Lege Artis Medicinae

[PRESENTATION OF ACUTE ABDOMINAL SYMPTOMS WITH UNDERLYING MALIGNANT DISORDERS]

ZARÁND Attila, BESZNYÁK István, MERSICH Tamás

MARCH 20, 2004

Lege Artis Medicinae - 2004;14(03)

[Patients with different type of undiagnosed malignancy occasionally referred to emergency departments with acute disease-related symptoms as first signs of their underlying process. However, this broad spectrum of clinical signs and symptoms do not occur very often but may result in very poor outcome for these patients. It is therefore essential to establish correct diagnosis in time and provide appropriate care of patients with acute abdominal complaints. Cancer patients are frequently referred to doctor because of gastro-intestinal obstruction, perforation or bleeding and with symptoms of inflammation. In 3-5% of the cases an urgent operation is necessary. As the cure rate of the cancer patients is largely dependent on the stage of the tumour, it is important to make relevant staging, to set up diagnosis at the earliest phase and start the appropriate therapy in due time in a multidisciplinary way.]

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URICH Elemér

[Insulin resistance is defined as a state of subnormal biological response to normal quantity of insulin. This phenomenon was first described by Hinsworth and Kerr in 1939, however it has come to the centre of interest only in the last two decades. It is the central pathogenetic factor of type 2 diabetes and the more complex clinical entity of metabolic syndrome, consequently also referred to as insulin resistance syndrome. In the background of insulin resistance alterations of the adipose tissue can be observed which clinically means obesity in most of the cases, however, this issue cannot be simplified to obesity only as increase in adipose tissue growth may be beneficial in certain cases. Current article discusses the explanation of this paradox and the pathophysiologic link between adipose tissue and insulin resistance. It also reviews the therapeutic aspects of insulin resistance emphasizing the role of thiazolidinedione type drugs having recently joined the therapeutic palette.]

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[COMET]

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Lege Artis Medicinae

[THE PROBLEM OF SMOKING]

RODÉ Magdolna

[Smoking causes a health catastrophy all over the world. Its importance is increasing in the less developed countries. More and more young people (especially women) have started smoking recently. Its devastating effect on women carries on to the next generations. Prevention should already begin in childhood. In Hungary, there is a wide network to assist for those who want to give up smoking - especially in the national network of lung health care clinics. Peer supporters have a prominent role in helping these patients. The market-strategy and publicity campaign of major tobacco producers also deserves intensive attention.]

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[SCIENTIFIC DIGEST]

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[TRIPTAN THERAPY OF MIGRAINE]

UNGUREAN Aurélia, TAJTI János, VÉCSEI László

[Migraine sufferers in Hungary present a major epidemiological challenge with about 12% of the population affected. Authors have reviewed an extensive body of internationally published literature relative to the 5-hydroxi-triptamin receptor agonists such as the triptans. While summarising most relevant data with a view to enable physicians to choose the most effective therapy for an individual, the article also discusses the prevailing questions of efficacy, tolerability and safety. For those patients with differential-diagnostic difficulties referrals should be made to the specialized 'headache centers' of neurological departments.]

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[Nausea and vomiting are very frequent problems in terminally ill cancer patients, with many causes in the background. Repeated vomiting considerably affects patients' quality of life and may also cause numerous complications requiring hospitalization. In palliative care these symptoms need to be alleviated knowing that triggering causes persist. To provide effective symptom control we need to understand the triggering mechanism of vomiting as well as to have a deep knowledge of most important antiemetics and to give efficient drugs regularly.]

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Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

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[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

Creutzfeldt-Jakob Disease: A single center experience and systemic analysis of cases in Turkey

USLU Ilgen Ferda, ELIF Gökçal, GÜRSOY Esra Azize, KOLUKISA Mehmet, YILDIZ Babacan Gulsen

We aimed to analyze the clinical, laboratory and neuroimaging findings in patients with sporadic Creutzfeldt-Jakob disease (CJD) in a single center as well as to review other published cases in Turkey. Between January 1st, 2014 and June 31st, 2017, all CJD cases were evaluated based on clinical findings, differential diagnosis, the previous misdiagnosis, electroencephalography (EEG), cerebrospinal fluid and cranial magnetic resonance imaging (MRI) findings in our center. All published cases in Turkey between 2005-2018 were also reviewed. In a total of 13 patients, progressive cognitive decline was the most common presenting symptom. Two patients had a diagnosis of Heidenhain variant, 1 patient had a diagnosis of Oppenheimer-Brownell variant. Seven patients (53.3%) had been misdiagnosed with depression, vascular dementia, normal pressure hydrocephalus or encephalitis. Eleven patients (87%) had typical MRI findings but only 5 of these were present at baseline. Asymmetrical high signal abnormalities on MRI were observed in 4 patients. Five patients (45.4%) had periodic spike wave complexes on EEG, all appeared during the follow-up. There were 74 published cases in Turkey bet­ween 2005 and 2018, with various clinical presentations. CJD has a variety of clinical features in our patient series as well as in cases reported in Turkey. Although progressive cognitive decline is the most common presenting symptom, unusual manifestations in early stages of the disease might cause misdiagnosis. Variant forms should be kept in mind in patients with isolated visual or cerebellar symptoms. MRI and EEG should be repeated during follow-up period if the clinical suspicion still exists.