Neurocysticercosis Presenting as Migraine in the United States

BACKGROUND Cysticercosis is a condition caused by infection with the larval form of Taenia solium, a pork tapeworm that uses pigs as an intermediate host. Humans become infected when they ingest water or food contaminated with tapeworm cysts. Cysticercosis is increasing in frequency in developed countries due to increased access to travel. Neurocysticercosis occurs when Taenia solium cysts embed within the nervous system. The clinical presentation of neurocysticercosis ranges from asymptomatic to life-threatening, largely depending on the brain parenchymal involvement. The diagnosis is typically made with a combination of clinical evaluation, serology, and neuroimaging. Treatment for parenchymal neurocysticercosis may involve anthelmintic agents, symptomatic agents, surgery, or a combination of methods. CASE REPORT A 52-year-old man with a medical history of migraine headaches, complicated type 2 diabetes mellitus, and obesity presented with a 4-month change in his migraines becoming severe, worse over his occiput bilaterally, and unresponsive to abortive therapy. His exposure history was unremarkable except for a habit of eating undercooked bacon, by which he would have developed neurocysticercosis via autoinfection. Neuroimaging and serology confirmed a diagnosis of neurocysticercosis and he was treated accordingly with antiparasitic and anti-inflammatory medications. CONCLUSIONS This presentation is nonspecific and can easily be overlooked, especially if there is an underlying known neurological condition such as migraine. This case illustrates that neurocysticercosis should be considered when an existing neuropathological condition displays a change in presentation or requires a change in therapeutic management, even without obvious risk factors.

Unusual Case of Ludwig Angina Caused by Clostridium sporogenes in an Immunocompromised HIV-Positive Patient with Alcoholism and Dental Abscess

BACKGROUND Ludwig angina is a cellulitis of the soft tissues of the neck and floor of the mouth. It is most commonly caused by Viridans streptococcal species, but other bacterial species have been shown to lead to this severe infection. Clostridium sporogenes is an anaerobic gram-positive, spore-producing bacillus found in soil and the human gastrointestinal tract. This report is of a case of a 49-year-old HIV-positive man with alcoholism and poor dental hygiene leading to a molar abscess who presented with Ludwig angina due to C. sporogenes. CASE REPORT A 49-year-old man presented with severe left molar pain, fever, and worsening neck swelling for 5 days. His medical history was significant for AIDS; he was not on antiretroviral therapy. Computed tomography of the neck was positive for extensive subcutaneous emphysema of the left sublingual space. Ludwig angina was diagnosed, and he was taken urgently for incision and drainage of the bilateral neck fascial space. On day 6 of hospitalization, 1 of 2 blood cultures grew C. sporogenes. He left the hospital on day 13 and was readmitted 6 days later with progression of the disease and alcohol withdrawal. CONCLUSIONS This case illustrates the need for rapid diagnosis and treatment of Ludwig angina and the importance of considering commonly pathogenic and rarely pathogenic bacteria when considering the underlying bacterial cause of an infection in an immunocompromised patient. To the best of our knowledge, this is the first case of Ludwig angina caused by C. sporogenes reported in the medical literature.

A Rare Case of Severe Stevens-Johnson Syndrome Triggered by Topical Ofloxacin

BACKGROUND Stevens-Johnson syndrome (SJS) is a rare dermatologic disorder that is characterized by nonspecific flu-like prodrome with fever, malaise, myalgia, cough, rhinitis, and sore eyes, followed by a characteristic rash and mucocutaneous manifestations. It is triggered by medications in up to 80% of cases in adults. In each of these cases, the medication is oral or parenteral. Severe and progressive SJS can result in life-threatening complications. Adult-onset medication-induced SJS presents within 8 weeks of exposure to the offending substance, lasting 8 to 12 days. Recovery of denuded skin generally is complete within a month. There is no consensus on treatment, but supportive care with corticosteroids is often the initial intervention. CASE REPORT A 36-year-old woman with a flare of allergic rhinitis and tearing resistant to over-the-counter options was treated with topical ophthalmic ofloxacin. She began experiencing a diffuse mucocutaneous rash, with oral desquamation, tongue swelling, vaginal desquamation, and rash of the palms and soles within 24 h, which suggested the possibility of SJS. A skin biopsy was obtained, and pathology confirmed this suspicion. She was treated with parenteral antibiotics, corticosteroids, and supportive care, and after 10 days was discharged from the hospital. She had a complete recovery in 30 days. CONCLUSIONS The clinical course of SJS induced by the ophthalmic application of medication can be just as severe as the oral or parenteral routes. This is, to the best of our knowledge, the first documented case of SJS being triggered by topical ofloxacin.

Ovarian Vein Thrombosis: An Unusual Cause of Abdominal Pain in Breast Cancer

Ovarian vein thrombosis (OVT) is a rare but potentially life-threatening complication that is usually seen in the intrapartum or postpartum period but can also be seen in patients with risk factors for venous thromboembolism. When symptomatic, it usually presents with abdominal pain and other vague constitutional symptoms, hence it is important for healthcare professionals to be aware of this condition when evaluating patients with risk factors. We present a rare case of OVT in a patient with breast cancer. Due to a lack of clear guidelines regarding the treatment and duration of treatment in non-pregnancy-related OVT, we followed the guidelines for the treatment of venous thromboembolism and started the patient on rivaroxaban for a three-month duration with close outpatient follow-up.

A 24-Year-Old Man Presenting with Lung Metastases from a Primary Retroperitoneal Extragonadal Choriocarcinoma

BACKGROUND Primary retroperitoneal choriocarcinoma is a rare form of extragonadal germ cell tumor that is highly aggressive and responds poorly to chemoradiation. Extragonadal choriocarcinomas are notoriously challenging to diagnose, and have often progressed to advanced disease by the time of diagnosis. The survival rate for extragonadal choriocarcinoma is approximately 30%, which is much lower than that of extragonadal non-seminomatous germ cell tumors (GCT) in general. CASE REPORT A 24-year-old man with no significant past medical history presented with left-sided, pleuritic chest pain and back pain radiating down his left leg, of 1-year duration. Computed tomography (CT) of the chest revealed multiple bilateral pulmonary nodules and a CT of the abdomen and pelvis showed a large heterogeneous soft tissue mass measuring 9.3×8×10.5 cm. A CT-guided core needle biopsy of a lung nodule was performed and the findings were consistent with the diagnosis of metastatic choriocarcinoma. Magnetic resonance imaging (MRI) of the brain was negative for metastatic disease. Tumor markers were significant for a markedly elevated beta human chorionic gonadotropin (B-hCG) of 104 712 mIU/mL. He was diagnosed with a stage IIIC germ cell tumor, further classified as a primary retroperitoneal choriocarcinoma with lung metastasis, and was started on urgent inpatient chemotherapy. CONCLUSIONS Due to the poor outcomes associated with extragonadal choriocarcinoma, it is important to promptly and correctly identify this malignancy in order to initiate treatment in a timely manner. The following case report explores the histopathologic characterization of this malignancy and describes the clinical course and outcomes from treatment for this patient.

Systemic Lupus Erythematous and Neuromyelitis Optica Causing Hypercapnic Respiratory Failure

Patient: Female, 54-year-old

Final Diagnosis: Systemic lupus erythematous and neuromyelitis optica

Symptoms: Chest pain • dysphagia

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

Left Ventricular Pseudoaneurysm and Left Ventricular Thrombus in a Patient Presenting with an Acute ST-Elevation Myocardial Infarction

Patient: Male, 73-year-old

Final Diagnosis: Pseudoaneurysm • thrombus

Symptoms: Chest pain • sycope

Medication: —

Clinical Procedure: —

Specialty: General and Internal Medicine

A mobile-assisted voice condition analysis system for Parkinson's disease: assessment of usability conditions

BACKGROUND AND OBJECTIVE

Automatic voice condition analysis systems to detect Parkinson's disease (PD) are generally based on speech data recorded under acoustically controlled conditions and professional supervision. The performance of these approaches in a free-living scenario is unknown. The aim of this research is to investigate the impact of uncontrolled conditions (realistic acoustic environment and lack of supervision) on the performance of automatic PD detection systems based on speech.

METHODS

A mobile-assisted voice condition analysis system is proposed to aid in the detection of PD using speech. The system is based on a server-client architecture. In the server, feature extraction and machine learning algorithms are designed and implemented to discriminate subjects with PD from healthy ones. The Android app allows patients to submit phonations and physicians to check the complete record of every patient. Six different machine learning classifiers are applied to compare their performance on two different speech databases. One of them is an in-house database (UEX database), collected under professional supervision by using the same Android-based smartphone in the same room, whereas the other one is an age, sex and health-status balanced subset of mPower study for PD, which provides real-world data. By applying identical methodology, single-database experiments have been performed on each database, and also cross-database tests. Cross-validation has been applied to assess generalization performance and hypothesis tests have been used to report statistically significant differences.

RESULTS

In the single-database experiments, a best accuracy rate of 0.92 (AUC = 0.98) has been obtained on UEX database, while a considerably lower best accuracy rate of 0.71 (AUC = 0.76) has been achieved using the mPower-based database. The cross-database tests provided very degraded accuracy metrics.

CONCLUSION

The results clearly show the potential of the proposed system as an aid for general practitioners to conduct triage or an additional tool for neurologists to perform diagnosis. However, due to the performance degradation observed using data from mPower study, semi-controlled conditions are encouraged, i.e., voices recorded at home by the patients themselves following a strict recording protocol and control of the information about patients by the medical doctor at charge.

Replication-based regularization approaches to diagnose Reinke's edema by using voice recordings

Reinke's edema is one of the most prevalent laryngeal pathologies. Its detection can be addressed by using computer-aided diagnosis systems based on features extracted from speech recordings. When extracting acoustic features from different voice recordings of a particular subject at a concrete moment, imperfections in technology and the very biological variability result in values that are close, but they are not identical. This suggests that the within-subject variability must be properly addressed in the statistical methodology. Regularization-based regression approaches can be used to reduce the classification errors by favoring the best predictors and penalizing the worst ones. Three replication-based regularization approaches for variable selection and classification have been specifically designed and implemented to take into account the underlying within-subject variability. In order to illustrate the applicability of these approaches, an experiment has been specifically conducted to discriminate Reinke's edema patients (30 subjects) from healthy people (30 subjects) in a hospital environment. The features have been extracted from four phonations of the sustained vowel /a/ recorded for each subject, leading to a database that has fed the proposed machine learning approaches. The proposed replication-based approaches have been proved to be reliable in terms of selected features and predictive ability, leading to a stable accuracy rate of 0.89 under a cross-validation framework. Also, a comparison with traditional independence-based regularization methods reports a great variability of the latter in terms of selected features and accuracy metrics. Therefore, the proposed approaches contribute to fill a gap in the scientific literature on statistical approaches considering within-subject variability and can be used to build a robust expert system.

Acute Hepatitis E: A Rare Cause of Acute Liver Failure in a Patient With Acute Myeloid Leukemia

Immunocompromised patients are particularly at risk to develop hepatitis E virus (HEV) infection and its related complications. We present a rare case of HEV infection in a 35-year-old Hispanic female with concomitant acute myeloid leukemia (AML). The patient presented with acute liver failure within a few weeks after receiving a blood transfusion. Our case likely represented an acute de novo HEV infection after chemotherapy in a patient with concurrent AML, evidenced by the presence of anti-HEV IgM antibodies as well as histological findings, and with a previous history of recent transfusions being one of the strongest risk factors for transmission. Liver failure from an acute de novo hepatitis E infection with concurrent AML can be catastrophic in the immunosuppressed patient. Our case is particularly unique due to the uncommon presentation of acute hepatitis E in a non-pregnant reproductive aged Hispanic female with recently diagnosed AML. Clinicians should maintain a low threshold to test serum HEV-RNA if a patient presents with signs and symptoms suggestive of acute hepatitis.

Portal vein aneurysm with acute portal vein thrombosis masquerading as a pancreatic mass

Portal vein aneurysm (PVA) with portal vein thrombosis (PVT) is an exceedingly rare vascular phenomenon with a limited number of reported cases in the medical literature. We describe a case of a 25-year-old man found to have a congenital PVA with PVT initially believed to be a pancreatic mass. While there remains some incongruity amongst clinicians with such a limited number of reported cases, herein, we describe the general consensus of the diagnostic approach and management of this vascular malformation.

Successful Use of Adjunctive Red Blood Cell Exchange Therapy for Treatment of an Acute Hemolytic Reaction After ABO-Incompatible Red Blood Cell Transfusion

An acute hemolytic transfusion reaction is a potentially fatal complication resulting from the transfusion of mismatched blood products. Symptoms vary from mild to severe depending on how much incompatible antigen was transfused and the nature of the recipient’s antibodies. There is no consensus agreement of appropriate management other than discontinuing the transfusion and basic supportive methods including adjunctive pharmacologic agents. A 40-year-old male presented with a gunshot wound to the upper torso. During surgery, the O+ patient lost 1.3 L of blood and postoperatively was inadvertently given one unit of A+ packed red blood cells. The blood bank noticed the error and notified the floor within the hour. An acute hemolytic transfusion reaction had progressed to shock and disseminated intravascular coagulation within hours. The clinical course continued to decline despite a norepinephrine drip and a red blood cell exchange transfusion was implemented within 5 h of the mismatched transfusion. The patient’s hematological parameters and clinical markers improved and he was eventually discharged in stable condition. An adjunctive red blood cell exchange transfusion may be useful when treating an ABO-incompatible acute hemolytic transfusion reaction if there has been a large volume mismatched transfusion and a poor clinical response to basic supportive methods.

Epidural Steroid Injection-Induced Pancreatitis: A Case Report

Patient: Female, 73-year-old

Final Diagnosis: Pancreatitis

Symptoms: Abdominal and back pain

Medication:—

Clinical Procedure: Epidural

Specialty: Neurology

Thrombocytopenia and endocarditis in a patient with Whipple's disease: case report

Background

Whipple’s disease (WD) is a rare multisystem infectious disorder that is caused by the actinomycete Tropheryma whipplei. It presents with joint pain followed by abdominal pain, diarrhea, malabsorption and finally failure to thrive. Diagnosis requires tissue sampling and histology with periodic acid-Schiff [PAS] staining. Thrombocytopenia associated with endocarditis associated with WD has been reported twice.

Case presentation

A 56 year old Caucasian male presented with years of steroid treated joint pain and recent onset diarrhea, weight loss and abdominal pain. Ultimately he was found to have a platelet count of 4000 with concomitant endocarditis and embolic stroke. Small bowel biopsy confirmed the diagnosis of WD approximately 1 year after his first visit. His platelets improved with antibiotic treatment but he eventually expired 16 months after his initial consult and 5 months after his definitive diagnosis.

Conclusion

WD can remain undiagnosed and untreated until late in the course of the illness. A high index of suspicion is recognized as necessary for early diagnosis to begin treatment. Critical thrombocytopenia associated with endocarditis is a rare and potentially poor prognostic sign in late stage Whipple’s disease.

Successful Treatment of Hypokalemic Rhabdomyolysis Caused by a Pancreatic VIPoma: A Case Report

BACKGROUND VIPomas are rare neuroendocrine tumors typically located in the pancreas. The majority of cases autonomously secret vasoactive intestinal polypeptide (VIP), which can result in profuse, refractory, watery diarrhea. The fluid and electrolyte imbalance can progress to dehydration and profound hypokalemia, resulting in the watery diarrhea, hypokalemia, achlorhydria (WDHA) syndrome. One previous case of a pancreatic VIPoma progressing to hypokalemic rhabdomyolysis has been described. CASE REPORT A 33-year-old woman presented with 3 months of progressive, refractory diarrhea and weakness. Her serum VIP level was elevated and imaging discovered a mass in the region of the pancreatic tail. Laparoscopic partial pancreatic resection was performed and a 3.7-cm diameter, solitary stage T2 N0 M0, well-differentiated carcinoma was removed. CONCLUSIONS A high index of suspicion is important when diagnosing chronic diarrhea. Minimally invasive surgery is an option in the surgical treatment of pancreatic VIPoma.

Lymphatic Malformation of the Nasopharynx in a Young Pregnant Female: A Case Report

BACKGROUND Lymphangiomas represent the focal proliferation of benign, well-differentiated lymphatic tissue. They are most likely congenital, thus more commonly diagnosed at birth and before the age of 2 years. When they are found in adults, they favor the head, neck and axillary region. Rarely do they involve the nasopharynx region or occur in a pregnant patient. CASE REPORT A 21-year-old primagravida in the third trimester of pregnancy developed difficulty swallowing that progressed into difficulty breathing over a 1-month period. Imaging and examination suggested a benign mass in the nasopharynx and the patient underwent surgical removal of the stalk with bipolar cautery. The pathology report revealed a simple 4.5×1.5×0.8 cm lymphangioma. She had no fetal compromise during anesthesia. CONCLUSIONS Surgical removal of a nasopharyngeal lymphangioma during the third trimester of pregnancy is indicated if respiratory obstruction may be a complication.

Epithelioid Hemangioendothelioma: A Rare Case of an Aggressive Vascular Malignancy

Patient: Female, 46

Final Diagnosis: Epithelioid hemangioendothelioma

Symptoms: Pain

Medication: —

Clinical Procedure: —

Specialty: Oncology

Full recovery from extreme hypernatremia in an elderly woman with hyperosmolar hyperglycemic syndrome and abnormal electroencephalogram

Background:

Hyperosmolar hyperglycemic state is a life-threatening endocrine disorder that most commonly affects adults with type 2 diabetes mellitus. The condition results from an osmotic diuresis-induced loss of water exceeding that of sodium. Altered mental status, hypernatremia and hyperglycemia are characteristic features at presentation. Abnormal electroencephalogram findings have been reported. Successful therapy requires judicious fluid replacement and close monitoring.

Case:

A 78-year-old Hispanic female with a significant past medical history of type 2 diabetes mellitus was admitted with altered mental status, severe hypernatremia and hyperglycemia. She was diagnosed with hyperosmolar hyperglycemic state, and fluid therapy was started. A continuous electroencephalogram revealed left frontocentral and temporal periodic lateralized epileptiform discharges that resolved as her hypernatremia and dehydration were treated. She survived and was discharged after 1 week of treatment.

Conclusion:

Abnormal electroencephalogram findings consistent with nonconvulsive seizure activity may be temporary and reversible and do not suggest a poor prognosis in an elderly patient suffering from hyperosmolar hyperglycemic state and altered mental status.

Monotypic IgG1-kappa Atypical Anti-Glomerular Basement Membrane Nephritis: A Case Report

Anti-glomerular basement membrane (anti-GBM) glomerulonephritis is a rare disease caused by autoantibodies against the glomerular basement membrane. Atypical anti-GBM nephritis is clinically less aggressive and characterized by the absence of circulating autoantibodies to the basement membrane. A previously healthy 53-year-old white woman presented with a rising creatinine over a short observation period. Renal biopsy, urinary sediment, and laboratory testing confirmed the diagnosis of atypical anti-GBM disease. She received plasmapheresis, steroids, and cyclophosphamide. She developed hemorrhagic cystitis early in the treatment from oral cyclophosphamide and mycophenolate mofetil was substituted as a first-line drug. She responded favorably and continued on mycophenolate mofetil without evidence of relapse. Despite the absence of circulating autoantibodies, a diagnosis of atypical anti-GBM nephritis should not be excluded if a high index of clinical suspicion exists. Early renal biopsy should be considered. Mycophenolate mofetil may be a reasonable replacement for oral cyclophosphamide in the treatment of atypical anti-GBM disease when cyclophosphamide is contraindicated.

Wooden-Breast, White Striping, and Spaghetti Meat: Causes, Consequences and Consumer Perception of Emerging Broiler Meat Abnormalities

Ten years ago, the occurrence of macroscopic defects in breasts muscles from fast-growing broilers challenged producers and animal scientists to label and characterize myopathies wholly unknown. The distinctive white striations in breasts affected by white striping disorder, the presence of out-bulging and pale areas of hardened consistency in the so-called wooden breast, and the separation of the fiber bundles in breasts labelled as spaghetti meat, made these myopathies easily identified in chicken carcasses. Yet, the high incidence of these myopathies and the increasing concern by producers and retailers led to an unprecedented flood of questions on the causes and consequences of these abnormal chicken breasts. This review comprehensively collects the most relevant information from studies aimed to understand the pathological mechanisms of these myopathies, their physicochemical and histological characterization and their impact on meat quality and consumer's preferences. Today, it is known that the occurrence is linked to fast-growth rates of the birds and their large breast muscles. The muscle hypertrophy along with an unbalanced growth of supportive connective tissue leads to a compromised blood supply and hypoxia. The occurrence of oxidative stress and mitochondrial dysfunction leads to lipidosis, fibrosis, and overall myodegeneration. Along with the altered appearance, breast muscles affected by the myopathies display poor technological properties, impaired texture properties, and reduced nutritional value. As consumer's awareness on the occurrence of these abnormalities and the concerns on animal welfare arise, efforts are made to inhibit the onset of the myopathies or alleviate the severity of the symptoms. The lack of fully effective dietary strategies leads scientists to propose whether "slow" production systems may alternatively provide with poultry meat free of these myopathies.

Rapidly Progressing Sporadic Creutzfeldt-Jakob Disease Presenting as a Stroke

Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare, fatal human prion disease that is characterized by progressive dementia and neurologic degeneration. It can mimic multiple other neurological disorders, and a high index of clinical suspicion is necessary to make a diagnosis. A 74-year-old woman with a 3-month history of a stroke and progressive neurologic deterioration was found to have sCJD. She expired within a week of her diagnosis. Autopsy revealed spongiform encephalopathy consistent with prion disease, and genetic analysis revealed 129 polymorphism and no pathologic mutation, confirming the diagnosis of nonfamilial human prion disease. No pathologic evidence of a stroke was found. Awareness of the disease by clinicians is important not only at the time of initial presentation but also during the following months. Since there is no treatment, invasive medical procedures should be limited to only those that are required for either diagnosis or hospice care.

Bilateral Pneumothoraces: A Rare Complication of Septic Pulmonary Emboli in Intravenous Drug Abusers

Patient: Male, 39

Final Diagnosis: Infective endocarditis

Symptoms: Cough

Medication: —

Clinical Procedure: None

Specialty: Critical Care Medicine

Burkitt's lymphoma with placental invasion diagnosed at cesarean delivery: a case report

Background

Burkitt’s lymphoma is a highly aggressive B cell non-Hodgkin lymphoma subtype. Its occurrence in pregnancy is rare and often results in a delayed diagnosis. The treatment plan and prognosis depend on a number of variables including the stage at diagnosis.

Case presentation

A 32 weeks pregnant, 34-year-old white woman presented with weeks of complaints that were similar to typical pregnancy symptoms. Laboratory and ultrasound findings suggested a pathologic process and during the workup non-reassuring fetal surveillance resulted in an emergency cesarean delivery. Biopsies were obtained that confirmed Burkitt’s lymphoma. Placental histology revealed microscopic involvement.

Conclusions

The placenta should be inspected for microscopic disease if Burkitt’s lymphoma is suspected, even if a vaginal delivery occurs and the placenta is ordinarily discarded. Repetitive somatic complaints during pregnancy should not be assumed to be secondary to the normal symptoms of pregnancy.

Utilizing Abdominal Sonography in the Diagnosis of Ascites Caused by Heart Failure: A Patient With Cirrhosis

Abdominal sonography is the most common imaging method used in the detection of ascites. In the presence of cirrhosis, the most likely etiology of ascites is portal hypertension, secondary to the chronic liver disease. A case study is presented of a male with hepatitis C cirrhosis, with symptoms of ascites, which was confirmed with abdominal sonography. Ascitic fluid obtained by paracentesis confirmed the etiology of the ascites was cardiogenic. Significant improvement was documented after heart failure protocol was implemented. Abdominal sonography can detect the presence of ascites with accuracy but lacks the accuracy to diagnose the precise cause.

Congenital glaucoma detected by unilateral megalophthalmos on prenatal sonography

A 36-week male fetus was noted to have isolated right megalophthalmos on prenatal ultrasound and was found to have buphthalmos and congenital glaucoma at birth. Detection of congenital glaucoma at birth may be occasionally possible if abnormal orbit dimensions are noted on late prenatal sonographic examination. Early neonatal intervention may improve the chances to retain vision. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:499-501, 2017.

Successful pregnancy after mucinous cystic neoplasm with invasive carcinoma of the pancreas in a patient with polycystic ovarian syndrome: a case report

Background

The incidence of invasive cancer within a mucinous cystic neoplasm of the pancreas varies between 6 and 36%. Polycystic ovarian syndrome is a disorder characterized by hyperandrogenism and anovulatory infertility. One surgical treatment that can restore endocrine balance and ovulation in polycystic ovarian syndrome is partial ovarian destruction. Successful pregnancies following preconception pancreaticoduodenectomies (Whipple procedures) and chemoradiation to treat pancreatic neoplasms have been reported rarely but none were diagnosed with pre-cancer polycystic ovarian syndrome-associated infertility. Gemcitabine is an antimetabolite drug used for the treatment of pancreatic cancer that can have profound detrimental effects on oogenesis and ovarian function. Whether the ovarian destructive property of gemcitabine could act as a method to restore ovulation potential in polycystic ovarian syndrome is unknown.

Case presentation

A 40-year-old white American woman with a history of pancreatic cancer treatment with a Whipple procedure and chemoradiation with gemcitabine had a successful pregnancy after years of pre-cancerous anovulatory infertility and polycystic ovarian syndrome. She received no fertility agents and delivered full term via a spontaneous vaginal delivery with no pregnancy complications.

Conclusion

Gemcitabine treatment for pancreatic cancer may result in resumption of ovulation in women with polycystic ovarian syndrome and these women should be counseled accordingly.

Reactivation of Goodpasture Disease During the Third Trimester of Pregnancy: A Case Report

BACKGROUND

Active Goodpasture disease (GD) in pregnancy is extremely rare and can result in significant maternal and fetal morbidity. Relapse of GD in a subsequent pregnancy has not been reported. Factors associated with a relapse of GD are unknown.

CASE

A woman in her second pregnancy presented with clinical findings of preeclampsia and biopsy evidence of GD in the third trimester. Her first puerperium was also complicated by GD, requiring temporary hemodialysis. After her second pregnancy she developed terminal renal failure.

CONCLUSION

Active GD is extremely rare in pregnancy and has never been reported in 2 successive pregnancies in the same patient. Pregnancy and preeclampsia may be risk factors for a GD relapse, and women with GD contemplating pregnancy should be counseled accordingly.

Mirtazapine versus fluoxetine in the treatment of panic disorder

Mirtazapine is an antidepressant whose side effect profile differs from that of first-line agents (selective serotonin reuptake inhibitors) used in the treatment of panic disorder. The present study compared the effect of mirtazapine and fluoxetine in the treatment of panic disorder in a double-blind, randomized, flexible-dose trial conducted with outpatients. After a 1-week single-blind placebo run-in, 27 patients entered an 8-week double-blind phase in which they were randomly assigned to treatment with either mirtazapine or fluoxetine. Both groups improved significantly in all but one efficacy measure (P < or = 0.01). ANOVA showed no significant differences between the two treatment groups in number of panic attacks, Hamilton Anxiety Scale or Sheehan Phobic Scale, whereas measures of patient global evaluation of phobic anxiety were significantly different between groups (F1,20 = 6.91, P = 0.016) favoring mirtazapine. For the 22 patients who completed the study, the mean daily dose of mirtazapine was 18.3 +/- 1.3 vs 14.0 +/- 1.0 mg for fluoxetine at the endpoint. Weight gain occurred more frequently in the mirtazapine group (50 vs 7.7%, P = 0.04) and nausea and paresthesia occurred more often in the fluoxetine group (P = 0.01). Results suggest that mirtazapine has properties that make it attractive for the treatment of panic disorder.

Use and misuse of benzodiazepines in Brazil: a review

Benzodiazepines are among the most prescribed and consumed medication groups in the world. Although benzodiazepines are used in the treatment of several psychiatric and non-psychiatric disorders, and are generally safe and well-tolerated, the potential for misuse and abuse is considerable. This makes the study and regulation of benzodiazepine prescription and consumption an item of concern in public health around the world. Most developed countries have consistent data of benzodiazepine sales and consumption; however, data from developing countries is scarce, making health policies on the use of benzodiazepines a much tougher issue in these countries. This article aims to review the epidemiology of benzodiazepine use in Brazil, as well as to analyze how legislation, physician misinformation and economic factors might contribute to making benzodiazepine abuse a problem in the country.

Time-dependent impairment of inhibitory avoidance retention in rats by posttraining infusion of a mitogen-activated protein kinase kinase inhibitor into cortical and limbic structures

Mitogen-activated protein kinase (MAPK) is abundantly expressed in postmitotic neurons of the developed nervous system. MAPK is activated and required for induction of long-term potentiation (LTP) in the CA1 area of the hippocampus, which is blocked by the specific inhibitor of the MAPK kinase, PD 098059. Recently it was demonstrated that MAPK is activated in the hippocampus after training and is necessary for contextual fear conditioning learning. The present work tests the role of the MAPK cascade in step-down inhibitory avoidance (IA) retention. PD 098059 (50 microM) was bilaterally injected (0.5 microl/side) into the CA1 region of the dorsal hippocampus or entorhinal cortex at 0, 90, 180, or 360 min, or into the amygdala or parietal cortex at 0, 180, or 360 min after IA training in rats using a 0.4-mA foot shock. Retention testing was carried out 24 h after training. PD 098059 impaired retention when injected into the dorsal hippocampus at 180 min, but not 0, 90, and 360 min after training. When infused into the entorhinal cortex, PD 098059 was amnestic at 0 and 180 min, but not at 90 and 360 min after training. The MAPKK inhibitor also impairs IA retention when infused into the parietal cortex immediately after training, but not at 180 or 360 min. Infusions performed into amygdala were amnestic at 180 min, but not at 0 and 360 min after training. Our results suggest a time-dependent involvement of the MAPK cascade in the posttraining memory processing of IA; the time dependency is different in the hippocampus, amygdala, entorhinal cortex, or parietal cortex of rats.

Differential effects of post-training muscimol and AP5 infusions into different regions of the cingulate cortex on retention for inhibitory avoidance in rats

Adult male Wistar rats were bilaterally implanted with indwelling cannulae in four different coordinates of the cingulate cortex: (1) the anterior cingulate (AC), (2) the rostral region of the posterior cingulate (RC), (3) the upper portion of the caudal region of the posterior cingulate (UC), and (4) the lower portion of the caudal region of the posterior cingulate (LC). After recovery, animals were trained in a step-down inhibitory avoidance task (3.0-s, 0.4-mA foot shock). Either immediately, or 90 or 180 min after training, animals received a 0.5-microl infusion of vehicle (phosphate buffer, pH 7.4), of muscimol (0.5 microg), or of AP5 (5.0 microg). Retention testing was carried out 24 h after training. Muscimol was amnestic when given into any of the three coordinates of the posterior cingulate cortex 90 min after training, and when given into LC immediately post-training. In addition, AP5 was amnestic when given into UC 90 min post-training, but not when given into any other region and/or at any other time. None of the treatments had any effect when given into AC. The results suggest that memory processing of the inhibitory avoidance task is regulated by the posterior but not by the anterior cingulate cortex, through muscimol-sensitive synapses, relatively late after training. AP5-sensitive synapses appear to play a very limited role in these processes, restricted to UC.

Increased training prevents the impairing effect of intra-amygdala infusion of the non-NMDA receptor antagonist CNQX on inhibitory avoidance expression

Intra-amygdala infusion of the non-N-methyl-D-aspartate (NMDA) receptor antagonist 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) prior to testing impairs inhibitory avoidance retention test performance. Increased training attenuates the impairing effects of amygdala lesions and intra-amygdala infusions of CNQX. The objective of the present study was to determine the effects of additional training on the impairing effects of intra-amygdala CNQX on expression of the inhibitory avoidance task. Adult female Wistar rats bilaterally implanted with cannulae into the border between the central and the basolateral nuclei of the amygdala were submitted to a single session or to three training sessions (0.2 mA, 24-h interval between sessions) in a step-down inhibitory avoidance task. A retention test session was held 48 h after the last training. Ten minutes prior to the retention test session, the animals received a 0.5-microliter infusion of CNQX (0.5 microgram) or its vehicle (25% dimethylsulfoxide in saline). The CNQX infusion impaired, but did not block, retention test performance in animals submitted to a single training session. Additional training prevented the impairing effect of CNQX. The results suggest that amygdaloid non-NMDA receptors may not be critical for memory expression in animals given increased training.

Differential involvement of cortical receptor mechanisms in working, short-term and long-term memory

Rats received, through bilaterally implanted indwelling cannulae, 0.5 microliter infusions of 6-cyano-7-nitroquinoxaline2,3-dione (CNQX) (0.5 microgram), D-2-amino-5-phophono pentanoic acid (AP5) (5.0 micrograms), muscimol (0.5 microgram), scopolamine (2.0 micrograms), SCH23390 (2.5 micrograms), saline or a vehicle into the CA1 region of the hippocampus, or into the antero-lateral prefrontal (PRE), posterior parietal (PP) and entorhinal cortex (EC). The infusions were given 6 min prior to one-trial step-down inhibitory avoidance training in order to measure their effect on working memory (WM), or immediately post-training in order to measure their effect on short-term (STM) and long-term memory (LTM), 1.5 and 24 h later, respectively. WM was inhibited by CNQX or muscimol given into any of the cortical areas, by SCH23390 given into CA1, PRE or PP, and by scopolamine given into PRE or EC. STM was unaffected by any of the treatments given into PRE, and was inhibited by CNQX or muscimol given into CA1, PP and EC and by scopolamine given into PP, and enhanced by SCH given into CA1. LTM was inhibited by CNQX, muscimol, scopolamine or SCH23390 given into PRE, by scopolamine given into PP, by SCH23390 given into the entorhinal cortex, and by AP5, CNQX, muscimol or scopolamine given into CA1. The results indicate a differential involvement of the various neurotransmitter systems in the three types of memory in the various brain areas, and a separation of the mechanisms and of the regions involved in each. In addition, some of the findings suggested links between WM and LTM processing in PRE, between WM and STM processing in EC and PP, and between all three types of memory in CA1.

Interaction between midazolam-induced anterograde amnesia and memory enhancement by treatments given hours later in hippocampus, entorrhinal cortex or posterior parietal cortex

Rats were bilaterally implanted with indwelling cannulae in the CA1 region of the dorsal hippocampus, the entorrhinal cortex or the posterior parietal cortex. After recovery from surgery, they were trained in a one-trial step-down inhibitory avoidance task using a 0.3 mA footshock. The animals received i.p. 15 min before training either saline (1 ml/kg) or midazolam (1 mg/kg). Three hours after training they received, through the cannulae, infusions of saline, norepinephrine (0.3 microg/side), SKF38393 (7.5 microg/side), or 8-Br-cAMP (1.25 microg/side) into the brain regions mentioned. Animals were tested for retention 24 h after the training session. Midazolam produced anterograde amnesia, and the post-training treatments (with the exception of SKF38393 given into the entorrhinal cortex) caused retrograde memory facilitation. The amnestic effect of midazolam and the facilitatory effect of the treatments given into the brain cancelled each other out. Therefore, the mechanisms triggered by midazolam can interact with others in areas involved in memory processing several hours after their onset.

Late and prolonged post-training memory modulation in entorhinal and parietal cortex by drugs acting on the cAMP/protein kinase A signalling pathway

Rats implanted bilaterally with cannulae in the entorhinal or posterior parietal cortex or in the amygdaloid nucleus were trained in one-trial step-down inhibitory (passive) avoidance using a 0.3 mA footshock. At 0, 3, 6 or 9 h after training, they received localized 0.5 microliter infusions into these areas of a vehicle, or of 8-Br-cAMP, forskolin (adenylyl cyclase activator), KT5720 (protein kinase A inhibitor), SKF38393 (dopamine D1 receptor agonist), SCH23390 (D1 antagonist), norepinephrine hydrochloride, timolol hydrochloride (beta blocker), 8-HO-DPAT (5-HT1A receptor agonist) or NAN-190 (5-HT1A antagonist) dissolved in 20% dimethylsulfoxide (DMSO) in saline (vehicle). Rats were tested for retention 24 h after training. 8-Br-cAMP, forskolin, SKF 38393 and norepinephrine caused memory facilitation and KT5720, SCH23390, timolol and 8-HO-DPAT caused retrograde amnesia when given into the entorhinal cortex 0, 3 or 6 h but not 9 h after training. When given into the posterior parietal cortex 0, 3 or 6 but not 9 h after training, KT5720 was amnestic. When given into this structure 3 or 6 h but not 0 or 9 h after training 8-Br-cAMP, forskolin and norepinephrine caused memory facilitation and KT5720, SCH23390 and timolol caused retrograde amnesia. All treatments given into the amygdala 0, 3 or 6 h after training were ineffective except for norepinephrine given at 0 h, which caused facilitation. The data point to a role of cAMP/protein kinase A-dependent mechanisms in memory formation in the entorhinal and parietal cortex, but not the amygdala, from 0 to 6 h after training, and to a strong modulation of these mechanisms by dopaminergic D1, beta-noradrenergic and 5-HT1A receptors. The lack of effect of NAN-190 but not 8-HO-DPAT in both cortical regions suggests that 5-HT1A receptors do not play a physiological role but can be activated pharmacologically. The fact that SCH23390 was amnestic but SKF38393 had no effect when given into the parietal cortex suggests that D1 receptors may play a maintenance rather than a stimulant role in this area.

Serum IgE levels in giardiasis

Raised levels of serum immunoglobulin E are found in many parasitic diseases. In order to determine the influence of Giardia lamblia on IgE levels of clinically symptomatic patients, a controlled study was performed. There was no difference between the serum IgE values from Brazilian patients with giardiasis and those from normal Brazilian controls, although in both groups there were many individuals with values higher than the normal range reported from the northern hemisphere.