[Interictal psychosis of epilepsy]

Interictal psychosis (IIP) refers to psychosis that occurs in clear consciousness in persons with epilepsy (PWE) with temporal onset not during or immediately following a seizure. The pooled prevalence estimate of psychosis in PWE is 5.6%. PWE and schizophrenia have very high mortality, and more than one in four persons with both disorders die between the age of 25 and 50years. IIP can manifest in brief or chronic forms. The chronic forms of IIP may closely resemble schizophrenia. However, some authors have described the typical presence of persecutory and religious delusions, sudden mood swings and the preservation of affect, as well as rarity of negative symptoms and catatonic states, but these differences remain controversial. Typically, IIP starts after many years of active temporal lobe epilepsy. Several epilepsy-related variables are considered pathogenically relevant in IIP including epilepsy type and seizure characteristics. Risk factors for developing IIP are family history of psychosis, learning disability, early age of onset of epilepsy, unilateral or bilateral hippocampal sclerosis, history of status epilepticus, history of febrile seizures, and poorly controlled temporal lobe epilepsy. In patients with epilepsy and psychosis, structural imaging studies have shown several relevant changes leading to conflicting findings. Altered neuronal plasticity and excitability have been described in epilepsy and psychotic disorders. Neuropathological data suggest that IIP are not the result of classic epileptic pathology of the temporal lobe. Forced normalization (FN) and alternating psychosis refer to patients with poorly controlled epilepsy (focal or generalized) who have had psychotic episodes associated with remission of their seizures and disappearance of epileptiform activity on their EEGs. FN mainly occurs in temporal lobe epilepsy when patients have frequent seizures that are abruptly terminated triggered by an antiepileptic drug, vagus nerve stimulation or epilepsy surgery. Treatment is based on withdrawal of the responsible drug, and by transient use of antipsychotics for acute symptomatic control on a case-by-case basis. FN is an entity whose pathophysiology remains uncertain. Antiepileptic drugs (AEDs) may sometimes induce psychotic symptoms and psychosis could be a direct effect of the AEDs. IIP has been reported more frequently following the initiation of zonisamide, topiramate, and levetiracetam when compared with other antiepileptic drugs. However, AEDs do not appear to be the only determinant of IIP. The management of IIP requires a multidisciplinary approach with early involvement of a liaison psychiatrist associated with a neurologist. IIP are underdiagnosed and mistreated. Existing recommendations are extrapolated from those established for the treatment of schizophrenia with some additional guidance from expert opinions. A two-step procedure, not necessarily consecutive, is suggested. The first step requires reevaluation of the antiepileptic treatment. The second step requires initiation of atypical neuroleptics. Antipsychotic drugs should be selected with consideration of the balance between pharmacological profiles, efficacy, and adverse effects. Regarding pharmacokinetic interactions, AEDs with inducing properties reduce the blood levels of all antipsychotics. It is important to consider implications of combining neuroleptics and AEDs with a similar spectrum of side effects. Regarding the duration of treatment, IIP episodes are more likely to be recurrent than in primary schizophrenia. In practice, atypical neuroleptics with few motor side effects such as risperidone can be used as first choice, given the low propensity for drug-drug interactions and the low seizure risk, with the added suggestion to start low and go slow. Clozapine could be prescribed in selected cases.

Characteristics of postictal headache in patients with partial epilepsy

Migraine-like features sometimes characterize the headache that follows epileptic seizure (postictal headache, PIH). We compared patients with different types of epilepsy to investigate the association between migraine-like PIH and seizure type. Subjects comprised 364 patients with partial epilepsy. Epilepsy types were temporal lobe epilepsy (TLE, n = 177), frontal lobe epilepsy (FLE, n = 116), and occipital lobe epilepsy (OLE, n = 71). Patients participated in a structured interview pertaining to PIH as well as interictal headache and family history of migraine. Headaches were classified according to the International Headache Society criteria, which was modified for this study. Forty percent had PIH and 26% of these patients had migraine-like PIH. Migraine-like PIH occurred significantly more often in cases of TLE and OLE than in cases of FLE. In addition, the incidence of interictal migraine headache was significantly higher in patients with migraine-like PIH. These results suggest that migraine-like PIH is related to particular regions of epileptogenic focus and that susceptibility to migraine headache predisposes to migraine-like PIH.

Glomerular crescents predominantly express cadherin-catenin complex in pauci-immune-type crescentic glomerulonephritis

AIMS

To investigate the expression of the cadherin complex in human crescentic glomerulonephritis to elucidate the role of intercellular adherens junction molecules in crescent formation.

METHODS AND RESULTS

Immunostaining revealed cadherin complexes localized in Bowman's epithelial cells, but not in podocytes, of normal human glomeruli. Eight adult cases with myeloperoxidase anti-neutrophil cytoplasmic autoantibodies (MPO-ANCA)-related (pauci-immune type) crescentic glomerulonephritis were examined on immunofluorescence microscopy with anti-pan cadherin, p120 catenin, and beta-catenin antibodies. The specimens provided six cellular crescents, 12 fibrocellular crescents, and four fibrotic crescents. Immunofluorescence was semiquantitatively estimated by the rate of the field of localization within the whole area of the crescent, according to the four-grade system [(-) - (++)]. All the tested molecules consisting of the cadherin complex were abundantly observed in cytokeratin-positive epithelial components in crescents, each with an equivalent area of localization. The expression of the cadherin complex was closely associated with that of cytokeratin and both diminished as the crescents developed from cellular to fibrotic.

CONCLUSIONS

The cadherin-catenin complex is a specific marker of Bowman's epithelial cells in human glomeruli. The cellular crescents in pauci-immune-type crescentic glomerulonephritis possess adherens junction molecules, indicating a principle parietal epithelial cell phenotype.

Differential effects of milnacipran and fluvoxamine, especially in patients with severe depression and agitated depression: a case-control study

We attempted to compare the antidepressant efficacy of milnacipran and fluvoxamine in 202 outpatients with major depression, using the 17-item Hamilton Depression Rating Scale (HDRS). Special attention was paid to the difference of responsiveness as a function of the severity of depression and individual HDRS factors. As a result, while no significant difference between the treatment groups was found overall, a positive response (50% or more decrease in total score from the baseline) was recorded significantly more often with milnacipran than fluvoxamine recipients whose baseline HDRS total score was greater than 19 points. Furthermore, there was a significant difference of response for the 'agitation' and 'insomnia' factors in favour of milnacipran. In both treatment groups, the incidence of adverse events, characteristic of tricyclic antidepressants such as dry mouth, constipation, somnolence and postural hypotension, was low. While complaints concerning the upper intestinal tract, such as epigastric distress, were predominant in the fluvoxamine group, urological complications and palpitations were reported only in the milnacipran group. In conclusion, we suggest that milnacipran is preferred to selective serotonin reuptake inhibitors for the treatment of depressed patients with agitation as well as severely depressed patients.

Acute pancreatic damage associated with convulsive status epilepticus: a report of three cases

Three cases involving a previously unreported association of acute pancreatic damage following convulsive status epilepticus (SE) are presented. A review of literature failed to reveal a similar association between SE and acute pancreatic damage. As possible pathophysiological mechanisms of this so far unknown sequel of SE, increased intraduodenal pressure during SE leading to the reflux of the duodenal contents into the pancreatic duct, along with altered metabolism of oxygen-derived free radicals during a prolonged seizure with hypoxia and ischemia resulting in acinar cell injury are suggested. We believe that SE should be considered as an additional risk factor of acute pancreatitis and that pancreatic enzymes should be monitored in patients who have prolonged seizures.

Presurgical postictal and acute interictal psychoses are differentially associated with postoperative mood and psychotic disorders

The authors studied 52 patients who had undergone surgery because of intractable temporal lobe epilepsy. Investigation of postoperative psychiatric illnesses focused on psychotic disorder (293.81 and 293.82) and mood disorder (293.83) due to a general medical condition diagnosed according to DSM-IV criteria. Presurgically, two episodic psychotic syndromes, acute interictal and postictal psychosis, were defined operationally. A correlation was confirmed between presurgical acute interictal psychosis and postsurgical psychotic disorder, as well as between presurgical postictal psychosis and postsurgical mood disorder. An excellent final outcome for postoperative mood disorder in contrast to a less favorable one for psychotic disorder was also suggested.

C-reactive protein frequently localizes in the kidney in glomerular diseases

AIM

In recent reports, C-reactive protein (CRP) has emerged as a component that may play important roles in atherogenesis. Based on the analogies set out in a previous report between focal-segmental sclerosis and atherosclerosis, we hypothesized that CRP contributes to the pathogenesis of glomerular diseases. To our knowledge, no immunohistochemical study of CRP localization in the kidneys has been previously reported.

PATIENTS AND METHODS

In the present study, we investigated 106 kidney biopsy specimens from children with various types of glomerular diseases and minor glomerular abnormalities. Of the 106 cases, 74 were proliferative diseases, 17 were non-proliferative diseases, and 15 were minimal-change nephrotic syndrome (MCNS). Immunohistochemical staining was performed using monoclonal antibody to CRP.

RESULTS

CRP immunoreactivity was found in 48 of 106 (45.3%) specimens. CRP deposition was encountered more often in patients with proliferative diseases (56.8%) than in those with non-proliferative diseases (23.5%) (p < 0.01). CRP deposition, most frequently observed along the capillary walls of glomeruli, was found in 33 of 46 (71.7%) cases with positive expression of CRP. CRP was also located in the peritubular capillary walls and small vessels in the interstitium in 13 of 46 cases (28.3%). CRP deposition was also found in 2 of 15 cases of MCNS. The two MCNS specimens showing positive CRP immunoreactivity were both from patients who had undergone cyclosporin therapy. CRP deposition was not shown in any cases treated with steroids or cyclophosphamide. The cases of patients who had undergone renal biopsies within 6 months after onset revealed a tendency toward positive CRP deposition. The clinical outcomes at the latest follow-up were quite similar between the groups of patients with and without CRP deposition.

CONCLUSIONS

We surmise that circulating CRP may deposit at the site of endothelial injury, and may not be relevant to the progression of renal lesions.

Long-term follow-up study of Lennox-Gastaut syndrome in patients with severe motor and intellectual disabilities: with special reference to the problem of dysphagia

A long-term follow-up study of Lennox-Gastaut syndrome (LGS) ( > 10 years) was conducted with 38 patients with severe motor and intellectual disabilities (SMID) to clarify the relationship between the rapid development of dysphagia and epileptic seizures, and to elucidate the long-term evolution of LGS in patients with SMID. Those who showed a relatively favourable seizure outcome were compared to those with a poor seizure outcome. Poor seizure outcome correlated strongly with: (a) an early appearance of dysphagia and additional deterioration of the already retarded mental function; (b) a predominance of atypical absence seizures; and (c) persistent frequent epileptiform discharges during electroencephalographic evaluations. Neither age at seizure onset nor intelligence level at the time of the last examination was correlated with seizure prognosis. Further, seizure prognosis was not related to the aetiology of LGS. Repeated seizures apparently caused development of progressive epileptic encephalopathy, in addition to the underlying severe brain damage. Since development of dysphagia burdens an already severely handicapped patient with intensive medical care, efforts to reduce the seizures and design a long-term care plan are of great importance.

Rub epilepsy: a somatosensory evoked reflex epilepsy induced by prolonged cutaneous stimulation

To delineate rub epilepsy--a type of reflex epilepsy induced by prolonged or repetitive cutaneous stimulation in a circumscribed area of the body--three cases are presented, as well as one of tooth brushing epilepsy for comparison. In all three cases of rub epilepsy, cutaneous stimuli in a particular body area on the left side initially induced a sensory jacksonian march in the middle of, or in close vicinity to, the trigger zone, which led to subsequent unilateral tonic contractions with intact consciousness. By contrast, a motor jacksonian seizure without sensory aura was induced in the patient with tooth brushing epilepsy. A review of cases with rub epilepsy, including those in this paper, disclosed a striking consistency in clinical manifestations. The symptomatology of the induced seizures indicates a propagation of epileptic discharges from the postcentral gyrus to the supplementary motor area. Rub epilepsy is proposed as a separate clinical entity, clearly demarcated from other somatosensory evoked reflex epilepsies such as startle and tooth brushing epilepsy.

Reexamination of interictal psychoses based on DSM IV psychosis classification and international epilepsy classification

We sought to examine interictal psychoses based on the international epilepsy classification and DSM IV criteria, with special attention paid to epilepsy types as well as to subcategories of psychoses. One hundred thirty-two outpatients were studied, each with definite evidence of both epilepsy and interictal psychosis clearly demarcated from postictal psychosis. We compared them with 2,773 other epilepsy outpatients as a control. Risk factors for psychosis were examined within the temporal lobe epilepsy (TLE) group and the more extended group of symptomatic localization-related epilepsy. Further, nuclear schizophrenia and other nonschizophrenic psychotic disorders were compared. We confirmed a close correlation between TLE and interictal psychoses. Within the TLE group, only early epilepsy onset and a history of prolonged febrile convulsions were revealed to be significantly associated with interictal psychosis. Within the symptomatic localization-related epilepsy group, such parameters as complex partial seizures, autonomic aura, and temporal EEG foci were closely associated with psychoses. There was also a significant difference between groups as to ictal fear and secondary generalization. Whereas patients with early psychosis onset and a low intelligence quotient were overrepresented in the nuclear schizophrenia group, drug-induced psychosis and alternative psychosis were underrepresented. TLE proved to be preferentially associated with interictal psychoses. Within the TLE group, medial TLE in particular was found to be more closely associated with psychosis. Our data support the original postulation of Landolt, stating that alternative or drug-induced psychoses constitute a definite subgroup of interictal psychoses, which are different from chronic epileptic psychoses that simulate schizophrenia.

Late recurrence of small-cell lung cancer: a case report

A 67-year-old man was admitted with small-cell lung cancer (SCLC). The patient was given four courses of platinum-containing chemotherapy followed by chest irradiation, and good partial response (PR) was obtained. The patient did well for 4 years, until he sought treatment for a painful subcutaneous tumor. Chest computed tomography scan revealed the mass extending from the tumor in lung parenchyma with osteolytic lesion of the third rib bone. Pathologic examination of the subcutaneous lesion revealed SCLC. The patient was given two courses of the same combination chemotherapy administered as initial therapy. Regression of the mass was observed, and the response was evaluated as a good PR. How to approach late recurrence of SCLC is discussed.

Familial aphasic episodes: another variant of partial epilepsy with simple inheritance?

We report on a family having partial epilepsy with simple inheritance. The affected members commonly have aphasic episodes with secondary generalization; onset occurred either in adolescence or adulthood. Patients' response to medication has varied greatly. No neurological defects or decline in intelligence were found. The case represents another variety of rare familial partial epilepsy with neocortical epilepsy features.

A case of post-anoxic encephalopathy with initial massive myoclonic status followed by alternating Jacksonian seizures

To contrast stimulus-sensitive generalized myoclonus with ensuing multifocal localized myoclonus in a patient with post-anoxic coma, we stressed the clinical as well as electroencephalographical differences between his initial generalized and subsequent focal myoclonus. While generalized myoclonus was presumably of extracortical origin and responsive to valproic acid, alternating Jacksonian seizures were definitely cortical and suppressed with phenytoin. These two different types of myoclonus should not be confused in post-anoxic coma.

Steroid-sensitive nephrotic syndrome associated with Kimura disease

We report an 11-year-old Japanese boy with Kimura disease and associated nephrotic syndrome. Before the diagnosis of Kimura disease was established, the patient had three episodes of swelling on the left cheek with subsequent nephrotic syndrome. Steroids were effective for both conditions. However, both conditions recurred within months of discontinuation of steroids. For the fourth episode of swelling on the left cheek, cyclosporine (CsA) was used. The subcutaneous tumor responded to CsA and disappeared within a few days. There has been no subsequent relapse of the nephrotic syndrome to date.

Interleukin (IL)1beta, IL-1alpha, and IL-1 receptor antagonist gene polymorphisms in patients with temporal lobe epilepsy

Proinflammatory cytokines, including interleukin (IL)-1beta, are known to modulate effects of neurotoxic neurotransmitters discharged during excitation or inflammation in the central nervous system (CNS). They also regulate development of glial scars at sites of CNS injury. To elucidate a genetic predisposition of temporal lobe epilepsy with hippocampal sclerosis (TLE-HS+), we studied polymorphisms in the IL-1beta, IL-1alpha, and IL-1 receptor antagonist (IL-1RA) genes in 50 patients with TLE-HS+ and in 112 controls. Fifty-three patients who had TLE without HS were also examined (TLE-HS-) as disease controls. The distribution of the biallelic polymorphism in the promoter region at position -511 of the IL-1beta gene (IL-1B-511) was significantly different both between TLE-HS+ patients and controls and between TLE-HS+ and TLE-HS- patients. The differences were due to overrepresentation of the homozygotes for IL-1B-511*2, which is suggested to be a high producer of IL-1beta, in TLE-HS+ patients compared with both controls and TLE-HS- patients. In contrast, there was no difference between TLE-HS- patients and controls. Our data suggest that, in the homozygotes for IL-IB-511*2, minor events in development such as febrile convulsions could set up a cascade leading to HS.

Running down phenomenon and acute interictal psychosis in medial temporal lobe epilepsy

PURPOSE

To examine the relationship between presurgical acute interictal psychosis and postsurgical running down phenomenon in a strictly homogeneous group with medial temporal lobe epilepsy.

METHODS

Forty patients with mesial temporal sclerosis and an ultimate excellent surgical outcome, were divided into running down positive and negative groups. Various clinical and laboratory data, including presurgical psychotic episodes, were analyzed in the two groups.

RESULTS

Patients in the running down positive group exhibited a significantly high incidence of presurgical history of acute interictal psychosis.

CONCLUSION

We hypothesize that areas of secondary epileptogenesis beyond the scope of the primary epileptogenic zone, suggested by postsurgical running down phenomenon, may play an important role in the blockage and shift of the habitual propagation of seizure activity from the primary epileptogenic zone, to which Wolf attributed acute interictal psychosis.

Prolonged post-ictal confusion as a manifestation of continuous complex partial status epilepticus: a depth EEG study

We report a peculiar depth-EEG recording of prolonged post-ictal confusion which proved to be continuous complex partial status epilepticus. A 33 year old male with intractable medial temporal lobe epilepsy exhibited this ictal EEG recording. After repetitive habitual complex partial seizures, and an ensuing short lucid interval with intact memory and full communicability, the patient became more and more unresponsive and, finally, even cataleptic. Concurrent with this change in responsiveness, an EEG revealed a gradual and steady increase of ictal EEG activity. Immediately after intravenous diazepam infusion, this ictal EEG activity was suppressed and the patient began to move. This case confirms that a paradoxical excitation can occur after clustered complex partial seizures, instead of the well-known neuronal exhaustion.

Lateralized memory deficits on the Wada test correlate with the side of lobectomy only for patients with unilateral medial temporal lobe epilepsy

The aim of this study was to determine whether the predictive value of the intracarotid amobarbital test (IAT) for the side to be resected is applicable only to medial temporal lobe epilepsy and to investigate whether there are different patterns of memory performances on the IAT between patients with unilateral mesial temporal sclerosis (UMT group) and those without (non-UMT group). We studied 30 patients in the UMT group and 10 in the non-UMT group, who underwent pre-surgical evaluation for intractable temporal lobe epilepsy. Memory performances on the IAT was defined as the percentage of memory items presented during unilateral hemispheric anesthesia that was recognized after recovery. More than a 20% decline of the memory performance on the IAT compared with the memory performance on the pre-test was regarded as a memory deficit. Age at onset of epilepsy was significantly younger in the UMT than in the non-UMT group. Surgical outcome was significantly better in the UMT than in the non-UMT group. The lateralizing value of unilateral memory deficits on the IAT was statistically confirmed. There was a significant association between falsely lateralizing memory performances and the non-UMT group. Excluding the exceptional cases with right-sided language dominance in spite of right-sided lesions, the high incidence of the unilateral right-sided memory deficits in the non-UMT group was statistically significant. This study suggested that the excellent lateralizing value of the memory performances on the IAT is limited to patients with mesial temporal lobe epilepsy. IAT memory performances in patients without such lesions can be misleading, even if lateralized, because their memory status presumably reflects a natural lateralization of the memory organization which is independent of the epileptogenic focus.

Plasma lipoprotein (a) levels in children with minimal lesion nephrotic syndrome

We studied the plasma lipoprotein (a)[Lp(a)] levels in 31 children with minimal lesion nephrotic syndrome (MLNS) in both stages of acute NS and remission. The mean Lp(a) levels in acute NS were significantly higher than those of the controls. The Lp(a) levels in remission were significantly lower than the Lp(a) levels in acute NS. In addition, the Lp(a) levels in remission were not significantly different from those of the controls. However, there were 5 patients whose Lp(a) levels remained higher than 30 mg/dl (the generally accepted limit for cardiovascular risk) after remission. Two of these 5 patients had Lp(a) levels greater than 40 mg/dl. In these patients apoprotein (a) [apo(a)] phenotypes were of lower molecular weight than those of the other 23 patients whose apo(a) phenotypes were examined. Additional episodes of relapse may put the patient with sustained elevated Lp(a) levels at significant risk for the development of cardiovascular disease in the long term.

Clinical significance of apolipoprotein (a) deposition in kidney diseases of children

AIM AND METHOD

To address the clinical significance of lipoprotein (a) (Lp(a)) deposition in renal diseases of children, we examined renal localization of apolipoprotein (a) (apo(a)), which is the major apoprotein of Lp(a), using a new monoclonal antibody as a probe, and compared histological changes and clinical courses between the cases with and without apo(a) accumulation. Our study comprised 78 cases with various renal diseases.

RESULTS

Of the 78 cases, 45 showed apo(a) deposition (group A) and the other 33 did not (group B). Nephrotic syndrome was similarly presented in groups A and B (46.7% vs 36.3%). Histological findings were analyzed in 62 proliferative and 16 non-proliferative original diseases separately. In the cases with proliferative diseases, severe histological changes were observed in group A more than in group B, severe proliferation (50.9% vs 26.1%: p < 0.01) and crescent formation (11.9% vs 5.1%: p < 0.01) were observed in group A over that of group B. However, the clinical status at the latest follow-up were quite similar, there was no difference of favorable (60.5% vs 62.5%) and unfavorable outcome (15.9% vs 16.7%) in groups A and B. In the cases with non-proliferative diseases, global sclerosis was more often encountered in group A than in group B (28.3% vs 6.5%). Group A carried poorer prognosis than group B in non-proliferative diseases.

CONCLUSION

These results suggest that apo(a) deposits just passively follow the histological injury, and they do not always accelerate it.

Ictal catatonia as a manifestation of de novo absence status epilepticus following benzodiazepine withdrawal

To describe ictal catatonia as a manifestation of de novo absence status epilepticus following benzodiazepine withdrawal. Ictal catatonia was documented by concurrent EEG recordings. A catatonic syndrome, first diagnosed as a psychogenic reaction, was found to be an ictal event by EEG recording. De novo absence status and benzodiazepine withdrawal should be considered when a catatonic syndrome suddenly occurs in elderly patients.

[Renal glucosuria and membranous glomerulonephritis in chronic inflammatory demyelinating polyradiculoneuropathy: CIDP]

Glucosuria was detected in a 7-year-old boy by a routine school mass examination in April 1991. The diagnosis of renal glucosuria was made in the affiliated hospital of the University of Tsukuba. The patient developed muscle weakness and gait disturbance in February 1993. Spinal fluid examination revealed a protein level of 62 mg/dl and a cell count of 4/3. Under the diagnosis of Guillain-Barré syndrome, he was treated with i.v. immunoglobulin and oral prednisolone. Although the therapy somewhat improved the symptoms, his muscle strength had not fully recovered at the end of the treatment. In November 1995, the muscle weakness became worse; he could not go up stairs, nor stand upright on one leg. In April 1996, proteinuria was detected in a school mass examination. He was referred to the University Hospital of Tsukuba for a full renal study in March 1997. Renal biopsy revealed global sclerosis in 16 of 19 glomeruli with extensive interstitial fibrosis and mononuclear cell infiltration. A diagnosis of membranous glomerulonephritis was established based on the findings of spikes in PASM staining, weak IgG deposition in the glomerular capillary and subepithelial deposits by electron microscopic study. Additionally, pituitary growth hormone deficiency was found by endocrinological examination. The diagnosis of CIDP was established by fibulal neuron biopsy, which revealed neuronal degeneration and profound demyelinization. The clinical course of the present case was unlike that of the few reported cases of MGN associated with CIDP described in the literature. The initial renal symptom was glucosuria, which started 5 years prior to the onset of proteinuria. Second, glomerulosclerosis was more extensive than that seen in the literature. We surmise that chronic interstitial nephritis of insidious onset was followed by MGN which developed subsequently, probably at the time of the start of proteinuria.

[Psychiatric disorders following and preceding temporal lobectomy]

We analysed pre- as well as post-operative psychiatric disorders in thirty eight patients with temporal lobe epilepsy. While postoperative paranoid disorders were closely correlated with preoperative acute interictal psychoses, episodes of postictal psychoses prior to surgery were associated with postoperative mood disorders. A good prognosis of postoperative mood disorders was stressed. The literature search supported the predominance of right-sided lobectomy in patients with de novo psychoses after surgery. The relationship between left-sided lobectomy and postoperative mood disorders needs further amplification and remains tentative. We stressed the need for a prophylactic psychotherapy to surgical candidates to cope with unrealistic wishes to get relieved from all the difficulties in their lives after temporal lobectomy.

Violence and epilepsy: a close relation between violence and postictal psychosis

PURPOSE

We investigated the incidence of well-directed violent behavior and suicide attempts in patients with temporal lobe epilepsy, with special attention to postictal psychosis.

METHODS

We compared 57 episodes of postictal psychosis with 62 episodes of acute interictal (or alternative) psychosis and with 134 complex partial seizures. All patients were matched for age and for age at onset of seizures.

RESULTS

The incidence of well-directed violent behavior against human beings was significantly higher (23%) during postictal psychotic episodes than during acute interictal episodes (5%) and postictal confusion (1%). Suicide attempts were also more frequent during postictal psychosis (7%) than during either acute interictal psychosis (2%) or postictal confusion (0%).

CONCLUSIONS

Our study showed that well-directed violent and self-destructive behavior was not a feature of epileptic psychosis in general but a specific hallmark of postictal psychosis.

Postictal psychosis as a risk factor for mood disorders after temporal lobe surgery

This study investigated the psychiatric consequences of 38 consecutive patients who had surgery for intractable temporal lobe epilepsy with special attention to postoperative mood disorders. A close interrelation between preoperative postictal psychosis and postoperative manic or depressive episodes was suggested. Left sided lobectomy augmented this correlation. Because the first sign of postoperative manic and depressive episodes appeared within 1 month and 2 months respectively, cautious psychiatric follow up for several months after surgery proved to be crucial to prevent postoperative suicides. Postoperative manic depressive episodes disappeared within the first 2 years after operation without exception, if treated suitably. This suggests that we do not have to preclude patients with postictal psychosis as surgical candidates, but measures must be taken to prevent postoperative depressions.

Epilepsy and recursive consciousness with special attention to Jackson's theory of consciousness

John Hughlings Jackson's theory of consciousness has been reconsidered. The author stressed that his uniqueness as a neuroscientist lay in his keen interest in the recursive nature of human consciousness. Two clinical symptoms of interest to Jackson were discussed: recurrent utterances and mental diplopia. Recurrent utterances were believed to represent an exceptional state, in which the unconscious process in speech production, otherwise destined to be swept away automatically, became manifest and observable. Jackson regarded mental diplopia as a revelation of otherwise inaccessible duality of all healthy mental actions. Therefore, he supposed that the essence of recursive consciousness resided in a transformation of multiple, multidirectional, unconscious processes into a linear, unidirectional process.

Characteristics and treatment of temporal lobe epilepsy with a history of complicated febrile convulsion

This study aimed to examine the close correlation between complicated febrile convulsions (CFC) and medial temporal lobe epilepsy and to delineate characteristics of temporal lobe epilepsy with CFC. Patients with temporal lobe epilepsy were divided into those with a prior episode of CFC (n=52), those with febrile convulsions other than CFC, and those without either (n=345). Clinical constellations, neuroimaging, drug resistance, and effects of temporal lobectomy of the three groups were compared. A close association between CFC and temporal lobe epilepsy was confirmed. The salient features of temporal lobe epilepsy with CFC were early age at onset of habitual seizures (about 10 years), the predominance of autonomic auras, and a high incidence of MRI evidence of unilateral medial temporal sclerosis. Patients with temporal lobe epilepsy with prior CFC had an excellent outcome after surgery, by contrast with an unfavourable response to drug therapy. The surgical results were discouraging in patients with temporal lobe epilepsy without history of any febrile convulsions and without solid brain tumours. These results indicate surgical intervention as the choice of therapy in a substantial number of patients with temporal lobe epilepsy with a history of CFC.

Periictal Capgras syndrome after clustered ictal fear: depth-electroencephalogram study

PURPOSE

To describe periictal Capgras syndrome as a result of rapid, successive bouts of ictal fear.

METHODS

This periictal psychotic state was documented by depth EEG recordings.

RESULTS

Episodes of paroxysmal fear, experienced as a vivid sensation of someone being nearby, corresponded with unilateral left limbic ictal discharge.

CONCLUSIONS

Depersonalization, regardless of organic or functional origin, is an important contributor to the genesis of Capgras syndrome.

Characteristics of temporal lobe epilepsy with mesial temporal sclerosis, with special reference to psychotic episodes

This study investigates the histories and the clinical course of 111 patients who had nonlesional temporal lobe epilepsy. We compared 61 patients with unilateral hippocampal sclerosis (UHS group) and 50 patients with minimal change (MRI negative group) assessed on the basis of MRI. In agreement with previous reports, we confirmed statistically that patients in the UHS group strongly tended to have had febrile convulsive status during early childhood or infancy and that habitual seizures tended to begin at a younger age than the other subset of nonlesional temporal lobe epilepsy. Strikingly, episodes of psychoses, especially postictal psychoses, occurred significantly more often in the UHS group than in the MRI negative group. Additional involvement of temporal neocortex further augmented this association. We stress the role of mesial temporal pathology, and its linkage to the temporal neocortex, in the genesis of postictal psychoses.

Postictal psychosis: a comparison with acute interictal and chronic psychoses

We studied 30 patients with postictal psychosis and compared them with 33 patients with acute interictal psychosis and 25 patients with chronic psychosis. All patients had either complex partial seizures (CPS) or EEG temporal epileptogenic foci. Patients with postictal psychosis had a high incidence of psychic auras and nocturnal secondarily generalized seizures. The most striking feature that distinguished postictal psychosis from both acute interictal and chronic psychoses was phenomenological: the relatively frequent occurrence of grandiose delusions as well as religious delusions in the setting of markedly elevated moods and feeling of mystic fusion of the body with the universe. In addition, postictal psychosis exhibited few schizophreniform psychotic traits such as perceptual delusions or voices commenting. Reminiscence, mental diplopia, and a feeling of impending death were also fairly frequent complaints of patients with postictal psychosis. Interictal acute psychosis and chronic epileptic psychosis were psychopathologically similar. Although acute interictal and chronic epileptic psychoses could simulate schizophrenia, postictal psychosis results in a mental state quite different from that of schizophrenic psychosis.

[Gasperini syndrome--differential diagnosis of peripheral facial nerve paralysis. Neurologic and imaging findings]

The Gasperini syndrome is a cause of peripheral facial palsy: In the following case report, a 75-year-old woman is described who presented with a peripheral left facial palsy. On examination left beating nystagmus was found with contralateral loss of pain and temperature affecting the right side of the body but sparing the face. The signs and symptoms corresponded to the Gasperini syndrome caused by a lesion in the dorsal caudal pons in the region of the anterior inferior cerebellar artery. MR imaging confirmed a lesion in this site.

[Effect of protoporphyrin IX on the induction of respiratory impairment of hepatic mitochondria by carbon tetrachloride in rats]

The effect of pretreatment with protoporphyrin IX (PP) on the impairment of hepatic mitochondrial respiration induced by carbon tetrachloride (CCl4) was studied in rats. Treatment of animals intraperitoneally with CCl4 resulted in marked impairment of states 4 and 3 respirations, respiratory control and oxidative phosphorylation of mitochondria in the presence of succinate, beta-hydroxybutyrate or glutamate as substrates. The PP, given intravenously, caused no alterations in those mitochondrial functions. The treatment with PP prior to the administration of CCl4 inhibited the induction of mitochondrial respiratory impairment by CCl4. CCl4 increased markedly the contents of lipid peroxide in the liver but not those in the mitochondria. The increase of hepatic lipid peroxides by CCl4 was markedly reduced by the pretreatment with PP. These results indicate that PP effectively protects the mitochondria from the functional disorder caused by CCl4.

Phi 80 transcription antitermination complex: a 15 kDa host-coded protein interacts with the gene N transcription antitermination protein of bacteriophage phi 80

We purified the transcription antitermination complex of phi 80 (phi 80-pN complex). This complex had a molecular weight of approx. 42,000, and the subunits of this complex could be separated by SDS polyacrylamide gel electrophoresis. The complex was composed of two different polypeptides, one was the phi 80 N gene product (phi 80-pN) with a molecular weight of approx. 12,000, and the other was a host-coded protein with a molecular weight of approx. 15,000. The densitometric analysis after SDS polyacrylamide gel electrophoresis showed that the molar ratio of two proteins was 2 to 1 (phi 80-pN: 15 kDa), and the complex was assumed to be a trimer. Bacteriophage phi 80 could grow in nusA, nusC, and nusE mutants of Escherichia coli, but failed to grow in a nusB mutant. The molecular weight of the nusB gene product is calculated to be 15,689 from the sequencing data. These results suggest that the partner of the N gene product is possibly a host-coded nusB gene product.

The temporal sequence of aura-sensations in patients with complex focal seizures with particular attention to ictal aphasia

The sequences of aura sensations in 143 patients with complex partial seizures, were analysed with special emphasis on aphasic symptoms. Anxiety, epigastric sensation and visual hallucination were experienced early in the course of the aura, while illusion of familiarity and aphasia occurred late in the course of the aura. Three groups of interconnections of aura sensations were found which corresponded possibly to the types of seizure constellations proposed by Weiser. Close interconnections between impairment of verbal comprehension during seizures and paroxysmal thought disorder, as well as between paroxysmal paraphasia and illusion of familiarity were noted. Paroxysmal aphasia in patients with complex partial seizures was characterised as a positive symptom in contrast to stable aphasia.

Tryptophan synthase alpha subunit glutamic acid 49 is essential for activity. Studies with 19 mutants at position 49

We have obtained a complete set of 20 variants of the alpha subunit of tryptophan synthase of Escherichia coli at position 49 in order to extend our previous studies on the effects of single amino acid replacements at position 49 on structure and function. Thirteen mutant alpha subunits have been newly constructed by site-directed mutagenesis using oligonucleotides. Six mutants were available from previous studies. We find that the wild type and all of the mutant alpha subunits form alpha 2 beta 2 complexes with the beta 2 subunit of tryptophan synthase with similar association constants and similarly stimulate the activity of the beta 2 subunit in the synthesis of L-tryptophan from L-serine and indole. Thus none of the changes at position 49 produces a change in the conformation of the alpha subunit which significantly interferes with normal subunit interaction. However, the 19 mutant alpha 2 beta 2 complexes are completely devoid of activity in reactions normally catalyzed by the active site of the alpha subunit. This is the first time that these several activities have been measured with a series of highly purified alpha subunits altered by mutation at a single site. Our finding that the mutant in which glutamic acid 49 is substituted by aspartic acid is totally devoid of alpha activity is especially significant and is strong evidence that glutamic acid 49 is an essential catalytic base in the reaction catalyzed by the alpha subunit. This result is consistent with the results of previous genetic studies, with evolutionary comparisons using sequence analysis, and with recent results from x-ray crystallography of the alpha 2 beta 2 complex of tryptophan synthase from Salmonella typhimurium.

Identification and purification of the N gene product of bacteriophage phi 80

To confirm the in vivo observation that the N gene product of phi 80, phi 80-pN, prevents termination of transcription at the tL1 region and is therefore a transcription antitermination factor (Tanaka and Matsushiro 1985), we demonstrated that phi 80-tL1 is a rho-dependent terminator, similar to lambda-tL1, and that phi 80-pN has a transcription antitermination function at this site in an in vitro transcription system using a nucleic acid-free S-100 extract. In the presence of rho-protein, transcription termination at tL1 was suppressed completely with an S-100 extract prepared from Escherichia coli strain NT525 containing the pBN1-N+ plasmid. Starting from this pN-overproducing cell extract, we purified phi 80-pN to homogeneity by chromatography on DEAE-Sephacel, Sephadex G-150 and CM-Sephadex C-50. The molecular weight of purified pN was about 12,000 and the NH2-terminal sequence was NH2-Met-Ile-Asp-Asp-Ile-Lys, which was consistent with the sequence deduced from the DNA sequence.

Phosphorylation of specific polypeptides in isolated murine splenocyte nuclei which is controlled by cyclic nucleotides

Murine splenocyte nuclei were phosphorylated with a less than 10(-5) M concentration of [gamma-32P]ATP at 0 degrees C and the phosphorylated nuclear proteins were analyzed by SDS-polyacrylamide gel slab electrophoresis and Sephadex gel filtration column chromatography. Two polypeptides of 10K and 11K daltons were predominantly phosphorylated. These polypeptides were likely linked by a disulfide bond to form a nonhistone protein of 21K daltons. Both phosphoserine and phosphothreonine were detected in the hydrolysate of the 10.5K dalton polypeptide, while phosphoserine was predominant in the 10K dalton polypeptide. Maximal activation of phosphorylation by cAMP of both polypeptides was shown at a concentration of 10(-6) M. On the contrary, cGMP activated phosphorylation of the 10K dalton polypeptide at 10(-8) M and at 10(-4) M. The phosphorylation of the 10.5K polypeptide was not activated by 10(-4) M cGMP and suppression of the phosphorylation was seen in both polypeptide chains by cAMP at higher concentrations.

Liposarcoma of the breast, review of the literature and a report of a case

A case of gigantic liposarcoma of the breast in a 52-year-old woman was reported. She had a small indolent mass in the left breast for twenty years. The mass grew rapidly from the summer of 1979 and became gigantic and penetrated the skin over the mass. Her general condition on admission was poor but resection of the tumor was carried out. She suddenly died of cardiac failure with electrolytes imbalance 13 days after the operation. The diagnoses of liposarcoma, predominantly myxoid, was made on the basis of light and electron microscopic findings. Forty cases of liposarcoma of the breast were collected from the literature. The possibility of malignant transformation of a benign tumor was suggested.