Lege Artis Medicinae

[The importance of the determination of auto-antibodies in diabetes mellitus - As recommended by the EASD 2004 Congress]

HOSSZÚFALUSI Nóra, PÁNCZÉL Pál

FEBRUARY 20, 2005

Lege Artis Medicinae - 2005;15(02)

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Lege Artis Medicinae

[SEVERE CASE OF HYPOSMOTIC HYPERVOLAEMIA DUE TO WATER INTOXICATION]

BOTOS Péter, MARTON Sándor, KISS Katalin, KOZMA Zsolt, GION Gábor

[INTRODUCTION - The regulation of fluid and electrolite homeostasis is of crucial importance to maintain the normal biochemical processes of the body. Any sudden and remarkable change in the salt and water metabolism may result in serious consequences. CASE REPORT - In the case report the authors describe the history of a 17 old patient, who was admitted to the Emergency Department following seizures, with mental confusion, hyperpyrexia and hyponatremia. CONCLUSION - The aim of the authors was to present a severe case of hyposmolar hypervolaemia of uncommon etiology. They focus on the importance of the anamnestic history emphasizing the significance of diffrential diagnosis and demonstrate the therapeutic considerations.]

Lege Artis Medicinae

[ALDOSTERONE AT THE BEGINNING OF THE 21ST CENTURY]

GLÁZ Edit, SZŰCS Nikolett, VARGA Ibolya

[The discovery of aldosterone as the principal mineralocorticoid hormone led to a new era in the study of the regulation and the pathological/clinical relevance of the fluid-salt homeostasis and blood pressure. Here, we discuss briefly the history of the discovery of aldosterone, its biosynthesis, the mechanism of action, regulation and the diseases which are associated with its pathologically increased production and hypertension: primary and secondary hyperaldosteronisms. Considering their clinical significance, we focus on primary hyperaldosteronisms as they represent a considerable portion of secondary hypertensions that can be definitively cured. Differential diagnosis issues related to other forms of hypertension of different origins are discussed in detail. Recent findings of the past fifteen years indicate that besides its classical genomical actions aldosterone has much more diverse non-genomic actions as well including proinflammatory and profibrotic effects even in physiological concentrations. Based on these observations, aldosterone can be regarded as a risk hormone in the aetiology of cardiomyopathies, vasculopathies and neuropathies and therapeutical consequences are also discussed.]

Lege Artis Medicinae

[The selection criteria of the preoperative ERCP]

LAKATOS Péter László, MESTER Gábor, RÉTI György, NAGY Attila

Lege Artis Medicinae

[LONG-TERM OXYGEN TREATMENT]

SOMFAY Attila

[Long-term oxygen therapy is the only treatment that has been shown to significantly improve life expectancy in patients with severe chronic obstructive pulmonary disease (COPD) exhibiting marked hypoxemia. There has been sginificant advances in the longterm oxygen therapy in the last two decades caused by the technological improvements in oxygen delivery systems as well as our better knowledge of the beneficial effects of the longterm oxygen therapy including better quality of life, exercise tolerance and pulmonary hemodynamic effects. This expansive therapy requires the documentation of chronic arterial hypoxemia by arterial blood gas analysis or pulsoximetry which should be reassesed during chronic care of these patients. Besides hypoxaemia, the consequences of tissue hypoxia induced by different problems in the oxygenation chain should also be considered. Indication of long-term oxygen therapy is optimally based on evidence and pathophysiology, thereby the undesirable placebo effect or psychological addiction to oxygen can be reduced. Late laboratory diagnostics and poor patient compliance are the main determinants of undertreatment. The real value of the long-term oxygen therapy in indications other than hypoxaemic COPD requires more controlled studies.]

Lege Artis Medicinae

[THE TREATMENT OF ACUTE ISCHEMIC STROKE BASED ON CURRENT GUIDELINES]

SZEGEDI Norbert, MAY Zsolt, ÓVÁRY Csaba

[Cerebrovascular diseases are third among the most frequent causes of mortality in developed countries and represent the most common cause of disability in adulthood. 80% of all acute stroke cases are of ischemic origin. The proven significant efficacy of intravenous thrombolysis with rt-PA in the NINDS rt-PA Stroke Trial was the cornerstone of the treatment of acute ischemic stroke, followed by several recommendations. From this time on, the attention shifted to early and appropriate recognition of symptoms and to organizing a quickly reacting emergency medical system in order to maximize the number of those patients transported immediately to the nearest stroke center to have the opportunity to be treated within three hours after their symptom onset. Specialized stroke facilities have documented benefit over other forms of stroke management concerning survival rates, but they need coordinated continuous multidisciplinary care for the patients, availability of CT scanner, laboratory examinations including tests of hemostasis, intensive care unit and well-trained stroke neurologists on 24-hours-a-day basis. Thrombolysis in these stroke centers with intravenous 0,9 mg/kg rt-PA improves the outcome of acute stroke with 30%. Although new guidelines strongly recommend the thrombolysis of selected ischemic stroke patients, the only evidence-based treatment of this condition has not yet become a part of the routine stroke management in Hungary. Regarding other specific antithrombotic therapeutic approaches, anticoagulation has the most contradictory status: in spite of well-defined theoretic considerations there are no evidence-based data in favour of routine anticoagulation in acute ischemic stroke, neither with heparin nor with low molecular weight heparins or heparinoids, while aspirin given within 24-48 hours after stroke onset was shown to have a significant but modest benefit. No data support the treatment with hemodilution or the administration of neuroprotective drugs. Evidence accumulating continuously determine the principles of general care including the methods and the targets in the acute phase of ischemic stroke regarding respiratory and cardiac care, management of blood pressure and blood glucose levels and body temperature.]

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Clinical Neuroscience

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?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[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.]

Hypertension and nephrology

[Association between cyclothymic affective temperament and hypertension]

NEMCSIK János, BATTA Dóra, KŐRÖSI Beáta, RIHMER Zoltán

[Affective temperaments (cyclothymic, hypertymic, depressive, anxious, irritable) are stable parts of personality and after adolescent only their minor changes are detectable. Their connections with psychopathology is well-described; depressive temperament plays role in major depression, cyclothymic temperament in bipolar II disorder, while hyperthymic temperament in bipolar I disorder. Moreover, scientific data of the last decade suggest, that affective temperaments are also associated with somatic diseases. Cyclothymic temperament is supposed to have the closest connection with hypertension. The prevalence of hypertension is higher parallel with the presence of dominant cyclothymic affective temperament and in this condition the frequency of cardiovascular complications in hypertensive patients was also described to be higher. In chronic hypertensive patients cyclothymic temperament score is positively associated with systolic blood pressure and in women with the earlier development of hypertension. The background of these associations is probably based on the more prevalent presence of common risk factors (smoking, obesity, alcoholism) with more pronounced cyclothymic temperament. The scientific importance of the research of the associations of personality traits including affective temperaments with somatic disorders can help in the identification of higher risk patient subgroups.]

Clinical Neuroscience

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

Clinical Neuroscience

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin, FOLYOVICH András, SZLOBODA Péter, SZENDREY-KISS Zsolt, BERECZKI Dániel, BAKOS Mária, VÁRALLYAY György, SZABÓ Huba, NYÁRI István

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.