Role of nurses and the nursing assistants in the implementation and monitoring of physical restraint in psychiatry

Introduction

Physical restraint is a therapeutic procedure allowing to immobilize an agitated patient.Although it is an effective method especially in the states of psychomotor instability, its practice is not devoid of risks which imposes a codified technique with particular monitoring.

Objectives

The aim of this work was to evaluate the knowledge of nurses and nursing assistants in the practice and monitoring of physical restraint and to establish a suitble protocol codifing it.

Methods

Our study was a descriptive cross-sectional study based on a questionnaire grouping together a set of questions on general and professional characteristics, the decision of physical restraint, its prescription, its means, its monitoring, informing the patient and his relatives, physical restraint’s risks, the patient’s experience, the caregiver’s experience as well as the relationship between caregiver and patient. Our target population was composed of nurses and orderlies of the psychiatry department <<D>> of the Razi hospital in Manouba.

Results

We collected 30 professinals.90% of them were women. 30% of our sample had less than five years of experience. Only 23.30% of caregivers had mental health training at the beginning of their professional career. 50% of them received training focused on physical restraint.83.30% reported using physical restraint for psychomotor agitation.56.6% ignored the psychological effects of the physical straint on patients. 73.3% of caregivers informed patients before straint.

Conclusions

A physical restraint protocol, codifying the technique of implementation and monitoring parameters is needed in order to improve the relation patient-cargiver and ensure an optimal care .

Disclosure

No significant relationships.

Assessment of anxiety related to Covid-19 in the elderly in Tunisia

Introduction

The COVID-19 pandemic has several risks particularly in the elderly, such a high death rate and severe forms.The risk also involves significant psychological distress especially anxiety.

Objectives

Assessment of anxiety symptoms due to COVID 19 in elderly subjects in Tunisia.

Methods

A cross-sectional descriptive study on a sample of 50 people aged between 65 and over. Data was collected using a questionnaire and a COVID Anxiety Rating Scale “Fear of COVID-19 Scale”.

Results

We found that most subjects agreed or strongly agreed that they were afraid of Corona and that 54% agreed or strongly agreed that they felt uncomfortable thinking about the Corona. Physical symptoms like having sweaty hands, or having palpitations related to the fear of having the disease were reported by 24% of the subjects. Almost half of the respondents (46%) were afraid of losing their lives due to Corona. Most subjects (66%) reported that they became nervous or anxious when viewing information posted on social media on Corona. Insomnia related to worries about having COVID was reported in 12% of subjects. We were able to retain that most of the subjects (68%) had a mild level of anxiety and that 30% of the subjects had a moderate level. No subject had severe anxiety.

Conclusions

Low to moderate level of fear due to the COVID 19 pandemic was observed among Tunisian elderly according to this study. This leads us to conclude that assessment of anxiety particularly in seniors should be more systematic.

Disclosure

No significant relationships.

Assessment of worries and attitudes towards the COVID-19 pandemic and the vaccine among Tunisian elderly

Introduction

The COVID-19 pandemic poses a threat particularly to the elderly. Although the current vaccination strategy is recognized as an adequate measure to reduce mortality, it still raises concerns about its efficacy and safety.

Objectives

Assessment of worries and attitudes among Tunisian elderly towards the pandemic.

Methods

A descriptive cross-sectional study on a sample of 50 consultants in a geriatric service, aged between 65 years and over. A questionnaire was formulated based on the recommendations of WHO and INEAS.

Results

The average age of our population is 74.6 years. The participants were mainly female, retired (76%) and with low educational attainment. Most of the elderly reported that they respected the wearing of the mask in public (90%) and washing their hands regularly (92%). Social distancing was respected by only 44% of the participants. Concerning the vaccine registration, we noted that 48% of the subjects expressed their willingness to register on the Evax.tn platform. On the other hand, 15 people expressed their refusal to receive the anti-Covid vaccine. We noted that only 22% had a dose of the Covid-19 vaccine. Only 4% of the respondents did not have concerns about new variants of the virus. About half (52%) of the subjects expressed significant concern about an increased risk of virulence and mortality due to the new variant. Vaccination was considered ineffective by most of the participants (70%).

Conclusions

Addressing worries about vaccine would be an important step to accept it among Tunisian elderly. Adequate information strategy is essential to change attitudes during the pandemic.

Disclosure

No significant relationships.

Gender disparities in a psychiatric department in Tunisia

Introduction

Gender disparities exist regarding prevalence, symptomatology and risk factors of mental disorders. In Tunisia, there is only one hospital dedicated entirely to mental health which is Razi hospital.

Objectives

The aim of the present study was to assess gender based mental health disparities in a psychiatric department and its related factors.

Methods

A cross sectional and comparative survey was conducted between March and April 2021 in the department of psychiatry D of Razi Hospital including 70 patients with a sex ratio= 1.

Results

The participants were aged between 17 and 68. Men had higher rate of celibacy: 80% of men against 48.57% of women (p=0.009). A total of 11.42% of women were illiterate against 2.85% of men, 48% of men were unemployed against 62.85% of women. There was a significant difference between gender and use of cigarettes, cannabis and alcohol (p<0.001). The diagnosis was mood disorders for 35.42% of women and 17.14% of men and schizophrenia for 57.14% of women and 77.14% of men. Gender and modality of hospitalization were significantly associated (p=0.046): 14% of women were involuntary hospitalized against 40% of men. Time between symptoms onset and consulting is 3.5 years (±5.67) for women and 1.77 (±4.75) for men. The mean number of admissions for women is 1.59 and for men 4.2 (p=0.009).

Conclusions

Onset of mental disorders for women is 3 to 4 years later than men. They have better premorbid functionning and better social networks.Gender disparities are not only determined biologically but also socially.

Disclosure

No significant relationships.

Capgras syndrome and poor facial emotion recognition

Introduction

Capgras syndrome is a disorder of personal identification characterized by the delusional belief that one or more persons close to the subject have been replaced by physically identical doubles.

Objectives

To deepen our knowledge of the Capgras syndrome

Methods

A case report about a Capgras syndrome.

Results

We report the case of a 46-year-old female patient who was admitted in February 2021 for incoherent speech and behavior disorder against her family members. Three years ago, she started to have hypochondriacal concerns. A week before her admission, she threatened her husband with a knife and she was convinced that her daughters were dead and that they had been replaced by clowns. She had a Capgras delusion with a hallucinatory and interpretative mechanism against her daughters, she reported olfactory and cenesthetic hallucinations. Biological explorations and brain CT were normal. The PANNS scale showed a positive scale of 36, a negative scale of 39, the general psychopathology scale of 53. She had a total score of 30/40 on The Penn emotion recognition test. The patient had difficulty in recognizing low intensity emotions (0 or 1) and 50% of the false responses were for the neutral emotion with responses tending towards anger first and then sadness.

Conclusions

Capgras syndrome remains poorly described in the literature and the hypotheses concerning its origin often oscillate between neuropsychological and psychodynamic. With the recent advances in neuroscience, it would be interesting to deepen its physiopathology in order to place it in a more modern nosological framework.

Disclosure

No significant relationships.

Rural-urban differences in accessing mental health care in Tunisia

Introduction

Despite improvement of mental health outcomes over the last years in Tunisia, there are still striking rural-urban mental health inequalities.

Objectives

The aim of this study is to evaluate the rural-urban differences in accessing mental health care among patients with psychiatric disorders

Methods

A cross sectional and descriptive survey was conducted between March and April 2021 in the department of psychiatry D of Razi Hospital including 70 patients admitted or treated as outpatients. The sex ratio was 1.

Results

The participants were aged between 17 and 68. About 11.42% came from rural areas. In these areas, 75% percent had low income versus 30.64% in urban areas. (p=0.047) The percentage of celibacy in urban areas was 68.85% versus 37.5% in rural areas (p=0.042) No significant difference was observed between the level of education and living in rural or urban areas. There was no association between rural or urban origin and number of admissions or treatment adherence or use of cannabis. The mean time between symptoms onset and consulting was 8.51 years in rural areas versus 2 years in urban areas. Moreover, time between symptoms onset and admission was significantly associated with rural or urban origin (p=0.045). The mean duration was 13,33 years (±10) in rural areas versus 3.12 years (±4.13).

Conclusions

Families living in urban areas had better income and would come to psychiatric hospital earlier. Therefore, we should help patients in rural areas access to mental health facilities for a better medical care.

Disclosure

No significant relationships.

Women’s access to mental health care in Tunisia

Introduction

Tunisia is viewed as an advanced country in terms of women’s rights in the Arab world. However, women are more exposed than men to many specific risk factors which greatly contribute to threaten their mental health.

Objectives

The main objective of this study was to find out the sociodemographic and clinical profiles of women admitted in Razi psychiatric hospital and their access to mental health services.

Methods

A cross sectional and descriptive survey was conducted between March and April 2021 in the department of psychiatry D of Razi Hospital including 40 female inpatients.

Results

The majority of patients had low (37.1%) to moderate (61.9%) socio economic status, with primary education (40%), secondary education (20%) and higher education (28.6%). The majority was unemployed (68.8%). A significant difference was observed between adherence to treatment and family support (p=0.04). It was mainly the father or the husband who was taking care of the patient in 50% of cases. The first psychiatric consultation was 2.68 years after having symptoms. Hospitalization was about 4.94 years later. Twenty five percent of them have seen a tradipractioner before consulting. About 46.87% of patients had conflicts with a member of her family and 15.62% of them were victims of either domestic or family violence. The main diagnoses were mood disorders (31.4%) and schizophrenia (42.9%) Time between symptoms onset and hospitalisation was significantly associated with socioeconomic status (p=0.047) and cultural beliefs (p=0.026).

Conclusions

The protection of women’s mental health is not only a medical challenge but also a cultural and political one.

Disclosure

No significant relationships.

Clozapine induced oesophagitis: A case report

Introduction

There are several case reports describing clozapine side effects such as agranulocytosis, constipation,tachycardia but rarely cases describing oesophagitis caused by clozapine were reported.

Objectives

To report the first case in our country about clozapine induced oesophagitis.

Methods

We describe a case in which a patient who has no gastrointestinal past history,has developed an oesophagitis stage 2 of Savary and Miller Classification without any gastroesophageal reflux disease, few weeks after introducing clozapine at therapeutic dose.

Results

A 25 years old male patient with resistant schizophrenia managed with clozapine,was admitted to reinitiate his treatment after weeks of stopping his medication.During hospitalization, our patient developed a sudden haematemesis in 10 days after commencement of clozapine. The patient had no history of gastrointestinal symptoms or disease. The clinical examination and blood tests did not find any signs of bleeding severity.A gastroscopy was performed, revealing esophagitis stage 2 of Savary and Miller classification and a cardiac polyp removed with biopsy forceps that showed no malignant lesions .The patient was treated with acid suppressant therapy.There was no further episode of haematemesis and our patient healed uneventfully within a week.As for clozapine, it wasn’t interrupted and we continued increasing doses very carefully with no further incident.

Conclusions

Although it is a rare side effect, oesophagitis may appear at therapeutic doses of clozapine, and this possibility should be taken into account when treating patients with resistant psychiatric disorders.

Disclosure

No significant relationships.

Role of nurses in the initiation and the monitoring of Lithium

Introduction

Lithium is the oldest known treatment of bipolar disorders and remains the gold standard. Nevertheless, it remains difficult to handle, largely due to its narrow therapeutic index and its long-term side effects. Thus, it requires special initiation and monitoring measures.

Objectives

This study aims to assess nurses’ knowledge and attitudes regarding lithium. A protocol on Lithium initiation and monitoring will be established.

Methods

This is a descriptive study including 20 nurses in a psychiatry department conducted from January to May 2021 based on an self-assessment questionnaire that was established to assess nurses’ knowledge about Lithium, its side effects, initiation and monitoring.

Results

None of the recruited nurses had any training regarding the use of lithium. The vast majority of subject (85%) said that lithium’s dosage must be individualized and adaptable to each patient throughout a specific blood test. 90% recognized renal failure as the most common contraindication of lithium. Complete Blood Count (CBC), and renal check-up were the only tests recognized as necessary by all the sample subjects. 90% answered that lithium is toxic and 65% answered that it is fatal. In case of toxicity by lithium all subjects (100%) agreed to call the responsible doctor of the patient, 25% of them chose it as a unique measure and 75% thought it was necessary to stop the lithium immediately as well.

Conclusions

Lithium is considered as a double-edged sword largely due to its narrow therapeutic index. Nevertheless, nurses are undertrained when it comes to its use and manipulation.

Disclosure

No significant relationships.

A possible explanation for resistance in schizophrenia

Introduction

Arachnoid cyst is a neurological tumor. It’s rare and benign. Its association to psychosis has been described in literature.

Objectives

Through a case report and a review of the literature we hypothesize that arachnoid cyst is the cause of resistance in a patient with schizoaffective disorder.

Methods

Starting from a case report, we conducted a literature review on “PubMed”, using key words “arachnoid cyst”, “arachnoid cyst a psychiatry”, “arachnoid cyst and schizoaffective disorder”, “arachnoid cyst and schizophrenia”

Results

Mr. AA is 50 years old, has diabetes treated with metformin, hypercholesterolemia and celiac disease under gluten free diet. He has been diagnosed with schizoaffective disorder in 1992, initially put on haloperidol and carbamazepine. Since the patient wasn’t getting better, we suspected no-compliance so we switched haloperidol for fluphenazine decanoate. The patient still suffered from persecutory delusion and auditory hallucinations. We started him on clozapine still with no improvement. So, we concluded to the resistance of schizoaffective disorder considered electroconvulsive therapy (ECT). A cerebral MRI was conducted, prior to ECT, objectifying a left anterior frontal arachnoid cyst of 26 millimeters from the main axis producing a mass effect on the cerebral cortex. This neurological tumor didn’t require neurosurgery.

Conclusions

Our patient was resistant to all treatments including clozapine. The only anomaly discovered was the arachnoid cyst. Could this explain the resistance of this patient and others like him? Could this be an interesting research path to further elucidate the mystery of metal disorder?

Disclosure

No significant relationships.

COVID-19: Studying dissociative experiences in a confined sample of tunisian people

Introduction

Dissociative experiences have been studied in different circumstances.

Objectives

In this study we aim to analyze dissociative phenomena under a stress factor: lockdown.

Methods

We conducted a cross sectional-study, using an online survey, spread during lockdown period in Tunisia, between the 2nd and the 8th of April. It was comprised of sociodemographic, geographic, medical history, confinement status and DES-II questionnaire in its french version. Age superior than 18 was the only inclusion criteria and the no respect of lockdown was the exclusion criteria. Based on former studies on DES-II, 3 sub scores have been assessed; amnesia (measures memory loss), depersonalization (sense of unreality of the self ) and absorption (the absorption has to do with one’s traumatic experiences).

Results

We recruited 167 individuals; 100 women and 67 men. The most common age class was 20 to 30 years old (60.5% of the sample). The Mean total score was 11.06 which was higher than mentioned in earlier studies. The mean score was 15,11 for absorption; 5,28 for amnesia and 6,88 for depersonalization subscale. Significant differences in scores were found based on different variables. Women had higher absorption score (p=0.011). Besides people living in COVID-19 clusters had lower total score (p=0.038). Finally, people with somatic medical history showed higher total score (p=0.013), absorption score (p=0.003) and depersonalization score (p=0.012) compared to those with none.

Conclusions

During lockdown, dissociative experiences showed to be more frequent. But does this mean that a resurgence in PTSD (posttraumatic stress disorder) or ASD (acute stress disorder) in the months to come.

Prevalence of maternal burn out and depression in tunisia during the coronavirus pandemic

Introduction

Lockdown due to coronavirus pandemic has been a stressful experience especially to mothers. Juggling work from home and childcare has led to maternal burn out and depression.

Objectives

The aim of the present study was to assess maternal burn-out rate during lockdown and its eventual relationship with depression and associated factors

Methods

156 Tunisian mothers responded to online questionnaire posted on social network after 1 month of lockdown. The questionnaire evaluated burnout and depression as measured by the Maslach Burnout Inventory (MBI) and depression and anxiety symptoms (HADS) respectively.

Results

The participants were aged between 24 and 64 years and 61.5% had more than one child. Mean score on the BMS10 was 4.11 out of 7 maximum score with 71.8% of participants fulfilling criteria for maternal burn-out. Among them, 30.1% had high level of burn out and 9.6% extreme burn out. The main factors associated with maternal burn out were age of children, financial difficulties and lack of leisure activities. Mother’s age, perceived husband support, medical or psychiatric history haven’t been associated with maternal burn out. HADS questionnaire indicated that 38.5% of mothers had moderate to severe anxiety disorder and 35,9% had moderate to severe depressive disorder. A postive correlation was found between burnout and anxiety (r=0.634, p<0.001) and burn out and depression (r=0.515, p<0.001).

Conclusions

The prevalence of maternal burn out during lockdown was significantly high resulting in higher rate of depression than ususal. However, severe forms of burnout may share several characteristics with depression raising the question of overlap of these two entities.

Association of high-sensitivity C-reactive protein with susceptibility to Schizophrenia in Tunisian population

The pathogenic mechanisms underlying Schizophrenia (SZ), one of the most frequent mental disorders, are complex and poorly understood. Several evidences suggest that inflammatory processes may underpin some of its neurobiological correlates. The aim of this study was: (i) to analyze the potential association between circulating levels of the C-reactive protein (CRP), a crucial inflammatory marker, and Schizophrenia in Tunisian patients and healthy controls (HC) cohorts; (ii) to investigate the genetic diversity of three CRP variants (rs1417938, rs1130864 and rs1205) and; (iii) to analyze a potential relationship between expression and genetic data and clinical and socio demographical characteristics. CRP polymorphisms were exanimated for 155 patients and 203 HC by taqMan5'-nuclease. High-sensitivity CRP (hs-CRP) serum level was measured in 128 clinically stable out-patient SZ patients and 63 HC subjects via an automated biochemical analyzer. We found that hs-CRP levels were significantly higher in SZ patients as compared to HC. No significant differences were found when the proportions of CRP variants were compared in patients and HC. Further analysis according to clinical and socio demographical characteristics revealed a positive association with age and hypertension. Our data on an original Tunisian sample confirm the previous finding in others population groups.

L-2-hydroxyglutaric aciduria: clinical and molecular study in three Tunisian families. Identification of a new mutation and inter-familial phenotype variability

We report clinical and molecular studies in three unrelated Tunisian families containing seven patients with L2HGA. Although the age of onset is similar in all these patients at nearly 6 years, they progressively developed peculiar clinical phenotypes different from family to family. The three patients of family 1 showed mental retardation, epilepsy, cerebellar ataxia and pyramidal and pseudobulbar syndromes. The two patients of family 2 showed mental retardation and parkinsonism especially extrapyramidal stiffness, dystonia and myoclonus. The two patients of family 3 showed an intermediate phenotype; they share some clinical signs of the patients of family 1 (epilepsy, pyramidal and extrapyramidal syndromes) and some clinical signs of the patients of family 2 (extrapyramidal stiffness and dystonia). Molecular study identified a novel homozygous c.185C>A, p.A62D mutation on the L2HGDH gene in families 1 and 3 and the already known homozygous c.241A>G, p.K81E mutation in family 2. We suppose that the type of mutation in the L2HGDH gene does not play a complete role in the inter-familial phenotype variability. Disturbance of other unknown metabolic pathways related to L2HGA may contribute to this phenomenon.

Wilson's disease: appreciable improvement of sub-cortical white matter abnormalities after copper chelating treatment: five years follow-up

Severe sub-cortical white matter abnormalities are unusual features in Wilson's disease and are reported to be poorly or not responsive to copper chelating therapy or to be worsened by it. We report on a 12-year-old boy with Wilson's disease and extensive sub-cortical white matter involvement. After five years of copper chelating therapy, an appreciable improvement of these lesions was obtained. The physiopathology of these unusual cerebral white matter abnormalities is discussed.

Osteoma of the calvaria in L-2-hydroxyglutaric aciduria

L-2-Hydroxyglutaric aciduria (L-2-OHGA) is a rare autosomal recessive neurometabolic disease linked to chromosome 14q21.1 and is caused by mutations in the gene that most likely encodes L: -2-hydroxyglutarate dehydrogenase, which normally catalyses L: -2-hydroxyglutarate to alpha-ketoglutarate. It is characterized by progressive mental deterioration, pyramidal and cerebellar syndromes, macrocephaly and marked polycystic white-matter degeneration mainly involving frontal lobes. Brain tumours of variable nature have frequently been observed in L-2-OHGA. We report a patient affected by this disease who at the age of 20 years developed a bone tumour involving the right frontal region of the calvaria. He had first presented at the age of 10 years with psychomotor delay, clumsy gait and moderate mental impairment. Examination showed macrocephaly, cerebellar ataxia and quadripyramidal syndrome. Brain MRI showed low signal intensities on T1-weighted images and high signal intensities on T2-weighted images in cerebral subcortical white matter. Serum and urinary amino acid assay was normal. Urinary 2-hydroxyglutaric acid was 1418 mmol/mol creatinine (controls <25). Analysis of the L-2-hydroxyglutarate dehydrogenase gene revealed a homozygous mutation in exon 2 (A320G). At the age of 20 years, an osteoma of the right frontal bone was diagnosed. This finding reinforces the opinion concerning the association of L-2-OHGA and tumorigenesis and prompted us to verify the possible responsibility of some overproduced substances in this disease for the development of tumours and to look for any correlation between the type of mutation in the L-2-OHGA gene and the tumorigenic potential observed in some patients affected by this disease.

Paralysie du regard latéral et scoliose progressive : à propos de 4 familles tunisiennes

In 1975, Sharpe and Silversides described a neurological entity in a Chinese family. Clinical picture was characterized by paralysis of horizontal gaze, pendular nystagmus and progressive scoliosis. To date, 43 cases have been reported. The pathogenesis remains unclear. The Authors report four Tunisian families with 12 affected individuals. The age of patients ranges from 6 to 34 Years. All examined patients have complete lateral gaze palsy, pendular nystagmus and progressive scoliosis. Blood routine tests, cerebrospinal fluid (CSF), evoked potentials, electromyography (EMG), muscle biopsy, CT scan and cerebral MRI were normal. Autosomal recessive (AR) mode of inheritance is the most probable pattern.

Nasu-Hakola disease in two Tunisian siblings: new radiological findings

We report radiological features of a biopsy-proven early infantile form of Nasu-Hakoka disease in two Tunisian sisters with new bony and cerebral findings.

Prognostic factors in congenital hemiplegia in full-term and preterm children

OBJECTIVES

To determine whether the cerebral CT scan patterns, the type of E.E.G recording, the gestational age, the etiological factors and the side of hemiplegia would influence the functional prognosis in congenital hemiplegia.

MATERIAL AND METHODS

53 children (35 males, 18 females) suffering from congenital hemiplegia were included in the study. They were divided into prematures (16 cases) and full-term children (37 cases). All of them were evaluated for I.Q level, motor performance and language ability. CT scan was performed in all cases and E.E.G recording in the majority of them.

RESULTS

Full-term gestational age, cortical and subcortical lesions in term children, irritative E.E.G recording and hemispheric atrophy in both gestational age groups were found to be bad prognostic indicators for functional status in congenital cerebral hemiplegia.

Localization of alpha-tocopherol transfer protein in the brains of patients with ataxia with vitamin E deficiency and other oxidative stress related neurodegenerative disorders

Vitamin E (alpha-tocopherol) is an essential nutrient and an important antioxidant. Its plasma levels are dependent upon oral intake, absorption and transfer of the vitamin to a circulating lipoprotein. The latter step is controlled by alpha-tocopherol transfer protein (alpha-TTP), which is a 278 amino acid protein encoded on chromosome 8, known to be synthesized in the liver. Mutations in alpha-TTP are associated with a neurological syndrome of spinocerebellar ataxia, called ataxia with vitamin E deficiency (AVED). Earlier studies suggested that alpha-TTP is found only in the liver. In order to establish whether alpha-TTP is expressed in the human brain, and what relationship this has to AVED, we studied immunohistochemically the presence of alpha-TTP in the brains of a patient with AVED, normal subjects, and patients with Alzheimer's disease (AD), Down's syndrome (DS), cholestatic liver disease (CLD) and abetalipoproteinemia (ABL). The neuropathology of both AD and DS is thought to be related in part to oxidative stress. The diseases of AVED, of cholestatic liver disease, and of abetalipoproteinemia are thought to be due to lack of circulating tocopherol, leading to inadequate protection against oxidative damage. We demonstrate the presence of alpha-TTP in cerebellar Purkinje cells in patients having vitamin E deficiency states or diseases associated with oxidative stress.

Juvenile form of dihydropteridine reductase deficiency in 2 Tunisian patients

Two brothers are described who had juvenile-onset DHPR deficiency. Both were considered normal until six years of age when they developed a fluctuating and progressive encephalopathy combining mental retardation, epilepsy, pyramidal, cerebellar and extrapyramidal signs.

A clinicopathological observation of Nyssen-van Bogaert syndrome with second motor neuron degeneration: two distinct clinical entities

OBJECTIVES

To report a novel clinicopathological observation of Nyssen-van Bogaert syndrome. To compare this observation with those previously reported. To discuss the nosological entity of this syndrome. To define the exact etiopathogenic mechanism of the neurogenic amyotrophy occurring at the late stage of the disease.

MATERIALS AND METHODS

The patient was a 16-year-old girl who developed loss of vision and deafness at the age of 8. Ataxia with slight cerebellar signs were present by the age of 14. Over the next 2 years, she developed distal weakness and wasting of the legs with depressed ankle reflexes. She died at the age of 16. Deparaffinized sections of the brain, the brain stem, the cerebellum and the spinal cord were stained with haematoxylin & eosin (H&E), Nissl, Woelcke, Bodian, periodic acid-schiff (PAS), Sudan Black and Kluver Barera. Antibodies anti-GFAP, anti-MPB and anti-neurofilaments were used for immunohistochemical stainings following the avidin-biotin-peroxydase complex (ABC) methods.

RESULTS

The clinical pictures in our patient are similar to those previously reported in juvenile patients with optico-cochleo-dentate syndrome. Pathological study of the nervous system confirmed the diagnosis of Nyssen-van Bogaert syndrome and also showed a severe anterior horn, posterior horn and Clarke's column nerve cell degeneration with anterior root atrophy.

CONCLUSION

From these clinical and pathological data, the authors suggest to include Nyssen-van Bogaert syndrome among the group of multiple system atrophy, propose to divide this syndrome into 2 forms (an early infantile form and a juvenile form) and consider that the neurogenic amyotrophy occurring at the late stage of the disease in juvenile and adult patients is mainly caused by the second motor neuron involvement.

Dihydropteridine reductase deficiency in a large consanguineous Tunisian family: clinical, biochemical, and neuropathologic findings

We report the case of a large consanguineous Tunisian family of seven siblings suffering from dihydropteridine reductase deficiency with either typical clinical, biochemical, or autopsy findings. Two cousins also were reported to have the same symptoms. This metabolic disorder is characterized by severe microcephaly, psychomotor regression, and progressive basal ganglia calcifications. Dihydropteridine reductase assay on samples collected from the two brothers still alive did not show measurable activity. The sister and four brothers died between the ages of 3 years and 7 years. A neuropathology study done on the sister showed diffuse demyelination throughout the white matter and spongy vacuolation in the subthalamic nuclei, the superior cerebellar peduncles and the tegmentum tracts of the brain stem. The anterointernal part of the putamen was completely necrotic with nearly total nerve cell loss. Abnormal vascular proliferation and calcification of the walls of small, medium, and large arteries and veins, as well as diffusely scattered pericapillary and isolated calcospherites, were seen in this necrotic region. We think that folate deficiency may be involved in the pathogenesis of the basal ganglia calcification.

Electrophysiology and nerve biopsy: comparative study in Friedreich's ataxia and Friedreich's ataxia phenotype with vitamin E deficiency

The authors report a comparative study of peripheral nerve conductions and nerve biopsy and somatosensory evoked potentials between 15 patients with Friedreich's ataxia and 15 patients with Friedreich's ataxia phenotype with selective vitamin E deficiency. The patients in the two groups are of similar age, age of onset, and clinical phenotype. Peripheral motor nerve action potential amplitude, and conduction velocities are within normal ranges in the two groups. In the Friedreich's ataxia group there is an early and severe peripheral sensory axonal neuronopathy, characterised by an important reduction of the amplitude of sensory action potential, and important loss of myelinated fibres with complete disappearance of large myelinated fibres without any regenerative process. In the Friedreich's ataxia phenotype with selective vitamin E deficiency group there is slight-to-moderate axonal sensory neuropathy with normal to moderate decrease of large myelinated fibre density and important regeneration in nerve biopsy. Somatosensory evoked potentials are markedly involved in the two groups asserting a severe involvement of somatosensory pathway in lumbar, thoracic and cervical spinal cord. These findings suggest that the pathological mechanism involved in the two diseases are different: central peripheral axonopathy in Friedreich's ataxia and central distal axonopathy in Friedreich's ataxia phenotype with selective vitamin E deficiency.

Methylmalonic acidaemia with bilateral globus pallidus involvement: a neuropathological study

A 16-month-old boy was hospitalized because of a 1-day history of severe ketoacidosis with lethargy, hypotonia, vomiting, and important dyspnoea. Organic acid assay by gas chromatography-mass spectrometry confirmed the diagnosis of methylmalonic acidaemia (MMA). On the sixteenth day, he developed an acute extrapyramidal disorder. The CT scan of the brain disclosed bilaterally symmetric lucency of basal ganglia. He died at 17 months of age. Post-mortem neuropathological examination, showed severe necrosis with spongiosis, cystic cavitation and numerous lipid-laden macrophages of the globi pallidi, and mild spongiosis of subthalamic nuclei, mammillary bodies, portion of internal capsule adjacent to globus pallidus, superior cerebellar peduncles and tegmentum of brainstem. Pallidal infarction, a focal ischaemic lesion, demonstrates that ischaemia/energy depletion may be important in the etiology of the neuropathology of MMA.

Atypical ataxia telangiectasia with early childhood lower motor neuron degeneration: a clinicopathological observation in three siblings

We report three brothers belonging to a consanguineous family and suffering from ataxia telangiectasia with severe early neurogenic amyotrophy. Pathological examination of the brain and spinal cord in one of them showed Purkinje cell loss with empty baskets and numerous axonal spheroids, dorsal column demyelination with astrocytic proliferation and severe anterior horn cell degeneration. We consider these pathological findings to be related to Louis-Bar disease. Anterior horn cell changes may be one of the early pathological features in ataxia telangiectasia.

Friedreich's ataxia with isolated vitamin E deficiency: a neuropathological study of a Tunisian patient

The neuropathological findings in a Tunisian patient with Friedreich's ataxia with vitamin E deficiency are reported. The main histological changes are: (1) spinal sensory system demyelination with neuronal atrophy, axonal spheroids and corpora amylacea; (2) neuronal lipofuscin accumulation in the third cortical layer of the cerebral cortex, thalamus, lateral geniculate body, twelfth and ambiguus nuclei, spinal horns and posterior root ganglia. Ultrastructurally, the lipopigments were of uniform granularity without lipid droplets.

Clinical and pathological study of three Tunisian siblings with L-2-hydroxyglutaric aciduria

This report describes three brothers belonging to a consanguineous family suffering from a progressive neurological disorder associated with L-2-hydroxyglutaric aciduria. Clinically this disorder is characterized by childhood onset, pyramidal signs, cerebellar and pseudobulbar syndromes and epilepsy. Pathological examination of the brain in the oldest patient, who died at the age of 30 years, showed bilateral and diffuse spongiosis with notable cystic cavitations of the cerebral white matter without abnormal storage in neurons and glial cells. We consider that these findings are related to L-2 hydroxyglutaric aciduria. To our knowledge this present case represents the first to be reported with neuropathological examination.

[Congenital fibrolipoma of the mesencephalic protuberation area]

BACKGROUND

Congenital origin of brain fibrolipoma is still debated. A case of such a tumor is presented.

CASE REPORT

A female newborn presented with severe hypotonia and macrocephaly that were seen since birth. She died at the age of 2 days. Post-mortem examination showed hydrocephaly due to a tumor located in the mesencephalo-protuberantial region. Histological features of this tumor were those of a fibrolipoma.

CONCLUSION

The presence of this brainstem tumor at birth confirms its congenital origin.

[Amebic brain abscess. Apropos of a case]

We report a case of double primary amoebic brain abscess in a 22 year old man, with signs of intracranial hypertension and deficit. Computed tomography found two hypodense lesions, not suggestive of pyogenic abscesses. Aspiration of one of the two abscesses, revealed the organism, and the two abscesses regressed in response to medical treatment. The authors insist on the rarity of these abscesses, their gravity, and the difficulty of the diagnosis.

Prevalence study of neurologic disorders in Kelibia (Tunisia)

A full-scale survey, in Kelibia, Tunisia, screening 34,874 persons started on July 1, 1985. The accuracy of this survey was evaluated by a second survey using a randomized sample of 1,673 subjects (control survey). Better selection and training of the interviewers during the control survey led to a higher positive predictive value with no modification in prevalence ratios of neurologic disorders. The control survey helped to validate the full-scale survey data which were then used to establish the prevalence ratios of major neurologic disorders in Kelibia. Prevalence ratios, age-adjusted to the WHO population, were compared to those of studies using similar methodology. Migraine prevalence ratios in Nigeria, Ecuador, and Kelibia were equivalent. Epilepsy and Parkinson's disease prevalence ratios were close to those of other similar studies. The stroke prevalence ratio was low, compared to other studies, but was not the lowest. It seems that in Kelibia, stroke does not constitute a public health problem as it does in the USA or urban China. The large full-scale survey, in Kelibia, provided estimates of prevalence ratios for stroke, epilepsy, migraine and other common neurologic disorders for comparisons with other countries. However, definitions of neurologic disorders and diagnostic criteria differ from one study to another making difficult the comparison of results between different countries. Had the WHO protocol developed well-defined criteria and a standardized neurologic examining tool, more accurate comparisons could have been made.

[Antenatal bilateral sylvian infarction and congenital syphilis]

BACKGROUND

The classical symptoms of congenital neurosyphilis include meningovascular lesions that are responsible for CSF abnormalities. Lesions of larger vessels are very unusual.

CASE REPORT

A boy was born from a neglected pregnancy, weighing 2.7 kg. He was abandoned by his parents and was admitted to hospital at 40 days of age (weight: 2,220 g; height: 47 cm; head circumference: 22 cm) with axial hypotonia, peripheral spasticity and shock syndrome. The TORCH screen was negative but the Treponema Pallidium Hemagglutination Assay (TPHA) was positive. The infant died 4 days later. Brain pathological studies revealed meningoencephalitis and bilateral sylvian infarction.

CONCLUSION

Local arteritis due to syphilis usually concerns small arteries, such as the meningeal and cortical vessels. The occlusion of the two middle cerebral arteries seen in this patient, which were responsible for atrophy of the parietal lobes, is uncommon in congenital syphilis.

Phenylketonuria: an underlying etiology of autistic syndrome. A case report

A 3.5-year-old girl with an autistic syndrome was investigated, and classic phenylketonuria (PKU) was identified. The search for PKU was undertaken systematically as part of an essential work-up of children with autism.

Arthrogryposis, cholestatic pigmentary liver disease and renal dysfunction: report of a second family

We report on a boy, born to consanguineous parents, who had arthrogryposis, cholestatic liver disease, and renal dysfunction. The child died at age 2 months, and autopsy showed pigmentary storage disease in liver cells, nephrocalcinosis, and rarefaction of motor neuron cells in the anterior horns of spinal cord. This association, reported in 1979 by Nezelof et al., is a distinctive syndrome. The possibility of an autosomal recessive or an X-linked inheritance is discussed.