of diazoxide in our pharmacies and the high cost of analogs of somatostatine, she was provided with prednisone 0.5 mg/kg/24h which was 40 mg/day after common agreement. The evolution was favorable. Conclusion: It should be noticed that medical treatment can be suggested if insulinoma is not localized. This observation proves that the localization of the insulinoma can be unsuccessful. It should also be noticed that our experience is the fourth described in literature, where hypoglycemia in insulinomas is controlled by prednisone.

Mycotic Infections in Diabetic Patients in Casablanca

Introduction: The diabetes constitutes the factor risk of mycotic infections. The pathogenic agents depend on the climate, geography and the migration. The objective of this study is to evaluate the prevalence of the mycotic infections within the hospitalized diabetic patients, to describe their localization and identify the responsible germs. Patients and methods: It is about a descriptive and retrospective study conducted from November 2015 to March 2016 in endocrinology office at CHU Ibn Roch of Casablanca. It was included all diabetic patients hospitalized with whom mycotic infection has been suspected. Results: In total 350 diabetic patients have been hospitalized during the period of research. A mycotic infection has been suspected in 138 patients corresponding to the prevalence of 39.4 percent. The means localizations of mycotic infections were feet (intertrigos: 38.4%), onychomycosis (29%), vulvovaginal (21.7%) and mouth (oral candidiasis: 13.3%). The most frequent pathogenic agents were dermatophytes (Trichophyton rubrum: 61%, Trichophyton mentagrophytes: 6.3%) and Candida albicans (23.1%). The direct test and the culture were negative in 7.3%. Conclusion: One-third of the diabetic patients showed a mycotic infection. The feet, constitute the predilection localization of mycotic infections in the diabetic. The dermatophytes and Candida albicans constitute the most frequent pathogenic agents found in our study.

Erythema Nodosum Manifestation Post COVID-19 Vaccine: A Case Report

Erythema nodosum (EN) is a delayed hypersensitivity response that may be triggered by a range of conditions, including infections and vaccines. Rare cases of EN caused by COVID-19 were recently reported but none due to COVID-19 vaccines were documented. We report here a case of EN occurring after COVID-19 vaccination. Patient presented with painful nodular lesions of all 4 limbs, evolving for one month. These lesions appeared 48 h after the second dose of COVID-19 vaccination. The patient reported no recent infectious episodes. The physical examination found numerous, erythematous dermohypodermatitis knots with no palpable adenopathy. Some were regressive according to biligenesis shades. Biology and radiology findings eliminated other common causes of this dermatosis. The skin biopsy was done and suggested EN. The final diagnosis was post COVID-19 vaccine EN. Patient received a symptomatic treatment and had a slight improvement of the lesions 10 days after diagnosis. Physicians should be aware of the side effects of the vaccine including skin manifestations, especially since more people are bound to be vaccinated.

Monophasic Synovialosarcoma of the Kidney: About a Case and Literature Review

Introduction: Primary renal synovialosarcoma (SVS) is a rare and aggressive disease in which the metastatic potential is very high. Its diagnosis is based on morphological and molecular studies. No therapeutic consensus has yet been established for this histological variant of renal cancer. We describe our experience with a patient followed at the Mohamed IV Center for cancer treatment for primary monophasic synovialosarcoma of the kidney. Case Presentation: In October 2020, a 58-year-old patient with hypertension under treatment, consulted for right back pain without hematuria or calculus emission. The initial examination found a slight right lumbar tenderness. Thoraco-abdominal computed tomography revealed a cystic lesion of the superior pole of the right kidney without secondary lesions. Surgical treatment consisted of an enlarged right total nephrectomy using a bi-subcostal approach. The post-operative consequences were simple. Histologically, it was a poorly differentiated cystic malignant tumor process measuring 17 cm long axis. The limits were healthy as well as the adrenal. Immunohistology made it possible to retain a monophasic synovialosarcoma. However, the patient did not receive genetic analysis. Given the poor prognosis of these tumors, treatment with adjuvant chemotherapy and radiotherapy has been imposed;as indicated in our case. Conclusion: Primary kidney SVS is a rare, aggressive disease with a poor prognosis. However, the prognosis may be improved by multimodal treatment. A positive diagnosis is difficult and can be confused with other types of renal carcinoma hence the interest in molecular biology.

Reconstruction of Scrotal and Perineal Defects in Fournier’s Gangrene

Fournier’s gangrene described in 1883 by Jean Alfred Fournier, still poses ethiopathogenic, evolutive and therapeutic problems. This is a therapeutic emergency;early diagnosis, medical and surgical treatments contribute to reducing mortality rate. Tissue defect engendered by infection and/or by its excision requires morphological and functional reconstruction. The choice of the reconstruction technique depends on several parameters: early or delayed coverage, the size of the defect, the local capital skin and the patient’s general condition. Through this study involving 95 cases of scrotal and perineal gangrene treated at the National Center of Burns and Plastic Surgery of Ibn Rochd University Hospital of Casablanca over a period of 10 years (2004-2014), we report our approach in the surgical management of defect secondary to Fournier’s gangrene.

Epidemiology and Outcome of Primary Cerebral Lymphoma in Immunocompetent Patients: A Monocentric Study

Primary cerebral lymphoma (PCL) is a form of extranodal non-Hodgkin’s lymphoma with a poor prognosis. Very few cohorts have been reported in the literature. It is a rare form in 1% of extranodal lymphomas, and 3% to 4% of brain tumors. The most common histological type is diffuse large B-cell lymphoma. Survival is improved by combining immunotherapy with chemotherapy. This is a descriptive retrospective study conducted at the Casablanca hematology center over a period of 9 years. The aim of this study was to report our experience by studying the clinical, paraclinical, therapeutic and evolutionary profile of patients with primary cerebral lymphoma. We present a study of 22 patients with PCL. The clinical, radiological and histological findings are shown along with the results of treatment. Patients were aged 25 - 75 years (mean 47 years) with a male predominance (77%). Computed tomography (CT) scans were performed on 16 patients (73%) and Brain magnetic resonance imaging for 16 patients (73%). Typically, lesions were multiple, isodense, and showed uniform enhancement with contrast medium. Immunocytochemical studies demonstrated 21 B-cell and 1 mantle-cell lymphomas. All patients received chemotherapy through high-dose MTX with whole brain radiotherapy (WBRT). After a median follow-up of 19 months, 54% are in complete remission, 32% have died, and 14% are lost to follow-up. Overall survival at 24 months and 36 months were 72% and 52%. The event-free survival at 24 months and 36 months were 60% and 48%. This study was to investigate the clinical features of PCNSL, and evaluate the efficacy of high-dose methotrexate (MTX)-based chemotherapy for immunocompetent Moroccan patients with PCNSL.

Micropulse diode laser therapy in refractory glaucoma

Purpose:Description of safety and efficacy of micropulse lYanssderal cydophotocoagulation as a treatment option for refractory glaucoma.Mahods:This is a prospective study including 39 eyes of 31 patients foil owed for refractory glaucoma,who benefited from transsderal cyclophotocoagulation using a mic topi used laser.The main indication for tire pro­cedure was increased ocular pressure refractory to quadri therapy in various types of glaucoma.Ihe patients were tieated using iridex Cyclo G6 laser with a Micropulse P3 infrared probe with a wavelength of 810 nm.The pa­rameter for tire procedure were a duration of 90 s per hemisphere with a power of 2000 mW and an eneigy of 180 J.Both tire upper and lower hemispheres were treated in tire same procedure,sparing tire 3 o'clock and 9 o'clock meridians,and aD tire patients benefited from a single treatment session.The following parameters were evaluated;ocular pain and overall tolerance;visual acuity;and tire evolution of IOP postoperatively up to 9 months.Results:The glaucoma subtypes treated are as follows:primaty open-angle glaucoma(n=05),chronic angle-closure glaucoma(n=13),neovascular glaucoma(n=07),aphakic glaucoma(n=06),malignant glaucoma(n=04),post-traumatic angle recession(n=02),and inflammatoiy glaucoma(n=02).The mean pre-operative intraocular pressure was 42.3±5.2 mmHg and tire mean post operative intraocular pressure at 9 months was 16.9±1.9 mmHg The reduction in IOP was 49.9%.The average number of intraocular pressure-lowering medications used prior to surgery was four,and tire average number of medications used at tire 9-month post­operative visit was 2.0±1.2(703%of patients were on dual therapy).The overall success rate was 60.9%.Conclusions:Micropulse transsderal cydophotocoagulation appears to be a safe and effident treatment for re­fractory glaucoma.Its indications should therefore be broadened and proposed early in various situations.