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Clinical Neuroscience

MAY 30, 2021

[A case of destructive cervical spondylarthropathy related to chronic dialysis]

BERTA Balázs, KOMÁROMY Hedvig, SCHWARCZ Attila, KAJTÁR Béla, BÜKI András, KUNCZ Ádám

[A case of a 61-year-old male patient suffered chronic renal failure and dialysed for 23 years with destructive cervical spondylarthropathy is presented. The patient presented with sudden onset of cervical pain radiating into his shoulders without neurological deficits. CT and MRI of the cervical and thoracic spine revealed severe destructive changes and compressive fractures of C6 and C7 vertebrae which caused the narrowing of the nerve root canals at these levels. A 360-degree fixation was performed to treat the unstable fracture and the patient’s pain (C6 and C7 corpectomy, autolog bone graft replacement of the two vertebral bodies, anterior plate fixation and posterior instrumentation with screws and rods). Postoperatively the patient had no significant pain, no neurological deficit and he was able to manage independent life himself. During the immediate follow-up CT of the neck showed the satisfactory position of the bone graft and the metal implantations. The 6 months follow-up CT revealed the anterior migration of the two screws from the Th1 vertebral body and 2 mm ventral elevation of the caudal end of the plate from the anterior surface of the Th1 vertebral body. The 1-year follow-up could not be performed because the patient died due to cardio-pulmonary insufficiency. This is the second Hungarian report of a chronic dialysis related severe spondylarthropathy which may cause pathologic fractures of the vertebral bodies. The typical radiological and histological findings are discussed. This disease affect patients’ quality of life and the conservative treatment alone seems to be ineffective in most cases. Based on the literature and personal experiences, the authors suggest 360-degree fixation of the spine to provide sufficient stability for the vertebrae of ”bad bone quality”, and early mobilisation of the patient can be achieved.]

Clinical Neuroscience

JULY 30, 2020

[The complex intensive care and rehabilitation of a quadriplegic patient using a diaphragm pacemaker]

FODOR Gábor, GARTNER Béla, KECSKÉS Gabriella

[A 21 year female polytraumatized patient was admitted to our unit after a serious motorbike accident. We carried out CT imaging, which confirmed the fracture of the C-II vertebra and compression of spinal cord. Futhermore, the diagnostic investigations detected the compound and comminuted fracture of the left humerus and femur; the sacrum and the pubic bones were broken as well. After the stabilization of the cervical vertebra, a tracheotomy and the fixation of her limbs were performed. She spent 1.5 years in our unit. Meanwhile we tried to fix all the medical problems related to tetraplegia and respiratory insufficiency. As part of this process she underwent an electrophysiological examination in Uppsala (Sweden) and a diaphragm pacemaker was implanted. Our main goal was to reach the fully available quality of life. It is worth making this case familiar in a wider range of public as it could be an excellent example for the close collaboration of medical and non-medical fields.]

Lege Artis Medicinae

MAY 01, 2000

[Gout]

MITUSZOVA Mila

[In spite of our increasing knowledge about the pathomechanism, clinical classification and therapy of gout as well as the improving care of gouty patients, many problems of the field are unsettled. Among others, the atypical character of female gout, its more frequent occurrence in elderly women, the often aggressive character of the cyclosporin-induced gout belongs to the unanswered questions. Understanding the role of crystals covered by proteins (mostly IgG) in the induction of inflammation was of great importance, however, the changing character of inflammation caused by intraarticular MNU-crystal deposition is still a challenging problem. It is well known, that not all gouty patients are middle aged males, the number of young, drug-resistant gouty males having extensive tophi is increasing. Although the relationship between hyperuricemia and gout was clarified in many respect, it would be important to understand why chronic hyperuricemia is not associated regularly with gout and why gout can develop in patients without high serum uric acid levels. We learned finally, that early diagnosis and adequate treatment of gouty attacks and the therapy resulting in the decrease of high level of serum uric acid are prerequisites for slowing down the progres sion of the gout and for the prevention of its complications. ]

Clinical Neuroscience

JULY 30, 2020

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.

Hypertension and nephrology

JUNE 24, 2021

[A new approach to renal osteodystrophy in the diagnosis and treatment of]

MÁCSAI Emília, SZLOVÁK Edina, DOLGOS Szilveszter

[Treatment of renal osteodystrophy (ROD) is one of the new osteoporosis recommendations requires a rethink of the current therapeutic approach. Addressing vitamin D deficiency and reducing quality of life deterioration caused by bone fractures it is also an important professional challenge in the renal insufficiency population. ROD is a classic nephrological treatment to improve the results of the newer molecular expected from better understanding of pathomechanisms and better imaging methods. Associated associations with vascular calcification are cardiovascular can help our efforts to prevent complications, a relationship with periodontal disease the importance of regular monitoring supports. In addition to phosphorus binders, vitamin D agonists and calcimimetics in the future is expected to be the resorption inhibitor denosumab, the bone-building processes supporting PTH analogues and the wider clinical use of romosozumab application.]