[A descriptive study of neurocysticercosis in a tertiary care hospital]

INTRODUCTION

Neurocysticercosis is the most frequent parasitic disease affecting the central nervous system. It is a disease that is endemic to certain countries in South America. The phenomenon of immigration, however, has increased its prevalence in developed regions due to the arrival of immigrants from endemic areas.

AIM

To present the clinical and demographic characteristics of the cases of neurocysticercosis attended in a tertiary care hospital in the city of Murcia.

PATIENTS AND METHODS

We conducted a descriptive, retrospective study by reviewing the medical records of patients with a hospital diagnosis of neurocysticercosis over a nine-year period (1997-2005). Demographic and clinical data on these patients were collected.

RESULTS

Twenty-three patients (three under 12 years of age) were found. Mean age: 29.6 years. Countries of origin: Ecuador and Bolivia. The most frequently observed clinical manifestations were: epileptic seizures (73.9%), headache (39.1%) and neurological focus (26.1%). Albendazole was employed in 91.3% of cases and corticoids in 73.9%. The most frequently used drug in patients who received antiepileptic therapy was phenytoin. Four patients required surgical treatment. During the follow-up period, 52.8% of the patients were asymptomatic.

CONCLUSIONS

Neurocysticercosis is a disease that is becoming increasingly more prevalent in Spain and we should suspect its presence in patients from endemic areas who visit because of clinical symptoms involving the central nervous system.

Novel HMBS founder mutation and significant intronic polymorphism in Spanish patients with acute intermittent porphyria

Acute intermittent porphyria (AIP) is an autosomal dominant disorder of heme biosynthesis, caused by a partial deficiency of hydroxymethylbilane synthase (HMBS). Knowledge of the nature of the HMBS mutations causing AIP in Spanish families is very limited. Here we report a novel 669_698del of the HMBS gene in twenty-two individuals from five independent Spanish AIP families, settled in Murcia (southeastern region of Spain). All mutation carriers shared a common disease associated haplotype indicating an ancestral founder effect. Identification of the 669_698del founder mutation allowed rapid and simple molecular diagnosis of AIP in families from this region in Spain. In addition, 771 + 58C>T in intron 12 on the non-669_698del allele was identified in six AIP patients, which promoted homozygous AIP misdiagnosis.

Measurement of motor disability in MPTP-treated macaques using a telemetry system for estimating circadian motor activity

The parkinsonian symptoms of primates after MPTP exposure can be measured by several visual methods (classical motor scores). However, these methods have a subjective bias, especially as regards the evaluation of the motor activity. Computerized monitoring systems represent an unbiased method for measuring the motor disability of monkeys after MPTP administration. In this work the motor activity of monkeys before and after MPTP administration is measured and compared with the activity of a control intact group by means of a telemetry system. A pronounced decrease in motor activity was observed after MPTP administration. These results suggest the monitoring method used is suited for characterizing the motor incapacity and possible improvements following treatments to test different therapies to control Parkinson's disease in MPTP models involving primates.

[Plasmapheresis: its use in multiple sclerosis and other demyelinating processes of the central nervous system. An observation study]

INTRODUCTION

We present a retrospective observation study aimed at analyzing the value of plasmapheresis in the management of patients with multiple sclerosis (MS) and other acute demyelinating processes affecting the central nervous system (CNS) who show severe exacerbations that do not respond well to conventional therapy with corticoids.

PATIENTS AND METHODS

A total of 11 patients were included in the study: nine with MS, one disseminated acute encephalomyelitis and one case of transverse myelitis. All of them presented an acute or subacute neurological deficit, which prevented them from carrying out their day to day activities, with or without repercussions on the EDSS, and with the risk of suffering a severe residual disability after not responding to intravenous methylprednisolone pulses. Each patient was submitted to three exchanges per week, for 2 weeks, with association of orally administered prednisone and they were then evaluated after the last session and at one, six and twelve months.

RESULTS

Following plasmapheresis all the patients experienced a significant drop in disability and seven of them (77.7% of the total number with MS) even improved during the first month with respect to their basal situation ( an extension of the Lazarus effect ). After a year s follow up, 100% of the patients still maintained the basal situation that was recovered from before exacerbation, and only two relapses were recorded. The patients with MS presented a transient exacerbation after the second exchange. New therapy with immunosuppressants, immunomodulators or both was associated in eight cases.

CONCLUSIONS

We consider plasmapheresis to be a safe, effective therapeutic procedure in the management of patients with MS and other demyelinating processes affecting the CNS. Its use should be considered as first choice in severe relapses and in swiftly progressing forms that do not respond to intravenous methylprednisolone.

[Paraneoplastic cerebellar degeneration as initial presentation of a pancreatic small-cell carcinoma]

INTRODUCTION

Oat (small) cell carcinoma is the type of tumour most frequently associated to neurologic paraneoplastic syndromes. It is usually located in the lungs although it has been described in some other locations. Cerebellar symptoms may appear alone, associated to anti Yo antibodies ( Breast and gynaecologic carcinomas), or as manifestation of a more generalized paraneoplastic encephalopathy, associated to signs and symptoms of some other neurologic systems affected.

CASE REPORT

A 52 year old patient consulted due to a pancerebellar clinical picture, which started about two months before, and later associated to polineuropathy. Abdominal CT showed a 4 cm mass in the head of the pancreas. Pathologic evaluation demonstrated a poorly differentiated small cell pancreatic tumour. Anti Hu antibodies in high titres were found both in serum and cerebrospinal fluid.

DISCUSSION

The association of anti Hu immunity and paraneoplastic encephalomyelitis has been observed in patients with neuroblastoma, seminomas, colorectal, breast and prostate carcinomas and some types of sarcoma. Only about 1% of pancreatic malignancies correspond to small cell type. We have not found any previous report about the association between a paraneoplastic syndrome and pancreatic poorly differentiated small cell carcinoma.

[Acute peritonitis and small bowel diverticula in a patient with mitochondrial neurogastrointestinal encephalomyopathy]

INTRODUCTION

Jejunal and ileal diverticula are acquired lesions that are often associated with intestinal motility disturbances like those occurring in myopathies and neuropathies with visceral affection. Mitochondrial neurogastrointestinal encephalomyopathy is characterized by gastrointestinal dysmotility, cachexia, ptosis with external ophthalmoparesis, neuropathy, leukoencephalopathy and laboratory evidence of mitochondrial alteration.

CLINICAL CASE

A female patient that since 9 months age presented digestive symptoms: diarrhea, nauseous, vomits, slow digestions and abdominal pain. She had myopia. At the age of 20, in a seven months period, she precised urgent abdominal surgical intervention in three occasions for acute diffuse peritonitis related to jejunal and ileal diverticula. She presented cachexia, mild palpebral ptosis, external ophthalmoparesis, hypertrophic major auricular nerves, scoliosis, pes cavus, distal weakness and hypoesthesia in extremities, bilateral neurosensorial hypoacusia and lactic acidosis. The electroneurographic study was compatible with severe chronic demyelinating sensitive motor polyneuropathy. In the cerebral MR leukoencephalopathy was detected. In muscular tissue it was seen alteration in all fibers type I with numerous lipid vacuoles and an increase of mitochondrial number in the form of thick grains and subsarcolemmal mitochondrial bags. There was no ragged red fibers nor ultrastructural mitochondrial alterations. There was chain respiratory complex III deficiency.

CONCLUSIONS

In patients with intestinal dysmotility manifestations and jejunal and ileal diverticula neuropathies and myopathies with visceral affection must be suspected, among them MNGIE syndrome.

[Susac syndrome: clinical and diagnostic approach. A new case report]

INTRODUCTION

The Susac syndrome is made up of the clinical triad: encephalopathy, visual and hearing defects. It is caused by microangiopathy of unknown origin affecting the small arteries of the brain, retina and cochlea. It is very uncommon. It mainly affects young women. The course of the illness is usually monophasic and self-limiting. The deficit of visual acuity is caused by occlusion of tributaries of the retinal artery. The auditory defect is bilateral and symmetrical, and particularly affects medium and low frequencies. NMR is of great diagnostic value, showing multiple lesions in the grey and white matter. Our case gives more data regarding the evolution of this condition and the contribution of cerebral SPECT to diagnosis, the results of systemic treatment, use of hyperbaric oxygen and reflections on the physiopathology of the process.

CLINICAL CASE

We present the clinical case of a young woman who presented with psychiatric symptoms and migraine followed by clinical encephalopathy and acute/subacute coma. There were also visual and auditory deficits. Other types of systemic disease were ruled out.

CONCLUSIONS

Findings on SPECT suggested the presence of a microangiopathic disorder of the brain. The patient responded to systemic treatment with cortico-steroids. The encephalopathy resolved in a few days and two months later she had resumed her former daily activities. Treatment with hyperbaric oxygen definitely reduced visual sequelae.

[Late onset epileptic crisis and cerebrovascular disease]

INTRODUCTION

Stroke is the most frequent cause of epilepsy in adults, specially in those over 60 years old. Our aim was to analyze the etiologic relevance of stroke among the different etiologies of late onset seizures and to evaluate the clinical characteristics of the subgroup of patients with late onset seizures associated to stroke.

PATIENTS AND METHODS

Patients aged over 20 who were admitted to the Neurology or Neurosurgery departments in our hospital for a first-ever seizure over a period of five years were identified retrospectively. The total number of patients included was 248.

RESULTS

The most frequent etiologies were stroke (26.2%), tumors (26.2%), unknown (24.6%) and chronic alcohol intake (18.5%). Stroke was the most frequent etiology in patients over 60 (50%). Five of the 65 patients with stroke related seizures had suffered an intracranial hemorrhage and the rest had ischemic lesions. Seven patients had clinically silent infarctions. Seizures were generalized in 60% of the cases. Nearly in all the patients lesions were placed close to the cortex and mainly in carotid artery territory.

CONCLUSIONS

Late onset seizures are due to a lesion in the brain in an important number of cases. Stroke is the most prevalent cause and this prevalence increases with age. A complete diagnostic procedures is warranted in this patients.

[Cerebral venous thrombosis in the region of Murcia]

INTRODUCTION AND OBJECTIVE

Massive usage of new neuroimaging techniques has produced an increase in the number of patients with cerebral venous thrombosis. Our aim has been to evaluate this shift in our county through the clinico-radiologic characteristics of the patients admitted to our unit.

MATERIAL AND METHODS

Over the last 7 years a total of 12 patients suffering from cerebral venous thrombosis were attended in our department. We have analyzed retrospectively their clinical records.

RESULTS

There were 11 women 1 man with a range of ages from 13 to 60 years old. The main associated factor was oral contraceptives intake. Most of them presented with symptoms of benign intracranial hypertension. Magnetic resonance imaging was the most sensitive diagnostic tool. Outcome was good in general. Most of them were treated with intravenous heparin during the acute phase and received oral anticoagulation for 6 months. More than half were diagnosed all over the last three years.

CONCLUSIONS

Our data seem to confirm this tendency towards a larger number of cases with the application of new diagnostic tools. In these cases, clinical course is more benign than reported in classical series.

[Diagnostic usefulness of glutamic acid decarboxylase antibodies in stiff-man syndrome]

Stiff-man syndrome (SMS) is a rare neurological disorder characterized by progressive rigidity of the axial musculature with superimposed spasms. Frequently, SMS remains undiagnosed for prolonged periods or the patients are diagnosed of a primary psychiatric disorder. 60% of the SMS patients harbor GAD-autoantibodies (GAD-Ab). We have analyzed the diagnostic value of GAD-Ab in a syndrome whose clinical expression is not well known, but its diagnosis is performed by clinical criteria. Five patients were studied following the established clinical criteria for diagnosis of SMS. GAD-Ab were analyzed by radioimmunoassay (RIA) and immunohistochemistry, and confirmed by immunoblot. The GAD-Ab titers were compared with those of 49 patients with insulin-dependent diabetes mellitus (IDDM), 322 with other neurological disorders, 14 non-IDDM first-degree relatives of IDDM patients with antibodies anti-islet cells and 91 normal subjects. Three patients fulfilled all clinical criteria (typical SMS). Unilateral limb symptoms alone, and acute onset with rapid progression involving the distal limb muscles constituted the atypical features of SMS in the remaining 2 patients. The 5 patients presented several serum organ-specific autoantibodies. All but one also presented autoimmune diseases. By RIA, GAD-Ab titers from all patients were elevated (mean: 24,532 +/- 26,892 U/ml) and significantly higher than the titers of IDDM patients without neurological disorders (mean: 48 +/- 112 U/ml) (p < 0.0001). GAD-Ab were absent in the non-SMS patients and in normal subjects. These findings suggest that clinical expression of SMS is more extensive than that recognized by the established criteria. GAD-Ab are helpful to define the clinical spectrum of SMS.

[Delayed diagnosis of phenylketonuria as the cause of mental retardation in an adolescent]

INTRODUCTION

The hyperphenylalaninemias (HFA) form a diverse group of recessive autosomic disorders. They are caused by defects in the hepatic system for hydroxylation of the amino acid phenylalamine to tyrosine. The estimated incidence is approximately 10 cases per 100,000 live births. Children with this metabolic disorder may present with varied neurological symptoms. Control of plasma levels, so that they are more normal as soon as possible after birth, significantly prevents mental retardation and other neuropsychological dysfunction. For this reason HFA has been included in neonatal screening. However, some patients are not detected on screening. When they are adults, these patients pose problems of diagnosis for neurologists who attend adults.

CLINICAL CASE

We describe an adolescent with mental and linguistic retardation, in whom neonatal screening to rule out metabolic defects was normal. At the age of 15, the phenylalanine in blood and urine were found to be raised. On cerebral magnetic resonance changes typical of pheynylketonuria (PKU) were seen.

CONCLUSIONS

The HFA should be considered as causes of cerebral dysfunction in adults, since in spite of neonatal screening, false negatives may occur. We describe a clinical case and consider different forms of hyperphenylaleninemias. Their diagnosis and treatment.

[Neurological manifestations of Paget's disease: presentation of one case and review of the literature]

INTRODUCTION

Paget's disease is a frequent metabolic disease. It is usually diagnosed as a accidental finding. Initial symptoms usually consist of generalized pain in bones. When it affects the Central Nervous System, symptoms usually appear in advanced cases and are due mainly to compression of the spinal cord. Neurological problems as the first manifestation of the disease are exceptionally found.

CLINICAL CASE

We report the case of a woman affected by Paget's disease who presented as a triventricular obstructive hydrocephalus. The patient was 72 years old and consulted first to the emergency ward due to headache, gait disorders and cognitive abnormalities.

COMMENTS

The most remarkable data about this patient are the indolent course of the disease which caused its debut as hydrocephalus associated to basilar impression, its favourable evolution after ventricular drainage and the almost absolute absence of previous similar cases reported in literature all over the last years.

[Cerebrovascular disease in young women]

INTRODUCTION

Cerebrovascular disease is an important cause of morbi-mortality. Although its incidence is maximal in older groups, its incidence in young people cannot be forgotten, even more if we consider the socioeconomic and personal consequences derived from it. There are several works on this subject but few of them analyze the specific problem of stroke in women. There is some degree of controversy in this subject, specially about the role of several factors which are more prevalent or either exclusive for women.

OBJECTIVES

We wanted to analyze the risk factors and clinical characteristics in a group of women under 45 who suffered a stroke and also to compare these risk factors between women under 35 and those from 35 to 45.

MATERIAL AND METHODS

We have carried out a descriptive study, including 61 women under 45 admitted to our centre consecutively between January 1989 and October 1996.

RESULTS

Among the most prevalent factors we have found hypertension (27.8%), tobacco consumption (24.5%) and the presence of cardiac abnormalities (22.9%), specially associated to valvular pathology, as well as a higher incidence of contraceptives consumption in women under 35 (80%).

CONCLUSIONS

These factors are similar to those found in studies on the general population of young people. Our data indicate that the relevance of the main factors for stroke is common for both sexes and is also significant in young patients.

[Stiff-man syndrome. Presentation of a new case]

INTRODUCTION

The stiff-man syndrome (SPR) is a rare neurological condition characterized by the presence of marked, involuntary rigidity of the axial muscles and limbs, together with intense painful muscle spasms which characteristically occur following external stimuli such as sudden noises, brusque movements or emotional stimuli. Symptoms are markedly improved by sleep and by diazepam. The aetiology is unknown, although it is associated with certain auto-immune disorders, particularly diabetes mellitus (DM) and others such as thyroid disease, vitiligo, pernicious anaemia, adrenal insufficiency, etc. The presence of high titres of glutamate-decarboxylase (GAD) antibodies seems to indicate an auto-immune aetiology.

CLINICAL CASE

We describe a 59 year old woman who complained of an illness starting seven years previously with progressive pain and contractions of the dorso-lumbar muscles, which later spread to the cervical and abdominal muscles and to the upper limbs. From the time of onset, there were exacerbations of the condition following external stimuli. Also there was generalized vitiligo and whilst this progressed, DM developed (which finally required insulin to control it). On EMG there was continuous muscular activity and absence of muscle relaxation. The presence of high titres of anti-nuclear antibodies, gastric parietal cell antibodies and anti-GAD was very marked. There was a spectacular response to treatment with diazepam, with progressive improvement although ever increasing dosage was required.

CONCLUSIONS

A new case of the 'stiff-man' syndrome is presented and aspects of aetiopathology and treatment are reviewed.

[Myopathy caused by inhibitors of hydroxymethylglutaryl-coenzyme A reductase]

INTRODUCTION

Hydroxymethylglutaryl-Coenzyme A (HMG-CoA) Reductase inhibitors are a group of drugs widely used for hypercholesterolemia. They are known to originate side-effects on muscles but with a very low incidence of myopathy.

CLINICAL CASE

We present two cases of myopathy induced by HMG-CoA reductase inhibitors. They are two women, who were on 20 mg daily of lovastatin and 30 mg daily of simvastatin and consulted due to weakness, myalgia and a rise in blood levels of muscle enzymes. Both of them recovered completely a few weeks after withdrawal of the drugs.

COMMENTS

Usage of this group of drugs is wide. Their side effects are rare but it is important to remember their capacity to induce a myopathy, usually reversible upon withdrawal of the drug.

[Risk factors in recurrent febrile seizures]

INTRODUCTION

Febrile convulsions are the most frequent type of seizures in children under 6 years old. They usually have a good prognosis. Only a few of these children will later suffer from non-febrile seizures. The low risk of non-febrile seizures and important side-effects of antiepileptic drugs have limited the use of continuous prophylaxis in children with recurrent febrile seizures.

OBJECTIVES

Our aim has been to identify the main factors that imply a higher risk for recurrent febrile convulsions and also to identify the frequency of antiepileptic prophylactic medication in our area.

MATERIAL AND METHODS

We have carried out a protocoled study in children which were sent consecutively and with no previous selection to a reference electroencephalography (EEG) outpatient unit in Murcia with the clinical diagnosis of febrile convulsions. Data included have been: sex, actual age and age at the time of the first seizure, total number of seizures, family and personal history of either febrile seizures or epilepsy, EEG findings, treatment and side-effects. Data collection was accomplished between September 1991 and June 1993. A total of 509 patients have been included.

RESULTS

A 34% of the children had suffered two or more seizures. Children with recurrent seizures were younger at onset (16.7 vs 21 months) and had more often family history of febrile seizures (40.6% vs 28%) and epilepsy (21.5% vs 12.5%). 60% of the children who had family history of febrile seizures of epilepsy and who suffered the first episode before the age of 16 months had recurrent febrile convulsions.

CONCLUSIONS

An age under 16 months at the moment of the first convulsion and the existence of family history of febrile seizures or epilepsy increase the risk of recurrent febrile seizures.

[Pontine hemorrhage as a cause of peripheral facial paralysis]

Bell's palsy is the most frequent type of peripheral facial nerve paralysis. Nevertheless there are other less frequent causes of peripheral facial palsy, among which, we can find lesions in the brain stem affecting the seventh cranial nerve nucleus or its fibers. These lesions of the pons which paralyze the muscles of the face are often accompanied by lesions to other structures in the vicinity of the nucleus. We present the case of peripheral facial nerve palsy caused by hemorrhage in the pons, seen both on brain CT-scan and MRI, which affected the nucleus of the seventh cranial nerve and was not accompanied by any other clinical manifestations due to lesions of structures placed in the vicinity of this nucleus.

[Meningiomas of the lateral ventricles: a case report]

We describe the case of a patient with an intraventricular meningioma, which initially manifested as transient mental impairment. Meningiomas are slowly growing, bening tumours, which usually remain asymptomatic or show only insidious clinical manifestations for long periods. In our case the distinct localization of the tumor gives rise to a peculiar clinical picture, with special reference to the episodic nature of symptoms. In this case we want to remark the role of both the clinical and neuroradiological data in the diagnosis of this pathology.

[Familial paroxysmal ataxia: a new case]

Over the last years several families affected of a clinical syndrome characterized by sudden ataxia, related to physical or mental stress, and lasting a few days have been described. Intercritical exploration is otherwise normal. We describe a new case which presents the clinical, laboratory and neuroradiological data characteristic of periodic familial ataxia. The patient is a 34 year old male who from his 23 has suffered three crisis of gait inestability, ataxia of trunk and limbs and spontaneous nystagmus in every direction, which increased in association with head movement. These episodes were always in relation with fatigue and stress and have decreased in severity. Mean duration of crisis has been 4 to 6 days. After starting treatment with acetazolamide there have no new crisis. In this case we have found no family history of the disease as it was the rule in previous description.

[Intraparenchymatous hemorrhagic pathology in patients aged over seventy: a comparative study with younger subjects]

The aim of our study was to compare a group of over 70 year-old patients suffering from spontaneous intracerebral haemorrhage with a similarly affected group under 70 years of age. With this in mind we carried out a prospective study of all patients admitted to the Neurology Service at the Virgen de la Arrixaca Hospital between March and December 1993. They totalled some 67 patients, 33 being over 70 years of age and 34 being younger than 70. Although our data clearly show that age is a factor indicative of bad prognosis, we found no other differences between these two groups which might justify these data with the exception of a greater prevalence of consciousness abnormalities at the moment of onset in those patients aged over 70. This fact, ascertained using the Canadian scale, may, we feel, be useful in dealing with patients presenting clinical pictures compatible with brain haemorrhage who attend hospitals not having computerized tomography.

[Intermittent acute porphyria in the region of Murcia]

Forty-three cases of intermittent acute porphyria (IAP) in 19 families grouped along the riverside of the Segura River in the region of Murcia (1,000,000) were collected. Twenty nine cases had the typical clinical manifestations of the disease, 22 with analytic confirmation. Fourteen asymptomatic disease carriers were detected by determination of the uro-synthetase activity. Out of 22 hospitalized patients, 18 presented neurologic manifestations, 13 with polyneuropathy mainly of the proximal type. In some cases weakness extended distally. In the few cases in whom the polyneuropathy was initially distal there was never a Landry type of ascent. The most severe cases of polyneuropathy left characteristic sequelae in the hands.