Epilepsia: una historia de voces y fantasmas / Epilepsy: A story of voices and ghosts

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Intoxicación por fenitoína. Reacción cruzada con barbitúricos / Phenytoin intoxication. Cross-reaction with barbiturates

Las intoxicaciones suponen un motivo frecuente de consulta en Pediatría. El cribado toxicológico en orina es una herramienta de diagnóstico rápido y bajo coste, pero debemos tener precaución en su interpretación, ya que existen reacciones cruzadas con otros fármacos de estructura química similar. Se describe el caso clínico de un paciente de 11 años con afectación neurológica y resultados positivos para barbitúricos en orina. La confirmación de niveles elevados de fenitoína en sangre permite confirmar el diagnóstico y la reactividad cruzada de los resultados en orina

Intoxications are a common reason for consultation in Pediatrics. Urine toxicology screening is a rapid and low-cost tool, but these results have to be interpreted with caution due to cross reactions with other drugs with similar chemical structure. We describe the clinical case of a 11 years old patient with neurological involvement and positive results for barbiturates in urine. Confirmation of high levels of phenytoin in blood guaranteed the diagnosis and cross-reaction results in urine

Intoxicación por fenitoína. Reacción cruzada con barbitúricos / Phenytoin intoxication. Cross-reaction with barbiturates

Las intoxicaciones suponen un motivo frecuente de consulta en Pediatría. El cribado toxicológico en orina es una herramienta de diagnóstico rápido y bajo coste, pero debemos tener precaución en su interpretación, ya que existen reacciones cruzadas con otros fármacos de estructura química similar. Se describe el caso clínico de un paciente de 11 años con afectación neurológica y resultados positivos para barbitúricos en orina. La confirmación de niveles elevados de fenitoína en sangre permite confirmar el diagnóstico y la reactividad cruzada de los resultados en orina

Intoxications are a common reason for consultation in Pediatrics. Urine toxicology screening is a rapid and low-cost tool, but these results have to be interpreted with caution due to cross reactions with other drugs with similar chemical structure. We describe the clinical case of a 11 years old patient with neurological involvement and positive results for barbiturates in urine. Confirmation of high levels of phenytoin in blood guaranteed the diagnosis and cross-reaction results in urine

Interacciones medicamentosas y falta de monitoreo terapéutico como causas de inefectividad y reacciones adversas a la medicación antiepiléptica en un grupo de pacientes epilépticos colombianos / Medical interactions and inappropiate therapeutic monitoring in a group of epileptic Colombian patients

INTRODUCCIÓN: Se evaluaron las interacciones medicamentosas (IM) y el monitoreo terapéutico de fármacos (MTF) inadecuado como causa de problemas de efectividad y/o seguridad a la terapia antiepiléptica en un grupo de pacientes colombianos. MÉTODOS: Todos los casos de RAM y/o de fallo terapéutico (FT) fueron detectados por un médico farmacólogo mediante farmacovigilancia activa y validados con un farmacéutico. También se evaluaron las IM con la herramienta Lexicomp®, y los niveles plasmáticos de los antiepilépticos. RESULTADOS: 11 de los 77 sujetos (14,3%; IC95% 7,4 -24,1) tenía un problema de efectividad; 30 (39,0% IC95% 28,0 - 50,8) un problema de seguridad; y 30 pacientes (39,0% IC95% 28,0 - 50,8) un problema mixto de efectividad y seguridad. CONCLUSIÓN: En el 70% de los pacientes con RAM y en el 37% de los pacientes con FT el problema pudo deberse a una IM y/o a un MTF inadecuado o insuficiente. Se recomienda el acompañamiento de farmacia clínica para el manejo de pacientes con epilepsia

INTRODUCTION: Drug interactions (DI) and inappropriate therapeutic drug monitoring (TDM) were evaluated as cause of therapeutic failures (TF) and/or adverse reactions to antiepileptic therapy (ADR) in a group of Colombian patients. METHODS: All cases of ADR and/or therapeutic failure (TF) were detected by a pharmacologist through active pharmacovigilance and validated with a pharmacist. DI were also evaluated with the Lexicomp® tool and plasma levels of antiepileptics were assessed. RESULTS: 11 of the 77 subjects (14.3%) had TF; 30 of them (39%) had at least one ADR. inally, 30 patients (39%) had TF and ADR at the same time. CONCLUSION: In 70% of patients with ADR and in 37% of patients with TF, the problem could be related to a drug interaction or inadequate therapeutic drug monitoring. The involvement of Clinical Pharmacy service is recommended for the management of patients with epilepsy

Ausencia congénita de uñas y pulgar digitalizado debida a la exposición prenatal a fenitoína / Congenital Absence of Nails and Digital-Type Thumb due to Prenatal Phenytoin Exposure

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Utilidad de la hemodiálisis en intoxicación por antionvulsivantes: reporte de dos casos / Usefulness of hemodialysis in anticonvulsant intoxication: report of two cases

La intoxicación aguda por anticonvulsivantes suele ser una complicación frecuente en los servicios de urgencias, por lo cual el médico de atención primaria debe estar capacitado y atento al manejo específico de este tipo de intoxicaciones, logrando impactar positivamene en los desenlaces del paciente y evitando complicaciones o, incluso la muerte. En el presente trabajo se exponen 2 casos de pacientes atendidos en un servicio de urgencias de alta complejidad que presentaron signos de intoxicación aguda por ácido valproico y fenitoína, respectivamente. Se describen las recomendaciones más recientes de acuerdo a la literatura disponible acerca del manejo y el uso de hemodiálisis como medida terapeútica en este tipo de intoxicación

Acute poisoning by anticonvulsants is usually a frequent complication in emergency services, so the primary care physician must be trained and aware of the specific treatment of this type of poisoning, which has a positive impact on patient outcomes and Avoid complications or complications. death. In the following article, 2 cases of patients attended in a high complexity emergency department who presented signs of acute intoxication with valproic acid and phenytoin, respectively, are presented. The most recent recommendations will be described according to the available literature on the management and use of hemodialysis as a therapeutic measure

Réplica: Interacciones potenciales con ivermectina como tratamiento coadyuvante en la epilepsia refractaria / Reply: Potential interactions with ivermectin as adjuvant therapy for refractory epilepsy

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Interacción entre levofloxacino y fenitoína: a propósito de 2 casos / Interaction between levofloxacin and phenytoin: report of two cases

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Patrones de prescripción de antiepilépticos en pacientes colombianos afiliados al Sistema General de Seguridad Social en Salud / Anticonvulsant prescription patterns in patients covered by the Colombian Health System

INTRODUCCIÓN: La epilepsia constituye un problema neurológico común caracterizado por convulsiones. OBJETIVO: Se pretendió determinar los patrones de prescripción de medicamentos antiepilépticos en pacientes afiliados al Sistema de Salud de Colombia. MÉTODOS: Estudio de corte transversal sobre una base de datos de 6,5 millones de personas. Se seleccionó a pacientes de cualquier sexo y edad, residentes en 88 ciudades, tratados con antiepilépticos desde junio a agosto del 2012. Se diseñó una base de datos de consumo de medicamentos, se hicieron análisis multivariados sobre utilización en terapia combinada y comedicación mediante SPSS 20.0. RESULTADOS: Se estudió a 13.793 pacientes, con edad promedio de 48,9 ± 22,0 años; el 52,9% eran mujeres; el 74,4% recibía monoterapia antiepiléptica y el 25,6%, 2 o más anticonvulsivos. El orden de prescripción fue: clásicos (72,9%) y nuevos antiepilépticos (27,1%). Los más frecuentemente empleados fueron: ácido valproico (33,3%), carbamazepina (30,2%), clonazepam (15,7%), pregabalina (10,3%), fenitoína (10,0%) y levetiracetam (7,9%). La mayoría, a dosis superiores a las recomendadas. Las combinaciones más comunes fueron: ácido valproico + clonazepam (10,9%), ácido valproico + carbamazepina (10,0%), carbamazepina + clonazepam (5,6%) y ácido valproico + fenitoína (4,4%). Las comedicaciones más frecuentes fueron: antihipertensivos (61,0%), hipolipidemiantes (45,8%), antidepresivos (36,7%), antipsicóticos (20,1%), ansiolíticos (7,9%) y litio (1,8%). DISCUSIÓN: Predominan los hábitos de prescripción de medicamentos de alto valor terapéutico, principalmente en la monoterapia antiepiléptica. La mayoría se emplea en dosis mayores a las recomendadas. Se plantea la necesidad de diseñar estrategias educativas para corregir algunos hábitos de prescripción e investigaciones que evalúen la efectividad del tratamiento

INTRODUCTION: Epilepsy is a group of long-term neurological disorders characterised by seizures that may respond to pharmacological treatment. OBJECTIVE: Determine the prescribing patterns of anticonvulsants for patients covered by the healthcare system in Colombia. METHODS: Cross-sectional study using a database containing 6.5 million people. From among residents in 88 Colombian cities, we selected patients of both sexes and all ages who were treated continuously with anticonvulsants between June and August 2012. We designed a drug consumption database and performed multivariate analysis for combination treatment and co-medication using SPSS 20.0. RESULTS: A total of 13,793 patients with mean age of 48.9 ± 22.0 years were studied; 52.9% of the participants were women. Of the patient total, 74.4% were treated in monotherapy and 25.6% received two or more anticonvulsants. Globally, 72.9% of the patients were initially treated with classic anticonvulsants and 27.1% with new drugs. The most frequently used drugs were valproic acid (33.3%), carbamazepine (30.2%), clonazepam (15.7%), pregabalin (10.3%), phenytoin (10.0%) and levetiracetam (7.9%). Most agents were used in higher doses than recommended. The most common combinations were valproic acid + clonazepam (10.9%), valproic acid + carbamazepine (10.0%), carbamazepine + clonazepam (5.6%), valproic acid + phenytoin (4.4%). The most frequently prescribed co-medications were antihypertensives (61.0%), lipid-lowering drugs (45.8%), antidepressants (36.7%), antipsychotics (20.1%), anxiolytics (7.9%), and lithium (1.8%). DISCUSSION: Doctors predominantly prescribe drugs with a high therapeutic value and favour anticonvulsant monotherapy. Most agents were used in higher doses than recommended. This underlines the need to design educational strategies addressing these prescribing habits, and to undertake research on the effectiveness of treatment

Humoral deficiency in three paediatric patients with genetic diseases

BACKGROUND: Primary immunodeficiencies (PID) represent a heterogeneous group of genetic disorders characterised by poor or absent function in one or more components of the immune system. Humoral or antibody immunodeficiencies are the most common form of PID, of which common variable immunodeficiency (CVID) is the most frequent symptomatic form. CVID is usually characterised by hypogammaglobulinaemia with poor antibody specificity, and an increased susceptibility to infections, autoimmunity and lymphoproliferation. Fewer than 10% of CVID patients have a known monogenic basis. Several chromosomal abnormalities (chromosome 18q-syndrome, monosomy 22, trisomy 8 and trisomy 21) are currently identified as causes of hypogammaglobulinaemia, and can manifest with recurrent infections and mimic CVID. Methods; Review of clinical charts and laboratory results of paediatric patients followed in the outpatient clinic of PID with a diagnosis of genetic disease and humoral immunodeficiency. RESULTS: Three patients with different genetic diseases (19p13.3 deletion, a ring 18 chromosome and Kabuki syndrome), were identified. During follow-up, they developed signs and symptoms suggestive of humoral deficiency mimicking CVID, despite which immunoglobulin levels were quantified with considerable delay with respect to symptoms onset, and specific management was subsequently delayed. CONCLUSIONS: Patients with genetic abnormalities and recurrent infections should be evaluated for hypogammaglobulinaemia. An early diagnosis of humoral deficiency can allow treatment optimisation to prevent complications and sequelae

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Síndrome Erythema Multiforme associated with Phenytoin And Cranial radiation Therapy (EMPACT) en paciente con neoplasia pulmonar / Erythema Multiforme Associated With Phenytoin and Cranial Radiation Therapy (EMPACT syndrome) in a Patient With Lung Cancer

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Torsade de pointes / Torsades de pointes

Presentamos el caso de un varón tratado por convulsiones con diazepam en varias ocasiones. Finalmente se demuestra un síndrome de QT largo adquirido que le predisponía a torsades de pointes manifestándose con convulsiones y, por tanto, tratado erróneamente. Se repasa el síndrome del QT largo, describiendo las diferentes causas tanto congénitas como adquiridas, diagnóstico electrocardiográfico, la medición corregida del intervalo QT según la frecuencia cardiaca y tratamiento (AU)

The present is the case of a male treated on several occasions for seizures with diazepam. Eventually, an acquired long QT syndrome was demonstrated which predisposed him to torsades de pointes, manifesting as seizures and henceforth treated erroneously. The long QT syndrome is reviewed, describing the different causes of long QT interval, both congenital and acquired, electrocardiographic diagnosis, according to heart rate and treatment (AU)

Síndrome de abstinencia alcohólica en pacientes hospitalizados / Inpatient alcohol withdrawal syndrome

Un varón de 55 años ingresó por fractura de fémur. A su llegada presentaba fétor enólico. Al día siguiente comenzó con temblor y nerviosismo, por lo que se administró haloperidol por vía intravenosa. Poco después presentó dos crisis comiciales generalizadas y posteriormente desarrolló un delirio con agresividad incontrolable. Se planteó el diagnóstico de síndrome de abstinencia alcohólica y se pautó midazolam por vía intravenosa en perfusión a dosis altas. A las pocas horas evolucionó a depresión respiratoria que obligó a su traslado a la Unidad de Cuidados Intensivos. Revisados sus antecedentes, el enfermo había ingresado en tres ocasiones previas por síndrome de abstinencia alcohólica, que tras presentar crisis comiciales evolucionó a delirium tremens. ¿Se podía valorar al ingreso el riesgo de desarrollar un síndrome de abstinencia alcohólica y la necesidad de profilaxis farmacológica? ¿Se utilizaron las medidas de control y tratamiento adecuadas? ¿Hubiera sido posible modificar su evolución clínica? (AU)

A 55-year-old man was admitted for a femur fracture; an alcohol fetor was noted on admission. The following day, the patient began to experience tremors and nervousness. Intravenous haloperidol was administered. Shortly afterwards, the patient experienced two generalized seizures and then began to experience delirium and uncontrollable agitation. The patient was diagnosed with alcohol withdrawal syndrome; high doses of intravenous midazolam were prescribed and infused. A few hours later, the patient presented signs of respiratory depression, requiring a transfer to the intensive care unit. After a review of the medical history, it was determined that the patient had been admitted on 3 previous occasions due to alcohol withdrawal and had progressed to delirium tremens after experiencing seizures. Can the risk of alcohol withdrawal syndrome and the need for prophylactic treatment be assessed on admission? Were appropriate monitoring and treatment measures employed? Would it have been possible to change his outcome? (AU)

Encefalopatía hiperamoniémica inducida por ácido valproico en un neonato. Tratamiento con ácido carglúmico / Valproate-induced hyperammonemic encephalopathy in a neonate: Treatment with carglumic acid

La encefalopatía hiperamoniémica inducida por ácido valproico (EHV) es una entidad grave e inusual. Para su diagnóstico, precisa un elevado índice de sospecha, pues resulta reversible con la retirada del fármaco y el tratamiento precoz de la hiperamoniemia. Presentamos el caso de un neonato tratado con valproico (AV) por convulsiones refractarias, que desarrolló una EHV grave que revirtió con la retirada del AV y el tratamiento con ácido carglúmico, junto con otras medidas para control de la hiperamoniemia

Valproate-induced hyperammonemic encephalopathy (VHE) is an unusual and serious complication of valproate (VA) treatment. When an early diagnosis is made, it can be reversed with VA withdrawal and early treatment for hyperammonemia. We describe the case of a 20 days old male, who developed a serious VHE after receiving VA for refractory neonatal seizures. The VHE was resolved with VA withdrawal in association with carglumic acid and other measures for hyperammonemia treatment

Eclampsia y encefalopatía posterior reversible / Eclampsia and posterior reversible encephalopathy syndrome

La eclampsia, síndrome clínico definido clásicamente por la aparición de convulsiones y/o coma en gestantes con hipertensión y proteinuria, se presenta frecuentemente como un síndrome de encefalopatía posterior reversible (PRES), entidad clínico radiólogica caracterizada por cefalea, alteraciones visuales, convulsiones y/o alteración de conciencia, junto a un patrón radiológico de edema cerebral vasogénico reversible localizado en territorio posterior. Discutimos dos casos de gestantes pretérmino que ingresaron en el Servicio de Urgencias de nuestro hospital tras debutar en su domicilio con cefalea y status epiléptico, sin antecedentes de enfermedad hipertensiva del embarazo ni proteinuria. Ambas presentaron en las pruebas de neuroimagen, criterios de síndrome de encefalopatía posterior reversible (PRES), lo que facilitó el diagnóstico diferencial y la toma de decisiones terapéuticas. Dada la estrecha asociación entre eclampsia y síndrome de encefalopatía posterior reversible (PRES), los estudios de neuroimagen constituyen una herramienta valiosa para el diagnóstico y tratamiento oportuno de estas pacientes, favoreciendo su recuperación neurológica completa sin secuelas posteriores(AU)

Eclampsia, a clinical syndrome classically defined by the occurrence of seizures and/or coma in pregnant women with hypertension and proteinuria, is often presented as a posterior reversible encephalopathy syndrome (PRES), a clinical-radiological entity characterized by headache, visual disturbances, seizures and/or alteration of consciousness, besides a radiological pattern of reversible vasogenic cerebral edema located in posterior territory. We discuss two cases of preterm pregnant women admitted to the Emergency Department of our hospital after debuting at their home with headache and status epilepticus, with no history of hypertensive disease of pregnancy or proteinuria. Both presented in neuroimaging criteria for posterior reversible encephalopathy syndrome (PRES), which facilitated the differential diagnosis and therapeutic decision making. Given the close association between eclampsia and posterior reversible encephalopathy syndrome (PRES), neuroimaging studies are a valuable tool for the diagnosis and treatment of these patients, favouring complete neurological recovery without sequelae(AU)

Discinesia orofacial aguda inducida por fenitoína / Phenytoin-induced acute orofacial dyskinesia

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Preeclampsia y eclampsia de presentación atípica / Preeclampsia and eclampsia with atypical presentation

Objetivo. Contribuir al diagnóstico y manejo adecuado de las formas atípicas de la preeclampsia-eclampsia. Caso clínico. Puérpera que ingresa con cuadro de hemólisis y durante su estancia hospitalaria desarrolla hipertensión arterial y otras complicaciones de preeclampsia, así como convulsiones tónico-clónicas. Se revisa la literatura médica relacionada con el tema, mediante búsqueda electrónica en las bases de datos: Ebsco, Medline y Scielo. Conclusiones. Deben considerarse las formas de presentación no clásica de la preeclampsia-eclampsia, para evitar errores de diagnóstico y resultados desfavorables (AU)

Objective. To contribute to the diagnosis and management of atypical preeclampsia-eclampsia. Case report. A puerperal woman was admitted to hospital with hemolysis. During her hospital stay she developed hypertension and other complications of preeclampsia, as well as tonic-clonic seizures. The literature on the topic was reviewed through an electronic search of the Ebsco, Medline and Scielo databases. Conclusions. Unusual presentations of preeclampsia-eclampsia should be considered to avoid a missed diagnosis and adverse outcomes (AU)

Interacción farmacocinética entre fenitoína y buflomedilo / Pharmacokinetic interaction between phenytoin and buflomedil

La prevalencia del tratamiento con fármacos antiepilépticos ha aumentado en pacientes ancianos. Esto unido a la especial fragilidad de estos pacientes, los sitúa entre los grupos farmacológicos que con mayor frecuencia se ven implicados en la aparición de interacciones en este grupo de población. Se describe el caso de una anciana que seguía tratamiento crónico con fenitoína y experimentó una reducción de su concentración plasmática al introducir buflomedilo como parte de su tratamiento. Los pacientes en los que se administren simultáneamente ambos fármacos serían candidatos a una estrecha monitorización con la finalidad de identificar precozmente esta interacción y evitar la posible toxicidad que pudiera derivarse de plantear un aumento de la dosis de fenitoína (AU)

There has been an increase in treatment with antiepileptic drugs in the elderly. This, together with the particular frailty of these patients, places them among the pharmacological groups that have a higher frequency of interactions in this population group. The case is presented of an elderly patient who followed long-term treatment with phenytoin and showed a reduction in her plasma phenytoin levels on introducing buflomedil as part of her treatment. Patients who are given both drugs simultaneously should be subjected to close monitoring, with the aim of identifying this interaction earlier and avoid the possibly toxicity that could arise from deciding to increase the phenytoin dose (AU)

The role of Calotropis procera in phenytoin induced toxicity in the postnatal developing cerebellum of Wistar rats - histologicaland gross morphometric studies

The role of methanolic leaf extracts of Calotropis procera in phenytoin-induced toxicity in the postnatal developing cerebellum of Wistar rat was studied.Forty sexually mature female rats, weighing about 160 g of the Wistar strain were randomly divided into five groups of eight animals per group. They were mated and pregnancy confirmed by the presence of a vaginal plug. The animals were fed with a standard diet of rat pellets and water provided ad libitum. The control animals received water, while the test groups received 50 mg/kg of phenytoin, 300 mg/kg, methanolic extracts of Calotropis procera and 200 mg/kg vitamin C orally, both separately and in combination during and after pregnancy. At the end of the experiment, the offspring for days 1, 7, 14, 21, 28 and 50 post-partum, five per group, were weighed and killed. The brains and cerebella were dissected out and weighed and the cerebella processed for histological studies.In the phenytoin-treated animals the results showed a non significant reduction in the body weight of the animals, P>0.05, and a significant reduction in the brain and cerebellar weights, P<0.05, was observed. The administration of extracts of Calotropis procera and vitamin C reversed these changes when compared with the phenytoin-treated group, but not significantly when compared with the control. Histologically, the outer molecular, Purkinje and inner granular layers of the cerebellar cortex were intact, and in all the groups the external granular layer was not seen on day 21 post-partum.In conclusion, supplementation with methanolic extracts of Calotropis procera reduced the rate at which phenytoin induced toxicity in the postnatal developing cerebellum of Wistar rats (AU)

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