Cardiac toxoplasmosis after heart transplantation diagnosed by endomyocardial biopsy.

We describe a case of cardiac toxoplasmosis diagnosed by routine endomyocardial biopsy in a patient with trimethoprim-sulfamethoxazole (TMP-SMX) intolerance on atovaquone prophylaxis. Data are not available on the efficacy of atovaquone as Toxoplasma gondii prophylaxis after heart transplantation. In heart transplant patients in whom TMP-SMX is not an option, other strategies may be considered, including the addition of pyrimethamine to atovaquone.

Hypertension and vascular dementia.

Postmortem surveys on patients treated for chronic hypertension often fail to demonstrate significant vessel changes. Nevertheless, hypertensive alterations in the brain can include infarcts and hemorrhages. Autopsies in a primary care hospital have shown that hypertension can affect arteries, arterioles, and capillaries in various patterns and degrees in the brain. These vascular lesions may be associated with large and small infarcts and hemorrhages in isolated or diffuse patterns. Widespread cerebral edema can occur with rapidly progressive hypertension. Atherosclerosis, arterial and arteriolar fibrinoid necrosis, and micro-aneurysms may be observed. Chronic hypertensive encephalopathy causes vascular dementia and can be associated with subcortical arterial and arteriolar leukoencephalopathy, leukoaraiosis and/or Binswanger's disease. Epidemiologic evaluations based on complete autopsy studies need to be correlated with compliance of therapy, appropriate diagnosis of hypertension, and its long-term effects on the nervous system. Although persistent poorly controlled hypertension is known to damage the brain both acutely and chronically, the effects of intermittent hypertension remain to be defined.

Anesthetic management of a patient with moyamoya disease: a case report.

A previously healthy 4-year-old female presented with an 18-month history of frequent headaches and seizures. Magnetic resonance imaging (MRI) and angiography revealed severe stenosis of the left proximal intracranial carotid artery, with bilateral development of moyamoya vessels, left greater than right. A diagnosis of moyamoya disease was made, and the patient was scheduled for surgical correction consisting of an encephalo-duro-arterio-synangiosis. Moyamoya disease is a rare, occlusive cerebrovascular disorder characterized by bilateral stenosis of the internal carotid arteries and their branches. While its etiology is currently uncertain, recent studies indicate that focal arteritis, secondary to an antigen-antibody reaction, leads to the development of the stenosis. Anesthetic management of patients with moyamoya disease focuses on maintenance of adequate cerebral blood flow, normalization of intracranial pressure, and avoidance of both cerebral vasoconstriction and vasodilation. Several anesthetic techniques have been successfully employed; one such method is presented.