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Clinical Neuroscience

MARCH 30, 2016

Cerebral amyloid angiopathy related inflammation: is susceptibility weighted imaging the clue for diagnosis?

CSÉCSEI Péter, KOMOLY Sámuel, SZAPÁRY László, BARSI Péter

Background - Cerebral amyloid angiopathy-related inflammation (CAA-ri) is characterized by various neurological symptoms such as gradually developing confusion, progressive cognitive decline, seizure or headaches; T2 hyperintensities on magnetic resonance imaging (MRI); and neuropathological evidence of cerebral amyloid angiopathy (CAA) and associated vascular or perivascular inflammation. Although histological confirmation is necessary for accurate diagnosis, in case of typical clinical features and neuroimaging, the diagnosis can be established without biopsy. Case summary - We present the case of a 57-year-old man with a history of hypertension who presented to the emer¬gency department 3-week history of progressive headache and a gradually developing altered mental status. On examination, he was found to have left sided weakness and decreased pscyhomotility. Routine clinical work-up (lab investigations, CT, cerebrospinal fluid analysis) did not show obvious diagnosis, so we performed an MRI. It raised the suspicion of CAA-ri which diagnosis was verified by neuroradiological evaluation. High dose steroid treatment was initiated. The patient rapidly responded to treatment, his focal neurological signs resolved. Control MRI after 1.5 months showed multiple haemorrhagic laesions in the field of previous inflammation which posteriorly supported the previous supposed work-diagnosis. Conclusions - Although histopathology is the gold standard for the diagnosis of cerebral amyloid angiopathy, the typical clinical presentation, good response to steroids and accurate neuroradiological criteria make biopsy unnecessary to diagnose CAA-ri.

Hypertension and nephrology

SEPTEMBER 12, 2018

[Treatment of hypertension in kidney transplant patients]

KOVÁCS Tibor, WAGNER László

[Most of the renal transplant recipients suffer from hypertension. Hypertension substantially contributes to the high cardiovascular mortality in this population. The recommendation of the Hungarian Society of Hypertension and the international guidelines suggest to achieve less than 130/80 mmHg as target blood pressure in these patients. Several factors may be in the background of hypertension after kidney transplantation, which can be summarized as factors from the recipient-side, the donorside and factors provoked by transplantation itself. In most of the cases early after transplantation high doses of immunosuppressive drugs (especially calcineurin inhibitors and steroids) are responsible for the increased blood pressure. There are some further special methods apart from the general recommendations which are needed during the examination of hypertension of kidney transplant patients: e.g. measurement of blood trough-level of immunosuppressive drugs, investigation of bone-mineral disorder, screening for the level and causes of anaemia, check-up of the renal graft circulation. Kidney transplant patients suffering from hypertension usually need more than two antihypertensive drugs beyond the use of non-pharmaceutical antihypertensive methods. In the early posttransplantation period calcium channel blockers are preferred antihypertensive medications, because they counterbalance the vasoconstrictive effect of calcineurin inhibitors. The administration of renin-angiotensin-aldosterone inhibitors are rather suggested after the stabilization of renal function (from the 1-3 months posttransplantation). When designing antihypertensive strategy, comorbidities and special factors should be regarded as well, especially volume overload, proteinuria, allograft function (GFR), diabetes, other cardiovascular risk factors, previous cardiovascular events. The setup of an individual therapeutical strategy is advised in view of all these factors, which is different according to the timing after transplantation: the perioperative, the early postoperative phases and from 1-3 months after transplantation have special focuses.]

Hypertension and nephrology

APRIL 10, 2016

[Hungarian virus research and NASA – nephrology aspects]

RADÓ János

[After the occurrence of varicella viruses remain in a latent condition in the ganglions, but could be reactivated from here causing the disease of herpes zoster. In the years of 1960, we described a herpes zoster „house epidemic” where only the steroid treated patients were infected. Varicella zoster virus was identified by virological methods. Also in a steroid treated patient fatal meningoencephalitis was caused by the generalized herpes zoster. The VZ infection was obviously potentiated by the steroid. Our publications about the interaction between the VZ virus and steroid treatment was echoed – among others – by an editorial of four leading medical journals. Investigators of a NASA medical group also cited our articles. They found during and after spaceflight that in the astronauts symptomless reactivation of the VZ virus, EBV and CMV occurred which was contributed to the stress induced hypercortisolemia. Today we see more worries in the prognosis and outlook in certain cases of the herpes zoster than before. One reason of that is the high number of newly recognized complications. Recently also several new pathway of pathomechanisms has been explored, which led to serious risks. In addition, it turned out that in certain disorders as the artheritis temporalis, where today antivirus antibiotic is the first choice drug, instead of steroid administered alone in the past, inducing further progression in the basic disease and sometimes fatal complications when given too long. Nephrological patients are at special risk in the presence of chronic renal disease, high age and associated diabetes mellitus. The risk may even increase after an otherwise successful renal transplantation in response to the administration of steroids and other compounds. Fortunately in the meantime a vaccine was developed against the VZ virus, studied in large populations and found to be very effective. It probably will be a benediction to the old people with chronic renal disease, after transplantation as well as in others suffering from high risk diseases.]

Lege Artis Medicinae

NOVEMBER 03, 2015

[Sudden death of a patient with purpura - post mortem recognized eosinophilic granulomatosis with polyangiitis]

DOBREAN Noémi, HAJNAL-PAPP Rozália, TUSA Magdolna, OROJÁN Iván, CSERNI Gábor

[INTRODUCTION - Systemic diseases may sometimes be challenging because physicians do not think about synthesizing the parts to a single entity. CASE REPORT - A 49-year-old asthmatic female was admitted to hospital for the investigation of her cutaneous symptoms suggestive of vasculitis associated with diffuse joint complaints. The chest X-ray raised the possibility of pneumonia or neoplastic disease. Following an episode of chest pain relieved by a non-steroidal anti-inflammatory drug, she suddenly died. Her previous history included restrictive cardiomyopathy, insufficiency of both atrioventricular valves and long dating eosinophilia. Autopsy revealed a partly granulomatous eosinophilic inflammatory process in several organs, including the heart, the lungs, the kidneys, the colon and the pituitary gland. Retrospective collection of unknown anamnestic features and symptoms made possible to unify the pieces of information and symptoms to a single entity, the Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis, EGPA). CONCLUSIONS - Bronchial asthma seldom leads to death. It can rarely be part of the Churg-Strauss syndrome, of which the manifestation may be related to the administration of leukotriene antagonists also used in the presented case. These drugs may allow the withdrawal of systemic steroid therapy which is beneficial not only in the treatment of asthma but also of the syndrome. Lowering the dose of steroids may promote the development of the full blown pattern of the latter.]

Clinical Neuroscience

MARCH 30, 2014

[A PSYCHIATRIST’S PERSPECTIVES ON STRESS, STEROIDS AND MENTAL ILLNESS]

DUNAI Magdolna

[The relationship between stress and mental illness has been extensively studied and there is a growing consensus that the occurrence of mental illness rather depends on a combination of factors than is caused by stressful external events. Significant hypothalamus pituitary adrenal axis abnormalities were observed among others in major depressive disorder and bipolar disorder. In both disorders, the extent of change in cortisol level was related to the severity of illness and to cognitive changes. Exogenous use of synthetic steroids also frequently resulted in severe psychiatric symptoms. In conclusion changes in the level of steroid hormones may cause impairments in the brain.]

Clinical Neuroscience

MARCH 30, 2014

[PERSONAL RECOLLECTIONS OF DR. HANS SELYE AND OF HIS INSTITUT DE MÈDECINE ET DE CHIRURGIE EXPÈRIMENTALES (IMCE)]

MILAGROS Salas-Prato

[This article is a short personal recollection of Dr. Hans Selye (HS) and of his institute in order to show, first, why and how he influenced us; second, who he was as a person, human being, physician, scientist, professor, mentor; third, what was the structure and functioning of the Institut de mèdecine et chirurgie expèrimentales (IMCE) and fourth, what HS’ contributions and accomplishments were.]

Clinical Neuroscience

MARCH 30, 2014

[HANS SELYE 70 YEARS LATER: STEROIDS, STRESS ULCERS & H. PYLORI]

SZABÓ Sándor

[Although Hans Selye is mostly known for his discovery & development of the stress concept, he also introduced the first physiologically sound, structure-activity classification of steroids that was also based on the chemical structure of steroids in 1943. He not only introduced the names of glucocorticoids & mineralocorticoids but discovered the anti- & pro-inflammatory properties, respectively, of these steroids in animal models. Furthermore, he not only described the first stress-induced gastric ulcers in rats (1936) & characterized the first human ‘stress ulcers’ during the air-raids in London during World War II (1943). Thus, Selye was a much more productive & creative scientist than it is generally considered.]

Hypertension and nephrology

JULY 20, 2013

[Hypertension and diabetes mellitus]

SZEGEDI János, KISS István

[Hypertension and diabetes mellitus are endemics which affect large crowds; they play an important role in the morbidity and mortality of the population. Both diseases are cardiovascular risk factors, their co-occurrence increases the coronary risk. According to forecasts, there will be 60% increase in the number of hypertensive patients by 2025; it will affect 29% of the world’s adult population, 1.56 billion people. The number of patients with diabetes increases in all countries; 552 million diabetic patients should be expected by 2030. The simultaneous occurrence of both diseases may be a coincidence, but there is also causal relationship between the two diseases (diabetic nephropathy, metabolic syndrome). The two diseases often occur in endocrine diseases, and in connection with medicinal therapy (steroids, etc.). The simultaneous occurrence of these two diseases determines the therapeutic strategy. During the prevention and treatment of both diseases, the change in lifestyle has an important role (obesity, salt intake, physical activity).]

Hypertension and nephrology

MARCH 22, 2013

[Causes of and therapeutic opportunities in resistant hypertension]

SIMONYI Gábor, GENCSI Kristína

[Hypertension is an independent cardiovascular risk factor and one of the most frequent diseases in Hungary. In the treatment of hypertensive patients usually more than two drugs are needed for the appropriate blood pressure control. Resistant hypertension (RH) is defined when blood pressure remains above target value despite full doses of antihypertensive medications, which consist of at least three different classes of drugs including a diuretic administered in maximal doses. The frequency of RH can reach 20-30% among hypertensive patients. RH increases the cardiovascular risk because of the lack of target blood pressure. RH is multifactorial and it is important to exclude pseudo-resistant hypertension (e.g. poor compliance, white coat effect). In the background of RH we can find lifestyle factors (e.g. obesity, excessive salt intake, alcoholism, etc.) and a variety of drugs (e.g. non-steroids, corticosteroids, sympathomimetics). In the pathogenesis of RH the increased activity of the sympathetic nervous system has an important role. In the treatment of RH we should manage lifestyle factors and it is important to assess the drugs and diseases (e.g. sleep apnea, chronic kidney disease, diabetes mellitus) which may cause increased blood pressure. It is no exact recommendations for the treatment of RH. Therapy often consists of 4-5 various drugs in combination. An important role has the device therapy of RH in recent years (e.g. stimulation of the carotid baroreceptors and renal denervation) as well.]

Lege Artis Medicinae

JANUARY 22, 2008

[PAIN AND PAIN CONTROL IN RHEUMATOLOGY]

GAÁL János

[In developed industrial countries the overall population prevalence of chronic rheumatic pain is around 35%. A classification that is useful in everyday practice is based on the origin of musculoskeletal pain and lists pain associated with degenerative joint diseases, pain related to metabolic bone diseases, non-articular and soft tissue rheumatism, and pain due to inflammation. In chronic pain syndrome pain itself has lost its adaptive biological role, and presents as a pathogenetic factor in its own right, accompanied by significant vegetative and psychological symptoms. Therapeutic exercise is of basic importance in the management of rheumatic pain. It is supplemented by various pharmacologic and nonpharmacologic methods. The latter include, among others, fomentations, packs, balneo- and hydrotherapeutic methods, electro-, mechanoand thermotherapeutic approaches. Pharmacological therapy usually means the use of simple analgesics, non-steroidal antiinflammatory drugs, steroids, minor opiates, and, lately, also major opiates, which may be supplemented by adjuvant agents such as tricyclic antidepressants and anticonvulsive drugs. When indicating the most often used non-steroidal antiinflammatory drugs, their potential side effects should carefully be considered. Invasive pain-killing methods on the border area between anaesthesiology and rheumatology (epidural steroid administration, ganglionic blockade, intravenous regional blockade) are applied in cases that do not respond to conventional therapy, and sometimes also as successful first-line intervention.]