[Gliomatosis cerebri: evolution to glioblastoma multiforme]

INTRODUCTION

Gliomatosis cerebri is a neoplastic disorder characterized by diffuse infiltration of glial cells with relative conservation of the underlying structures. Seizures, headache and behavior disorders are generally the initial manifestations.

CLINICAL CASE

A 38 year-old male who had complex partial seizures and behavior disorder of three months' evolution. The brain magnetic resonance imaging showed hyperintense lesions in T2 suggestive of gliomatosis cerebri, this being confirmed with the brain biopsy. Several months later, he suffered rapid clinical deterioration, observing the development of a glioblastoma multiforme over the lesion.

CONCLUSIONS

In spite of its rareness, gliomatosis cerebri should be taken into account in the differential diagnoses of diffuse infiltrative lesions of the white matter. Rapid evolution clinical deterioration and the appearance of focal lesions that capture contrast should make us suspect a transformation to lesions of greater malignancy.

[Type 1 glutaric aciduria: clinical and therapeutic implications]

INTRODUCTION

Type 1 glutaric aciduria is a genetic disease that produces a deficiency in the glutaryl CoA dehydrogenase enzyme. This deficiency entails an elevation of glutaric acid and 3-OH glutaric acid. Dystonia is the predominant symptom. The symptoms appear after an asymptomatic period during the first months of life. It may present chronically and insidiously or acutely as metabolic encephalopathy during a banal infectious condition or vaccination. Treatment with Carnitine, protein restriction and early approach of the hypermetabolism conditions has been shown to be effective in decreasing the encephalopathy episodes in the first years of life.

CASE REPORT

A 16 year old woman with macrocrania and picture of insidious onset of left hemidystonia from 6 months of age. Early treatment was begun as she had a sister suffering from type 1 glutaric aciduria. She has a clinical picture with less seriousness than her sister even though both have the same genotype.

CONCLUSIONS

This disease must be considered when there is dystonic cerebral palsy and paternal consanguinity. Early onset of treatment could entail a decrease in the symptoms even in cases of insidious initiation. This would suggest therapeutic maintenance even after having passed the age in which acute encephalopathies occur.

[Afibrinogenemia: description of a case with recurrent intracranial bleeding]

INTRODUCTION

Congenital afibrinogenemia is a very rare autosomal recessive disorder of the coagulation. The lack of fibrinogen makes the blood inclotting and patients suffer from bleeding at a minimal trauma. It is usually noticed within the first few days of life because of the umbilical cord bleeding. Intracerebral hematoma is infrequent.

CASE DESCRIPTION

46-year-old woman who suffers from congenital afibrinogenemia and has five episodes of intracerebral bleeding, all of them in the posterior circulation. As a complication, she also presents an epilepticus status and the therapy with concentrated fibrinogen caused pulmonary thromboembolism.

CONCLUSIONS

After analysing the cases described in literature, there are evidences that the majority of the intracerebral hematoma are located in the posterior circulation. A few patients developed major thomboemolisms following infusion with concentrated fibrinogen and there are only isolated descriptions of beneficial prophylactic effects. So, it is would necessary studies more extensive research to achieve effectiveness in the prevention of the bleeding.

[Bruns' syndrome: description of a case of neurocysticercosis with pathological study]

Bruns' syndrome is characterized by sudden and strong headache, accompanied by vomiting, acuphenos and vertigo, triggered by abrupt movement of the head and can produce deep coma and death. This can be due to neurocysticercosis by cyst in the fourth ventricle, which contains the larval stage of Taenia solium. In the last years, new cases of this parasitosis are being seen in Spain because of the immigration from endemic areas, but the clinical forms of this infestation are not varied. We present a 44 year old man Ecuadorian who has clinical symptoms consistent with Bruns' syndrome secondary to cyst in the fourth ventricle that progressed badly despite undergoing surgery with ventriculoperitoneal shunt and treatment with albendazol. Finally, he was operated with the excision of the lesion by means of suboccipital craniectomy. We conclude that this syndrome must rule out a cystic or non-cystic, intraventricular lesion and that the appropriate manipulation of the cysticerotic ventricular cysts carries a more favourable prognosis.

New onset of body dysmorphic disorder following frontotemporal lesion

The etiology and pathophysiology of body dysmorphic disorder (BDD) have not been delineated. The authors report a 24-year-old man who developed BDD at age 21 after an inflammatory brain process. Neuroimaging studies showed new atrophy in the frontotemporal region. The authors review cases from the literature with similar clinical features and neuroimaging findings as well as discuss the possible correlation between the neuroanatomic lesion and the clinical presentation of BDD in the patient.

[The prevalence of dementia and its main subtypes in subjects older than 65 years: impact of occupation and education. The Toledo Study]

BACKGROUND

To assess the prevalence of dementia and its subtypes in a population with a low level of education, and to determine whether there is any association between occupation, education and dementia.

SUBJECTS AND METHOD

Cross-section study of the population, with a sample of 3,214 individuals representative of the population of Toledo, Spain, aged 65 years and older. The Mini-Mental State Examination (MMSE) was used in the first phase of the study to detect those individuals with cognitive deterioration. The second phase consisted of a semi-structured clinical interview and neuropsychological evaluation. Dementia and sub-types of dementia were determined using well-established diagnostic criteria. The process was applied using an algorithm to optimise diagnostic agreement.

RESULTS

The overall prevalence of dementia, Alzheimer's disease and vascular dementia amounted to 7.6, 4.6 and 1.8%, respectively. A direct relationship was detected between these three entities and age. The prevalence of dementia was greater in women, illiterate persons and occupations which require less skill. Once adjustment had been made for other socio-demographic variables, only age was associated with the presence of dementia.

CONCLUSIONS

The overall prevalence of dementia, Alzheimer's type dementia and vascular dementia increases with age. No clear association was found between education, occupation and dementia.

Effects of IV cyclophosphamide on HIV viral replication in a patient with systemic lupus erythematosus

Several cases of patients with concomitant SLE and HIV infection have been reported in the literature; however, the effect of immunosuppressive therapy on HIV replication has not been described. We present the case of a 46 y/o woman with a ten-year history of HIV infection who was treated with IV cyclophosphamide for SLE nephritis. She had a positive HIV Western Blot just a few months before the diagnosis of SLE. Serum levels of HIV RNA had been persistently non-detectable since the assay became available. The patient was not receiving any antiretroviral therapy, raising doubts about the diagnosis of HIV infection. After 3 pulses of IV cyclophosphamide, HIV RNA levels went up to 135,720 copies/ml. Shortly after discontinuation of therapy viral levels were again undetectable. This case shows one of the possible clinical scenarios in patients with coexistent HIV infection and SLE. In our patient SLE appears to provide some immunologic defense against viral replication. Cross-reactivity of autoantibodies with HIV proteins may play a role in this mechanism. Effective immunosuppressive therapy suppresses this protection and leaves the immune system vulnerable to HIV reproduction. Treatment in these cases can be difficult and should be individualized in an attempt to achieve a balance between control of viral infection and SLE activity.

Amniocentesis after multifetal pregnancy reduction: is it safe?

OBJECTIVE

This report reviews the obstetric outcomes of women with multifetal pregnancy reductions who subsequently underwent elective amniocentesis.

STUDY DESIGN

Five hundred eight patients underwent multifetal pregnancy reduction at our institution. Among these, 91 patients underwent subsequent elective amniocentesis. The obstetric outcomes of all 508 patients were followed up. By means of logistic regression we evaluated several variables to determine any association with loss rate: (1) the finishing number of fetuses, (2) the number of fetuses undergoing reduction (starting number of fetuses minus the finishing number of fetuses), (3) the gestational age at reduction, (4) the maternal age at reduction, and (5) the procedure protocol. We observed that the finishing number of fetuses, the number of fetuses removed, and the procedure protocol were significantly associated with pregnancy loss rate. Women who underwent subsequent amniocentesis were compared with those who did not undergo amniocentesis. By means of multivariate conditional likelihood analysis we stratified the two groups according to the previously mentioned significant variables to compare the pregnancy loss rates.

RESULTS

Among patients who subsequently underwent elective amniocentesis the total uncorrected pregnancy loss rate was 9.0% and the early premature delivery rate was 4.5%. The number of fetuses removed, the finishing number of fetuses, and the procedure protocol were statistically significantly associated with the loss rate. The adjusted odds ratio relating amniocentesis to the pregnancy loss rate was 0.7 (95% confidence interval, 0.31.5; P =.3.)

CONCLUSIONS

The uncorrected rates of pregnancy loss and of early premature delivery among patients with multifetal pregnancy reduction who underwent subsequent amniocentesis were comparable to those of patients with multifetal pregnancy reduction who did not undergo amniocentesis.

[Encephalomyelitis due to Epstein-Barr virus]

We present a 28-year-old woman with encephalomyelitis and concomitant central nervous system infection by Epstein-Barr virus. Progression took place in 2 phases, with myelitis at the beginning and encephalitis developing later. Despite great functional impairment, recovery was good and the patient was left suffering only from urinary retention that was presumably caused by spinal lesions. The etiology of the case is unusual, particularly in adults.

Depletion of monocytes from human peripheral blood leucocytes by passage through sephadex G-10 columns

Passage of human peripheral blood leucocytes through Sephadex G-10 columns results in a complete depletion of monocytes. Microscopic examination and ingestion of latex particles failed to reveal any monocytes in the column-passed cells. The study of surface markers shows a slight enrichment of T-cells and a decrease of B-cells that is more pronounced in the IgG- and IgA-bearing lymphocytes. No changes were seen in the Fc receptor-positive cells. Con A-induced activation was significantly affected. Pokeweed mitogen activation was reduced 50% at optimal doses of mitogen whereas the response was unaffected at suboptimal doses. Mixed leucocyte reactions (MLR) were greatly depressed when monocytes were removed from either the responder or the stimulator cells, indicating an important role of monocytes both in the elicitation of the response and as auxiliary cells in the mixed leucocyte culture.