Objective: To identify the early predictors of severe envenomation in the southern region of Tunisia. Methods: It was a retrospective monocentric study including consecutive patients admitted to the emergency department for snakebite envenomation. Snakebite envenomation was defined by a history of snakebite. Predictors of severe envenomation were determined by univariate and multivariate analyses. Results: Our sample consisted of 109 patients aged 30 (20-44) years with a 1.1:1 sex-ratio (56 males and 53 females). During the 24-hour surveillance period, 25 patients developed severe envenomation (22.9%). The in-hospital mortality rate was 4.6% (n=5). The independent predictors of severe snakebite envenomation were leucocyte count over 11 550/mm³ (OR: 18.7, 95% CI: 3.3-107.8), creatine kinase over 155 IU/L (OR: 6.16, 95% CI: 1.1-35.6), and/or tourniquet before arrival to the ED (OR: 32.14, 95% CI: 3.5-295.9). Conclusions: This study emphasizes the importance of early evaluation of snakebite envenomation. Further studies are required to approve a severity scale proper to snakebite envenomation in Tunisia.

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Rationale: Coexistence of anti-glomerular basement membrane (anti-GBM) disease with anti-neutrophil cytoplasmic antibody (ANCA) in a case of glomerulonephritis is often identified as a “double-positive” disease. Interestingly, the majority of “double positive” ANCA is myeloperoxidase (MPO)-ANCA and some of the MPO-ANCA positive cases showed intrarenal arteritis, suggesting an ANCA-associated kidney lesion. Proteinase 3-ANCA positive diseases are also rarely reported. Patients positive for all three antibodies, i.e., triple-positive patients, are extremely rare. Patient’s Concern: A 53 year-old female presented with anasarca and oliguria of 2 months’ duration. Diagnosis: Pauci-immune type renal limited crescentic glomerulonephritis positive for MPO-ANCA, proteinase 3-ANCA, and anti-GBM antibody (triple-positive). Interventions: Intravenous high dose cyclophosphamide, oral azathioprine, intravenous methylprednisolone, and plasma exchange as per British Health Professionals in Rheumatology Guidelines. Outcomes: After one-month follow-up, anasarca and proteinuria were lessened, serum creatinine was normalized, titers of MPO-ANCA levels were decreased, and anti-GBM antibody levels were normalized. Lessons: Triple-positive renal limited vasculitis is rare and response to combined immunosuppressive therapy and plasma exchange can contribute to successful remission.

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Rationale: Tuberculous meningitis (TBM) is severe extrapulmonary tuberculosis that can cause poor outcomes without timely treatment. We report a case of presumed TBM that presented solely ocular complaints without other neurological features. Patient’s concerns: A 71-year-old man presented with a sudden central visual defect in both eyes for 10 days. Fundoscopy showed bilateral hyperaemic swelling disc with infiltrates. Diagnosis: A diagnosis of presumptive TBM was made with Mantoux test reading 15 mm, elevated erythrocyte sedimentation rate, subdural effusion on CT scan, and high opening pressure. Intervention: Anti-tuberculous treatment. Outcomes: Bilateral vision improved and optic discs swelling resolved. Lessons: Early recognition of TBM with optic nerve infiltration is crucial for prompt treatment that may lead to a good prognosis. Neuroimaging will facilitate the diagnosis when other investigations show a borderline result.

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Objective: To investigate the effect of manual reduction with traditional small splints fixation for distal radius fractures in older patients in the emergency department. Methods: Older patients (aged at least 60 years) with distal radius fractures were enrolled in this study. The patients were randomly divided into the treatment group and the control group. The treatment group was treated with manual reduction and small splints fixation. The control group was treated with manual reduction and resin plaster fixation. Before treatment, after reduction, and 3 months after treatment, the palmar tilt angle, ulnar deviation angle, and radial length were recorded. Before treatment and 3 months after treatment, the Cooney wrist joint scores were recorded. The time of fracture healing and related adverse events during the treatment were recorded. Results: Before treatment and after reduction, there were no statistically significant differences between the two groups in palmar tilt angle, ulnar deviation angle, or radial length (P>0.05). Three months after treatment, the palmar tilt angle, ulnar deviation angle, and radial length of the treatment group were better than those of the control group (P<0.05). The Cooney wrist scores of the treatment group was significantly higher than that of the control group three months after the treatment (P<0.05). The time of fracture healing of the treatment group was shorter than that of the control group, but the difference was no statistically significant (P>0.05). Conclusions: Compared with resin plaster fixation, traditional small splints fixation for distal radius fractures in older patients have the advantages of less loss of fracture reduction and faster functional recovery. Besides, the method is simple and low cost thus, it needs to be promoted.

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Objective: To determine the efficacy of tranexamic acid (TXA) in the management of acute upper gastrointestinal (GI) bleeding. Methods: A total of 70 patients with acute upper GI bleeding were included in this double-blinded randomized controlled clinical trial from September 2018 to December 2018. Patients were divided into the control group (received fluid therapy and intravenous infusion of pantoprazole, 35 cases) and the TXA group (received intravenous TXA besides the treatment of control group, 35 cases). Rebleeding, admission duration, and need for blood transfusion were compared between the two groups. Results: Fifteen patients (42.9%) in the TXA group and 10 patients (28.6%) in the control group stayed in hospital for more than 3 days during their admission (P=0.21). Rebleeding occurred in 8 patients (22.9%) and 5 patients (14.3%) of the TXA group and the control group, respectively (P=0.35). More patients in the TXA group (21 cases, 60%) received blood transfusion than the control group (8 cases, 22.9%) (P=0.02). Conclusions: TXA did not improve the outcome of patients with acute upper GI bleeding.

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Objective: To describe the clinical, laboratory and radiological characteristics and outcomes of moderate-to-severe coronvirus disease 2019 (COVID-19) patients. Methods: We retrospectively analyzed 43 RT-PCR confirmed moderate-to-severe COVID-19 patients who were admitted to a tertiary care center. The primary composite outcomes were admission to intensive care unit, requirement of mechanical ventilation, and death. Results: The median age of the patients was 50 years, and 62.8% of the patients were male. Out of 43 patients, 15 (34.88%) were categorized as severe. A total of 26 (60.47%) patients had 1 or more comorbidities [diabetes (34.88%) and hypertension (30.23%)]. The median duration from the onset of symptoms to admission was 3 days, and the most common symptoms were dyspnoea (90.7%), cough (79.07%), fever (69.77%), and body ache (46.51%). Leucopenia was presented in 14 (32.56%) patients, lymphopenia in 26 (60.47%) patients, and monocytosis in 7 (16.28%) patients. Besides, 40 (93.02%) patients had bilateral patchy nodular or interstitial infiltration on chest X-ray. The primary outcomes occurred in 20 patients (46.5%), among whom 8 required mechanical ventilation. The patients who had met the primary outcomes were older. They were prone to have at least 1 comorbidity (P=0.004), diabetes (P=0.01), hypertension, higher sequential organ failure assessment score, more tachycardia, lower SpO₂, lower PaO₂/FiO₂, more thrombocytopenia, and more pancytopenia. Conclusions: This retrospective study identified several risk factors for poor outcomes in adults with COVID-19. In particular, older age, tachycardia, high SOFA score, low SpO₂, low PaO₂/FiO₂, presence of comorbidities in form of diabetes and hypertension, thrombocytopenia, and pancytopenia at admission were associated with higher odds of ICU admission, a requirement of mechanical ventilation and in-hospital death.

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Severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and SARS-CoV-2 are three kinds of coronaviruses that are exceptionally pathogenic to humans via zoonotic infections. The outbreaks of SARS-CoV and MERS-CoV, and SARS-CoV-2, to some extent, posed a severe threat to human health, daily activities as well as the economic status of many countries. When faced with these emerging viruses and no accessible vaccines and drugs, convalescent plasma (CP) is required as passive immunotherapy, since CP has the potential to neutralize and eliminate the virus from blood circulation. The sources of CP are individuals who have recovered from the viruses. Currently, CP is administered as emergency use and investigational treatment. Some studies have shown that CP is effective to treat infected individuals with viral pandemics such as influenza A, Ebola virus, SARS-CoV, and MERS-CoV. Moreover, following the deadly outbreak of SARS-CoV-2 in 2019, plenty of non-randomized clinical studies have been done on the effectiveness of CP for the treatment of Coronavirus Disease 2019 (COVID-19), and most of these studies have indicated that CP therapy is promising and saved many critically-ill patients. Therefore, CP is a helpful immune therapeutic agent for the immediate response of such pandemics because of its clinical efficacy, immediate availability, cost-effectiveness, ease of production, delivery, and storage. This review aims to summarize the effectiveness of CP in the treatment of these three coronaviruses, i.e. SARS-CoV, MERS-CoV, and SARS-CoV-2.

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