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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.

Lege Artis Medicinae

SEPTEMBER 20, 2018

[Multidisciplinarity and pulmonary hypertension in idiopathic pulmonary fibrosis]

BOHÁCS Anikó, KARLÓCAI Kristóf, KERPEL-FRONIUS Anna

[Idiopathic pulmonary fibrosis (IPF) is a subgroup of the fibrotising idiopathic interstitial pneumonias occuring primarily in older adults. It is characterised by progressive decline of lung function and is associated with high mortality. IPF is frequently associated with pulmonary hypertension (PH). PH has unfavourable impact on the prognosis of IPF. PH should be suspected in IPF patients presenting with dyspnoe, desaturation on exertion and disproportionately low diffusion capacity. Transthoracic echocardiography is used to screen for PH in IPF patients. Although right heart catheterization is the gold standard procedure for the diagnosis of PH, this is not regularly performed on IPF patients. Chest high resolution computer tomography (HRCT) is essential for the diagnosis of IPF. IPF is typically characterised by the presence of usual interstitial pneumonia (UIP) pattern on HRCT. Multidisciplinary discussion bet­ween experienced pulmonologists, radiologists, and pathologists is key in the early and accurate diagnosis of IPF. An important role of the interstitial lung disease-multidisciplinary team (ILD-MDT) is to determine whether other diagnostic examinations and surgical lung biopsy is needed, in an attempt to reduce unnecessary risk. ILD-MDT should propose the initiation of antifibrotic therapies that have the potential to reduce disease progression. All patients diagnosed with IPF, with no contraindications for lung transplantation, should be referred early to a transplant committee.]

Lege Artis Medicinae

AUGUST 30, 2018

[How to diagnose idiopathic pulmonary fibrosis. Part 2]

HORVÁTH Ildikó, KERPEL-FRONIUS Anna, HARKÓ Tünde

[Idiopathic pulmonary fibrosis is a severe irreversible lung disease with a progressive course. The disease onset is hard to discover due to the unspecific signs and symp­toms. It occurs mainly in elderly people. In the past decades its prevalence has increased continuously. Physical examination, restrictive pattern on lung function test with decreased diffusion capacity are characteristic features of the disease. Chest X-ray showing fibrotic pattern also points toward the diagnosis of idiopathic pulmonary fibrosis. Differential diagnosis is based on high resolution komputertomográfy. Diag­nosis of IPF is based on the appearance of usual interstitial pneumonia pattern together with the lack of external risk factors and autoimmune or other diseases also known to cause this pattern seen on chest imaging. If no firm diagnosis can be built lung biopsy is required. Multidis­ciplinary teams from clinician, radiologist and pathologist are set in predefined centres that could provide care with novel antifibrotic drugs. These can slow disease progression and are in the frontline in the treatment of the disease. Further research is required to understand the pathomechanism and foster the discovery of further treatment options. ]

Lege Artis Medicinae

JULY 20, 2017

[Aliennes and alien language in the Arrival (film)]

HORVÁTH Lajos, GÁSPÁR László Ervin, HORVÁTH Henrietta

[The paper aims to provide an integrative analysis of a science fiction film, Arrival. Even in the context of previous sci-fi films and their criticism, it is hard to define the genre of the movie. Maybe the movie Interstellar can be considered as the closest work. Suddenly appearing Aliens and the communication with them is the central problem of the movie. With the resource of context-free grammar and cosmological time-perception we analyze the situation outlined in the story. Can mechanism of human language acquisitions and language theory help us in the case of alien contact? Is it possible that the use of physical constants decrease the chance of basic misunderstandings? ]

Hypertension and nephrology

FEBRUARY 10, 2017

[The importance and techniques of fluid status assessment in patients with heart and kidney disease]

LEDÓ Nóra, HORVÁTH Viktor József, TISLÉR András

[Managing the fluid balance in patients with chronic heart and kidney disease is critical, it exceptionally affects the success of the therapy. Therefore, it is crucial to recognize and treat the fluid overload or depletion as soon as possible. Plenty of methods are available to assess fluid status, which can help us to find the right diagnosis, plan and follow the therapy of the patients. The aim of our review article is to present the current techniques of estimating fluid status. Beside the widely used methods (e.g. physical examination, laboratory testing) we describe other techniques which are less common in the Hungarian clinical practice but easy to use, such as chest sonography and bioimpedance spectroscopy. To choose the right approach for assessing fluid status, we have to examine the advantages and disadvantages of the methods in consideration of the patient’s individual needs.]

Clinical Neuroscience

JANUARY 20, 2017

[Thrombolysis in case of ischemic stroke caused by aortic dissection]

LANTOS Judit, NAGY Albert, HEGEDŰS Zoltán, BIHARI Katalin

[Seldom, an acute aortic dissection can be the etiology of an acute ischemic stroke. The aortic dissection typically presents with severe chest pain, but in pain-free dissection, which ranges between 5-15% of the case, the neurological symptoms can obscure the sypmtos of the dissection. By the statistical data, there are 15-20 similar cases in Hungary in a year. In this study we present the case history of an acute ischemic stroke caused by aortic dissection, which is the first hungarian publication in this topic. A 59-year-old man was addmitted with right-gaze-deviation, acute left-sided weakness, left central facial palsy and dysarthric speech. An acute right side ischemic stroke was diagnosed by physical examination without syptoms of acute aortic dissection. Because, according to the protocol it was not contraindicated, a systemic intravenous thrombolysis was performed. The neurological sypmtoms disappeared and there were no complication or hypodensity on the brain computed tomography (CT). 36 hours after the thrombolysis, the patient become restlessness and hypoxic with back pain, without neurological abnormality. A chest CT was performed because of the suspition of the aortic dissection, and a Stanford-A type dissection was verified. After the acute aortic arch reconstruction the patient died, but there was no bleeding complication at the dissection site caused by the thrombolysis. This case report draws attention to the fact that aortic dissection can cause acute ischemic stroke. Although it is difficult to prove it retrospectively, we think the aortic dissection, without causing any symptoms or complain, had already been present before the stroke. In our opinion both the history of our patient and literature reviews confirms that in acute stroke the thrombolysis had no complication effect on the aortic dissection but ceased the neurological symptoms. If the dissection had been diagnosed before the thrombolysis, the aortic arch reconstruction would have been the first step of the treatment, without thrombolysis. ]

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.]

Journal of Nursing Theory and Practice

APRIL 30, 2015

[An in-depth look at chest pain, for ambulance nurses]

MOSKOLA Vladimír, HORNYÁK István

[Ambulance nurses often deal with complaints of chest pain, both when working independently and when on call in an emergency ambulance or quick response vehicle. It is essential that they know as much as possible about any life-threatening symptoms, and are as up-to-date with the latest skills when attending patients. This also helps teamwork and efforts to ensure an improvement and the proper treatment of the patient’s condition (in the context of an ambulance nurse’s duties). This all requires a knowledge of differential diagnosis, which gives a broad outline of the diseases that could potentially underlie the chest pains suffered by a patient who calls an ambulance. The more in-depth theoretical knowledge also promotes an understanding of the importance of intervention by ambulance crew/doctors in the case of certain diseases, the importance of the time factor, and the reason for urgency even if the patient’s condition does not appear serious at first glance. In the light of these factors the authors have undertaken to provide readers with new, evidence-based knowledge.]

Clinical Neuroscience

MARCH 25, 2015

[Effects of maternal epilepsy and antiepileptic therapy in women during pregnancy]

VANYA Melinda, ÁRVA-NAGY Nóra, SZILI Károly, SZOK Délia, BÁRTFAI György

[Objective - The aim of this study was to analyse the effects of epilepsy and antiepileptic drug (AED) treatment on pregnancy and the perinatal outcome, retrospectively. Methods - We examined the obstetric and fetal outcomes among women with epilepsy (WWE), who were followed-up at the Department of Neurology, and who delivered at the Department of Obstetrics and Gynaecology (n=91) between 31th December 2000 and 31th March 2014. Statistical comparisons of different obstetric and fetal parameters on a sample of 91 WWE and 182 non-WWE were assessed by the chi-square-test, the independent sample t-test. Results - The rate of major congenital malformations (MCMS) among the newborns of all AEDs exposed mothers was 7.69%. There were three peaks of seizures: during the third trimester, during delivery and in the puerperium. The prevalence of miscarriages, post-term birth and the rate of caesarean section were significantly higher among the WWE than among the non-WWE (p=0.001; p<0.001; p=0.02). Parameters of neonates (birth weight, birth length, head-, and chest circumference) were significantly different between the WWE group and the non-WWE group (p=0.003, p<0.001, p<0.001, p<0.001) Conclusions - In contrast with recent publications, there were significant differences in the parameters of neonates between the two groups. Our results are in accordance with those of previous studies from the aspect of AED-related MCM, the elevated risk of miscarriages and pre-existing hypertension. ]

LAM Extra for General Practicioners

SEPTEMBER 20, 2014

[REGIONAL ADVISORY BOARD POSITION STATEMENT ON OPTIMAL PNEUMOCOCCAL VACCINATION IN ADULTS. UPDATE TO 2011 CONSENSUS ON ADULT PNEUMOCOCCAL DISEASE: UPDATE ON OPTIMAL PNEUMOCOCCAL VACCINATION IN ADULTS]

LUDWIG Endre, SERHAT Ünal, MIRON Bogdan, ROMAN Chlíbek, YAVOR Ivanov, ROMAN Kozlov, HARTMUT Lode, MÉSZNER Zsófia, ROMAN Prymula, GALIA Rahav, SKOCZYNSKA Anna, SOLOVIC Ivan, ABDULLAH Sayiner

[BACKGROUND - An important development in the field of adult pneumococcal vaccination since the last Consensus Statement, published by the Expert Panel of Central and Eastern Europe and Israel (the Region) in September 2012, was the licensure of the 13-valent pneumococcal conjugate vaccine (PCV13) for adults aged 50 years and older. DISCUSSION - The Expert Panel has developed this Position Statement as an update to its previous Consensus to address the following topics which are likely to be on the agenda of national scientific societies during the ongoing updates of vaccination recommendations in the Region: the availability of a pneumococcal conjugate vaccine for adults over 50 years of age, the available clinical evidence on its use in adults, and the future place of conjugate vaccines in adult pneumococcal vaccination. The Expert Panel concluded that there is sufficient epidemiologic immunogenicity and safety evidence to use PCV13 in adults over 50 years of age. RESULTS - The use of conjugate vaccine induces immunological memory and can overcome some limitations associated with the plain polysaccharide vaccine (PPV). It was also agreed that, if the use of PPV is considered appropriate, PCV13 should be administered first, regardless of prior pneumococcal vaccination status.]