[Neurologic manifestations of infective endocarditis: a diagnostic and prognostic challenge]. / Manifestaciones neurológicas de la endocarditis infecciosa: un reto diagnóstico y pronóstico.

INTRODUCTION: Infective endocarditis (IE) is an ongoing challenge in terms of excess morbidity and mortality. Neurologic complications occur in 20-40% of patients, and the brain is the main location of IE extracardiac complications. AIM: To analyse clinical characteristics of the neurologic complications found in patients with IE, focused on the diagnostic and prognostic aspects. PATIENTS AND METHODS: We studied retrospectively the cases of patients with IE admitted to the Hospital de Valme and Hospital de la Merced between 1998 and 2003. Laterly, patients with and without neurologic manifestations were compared. Sixty episodes of IE were evaluated. RESULTS: Neurological complications occurred in 12 patients (20%). The most frequent neurologic manifestation was unilateral hemi paresis, which occurred in seven cases (58.3%), three cases with acute confusional state (25%) and two patients developed meningitis (16.6%). Brain infarction was the most common lesion found in neuroimaging, in 6 patients (50%), followed by 2 cases (16.6%) of brain hemorrhage, and without significant findings in the cases left. Cases with neurologic complications had significantly higher mortality (p < 0.001) and higher frequency of negative blood culture (p < 0.001). CONCLUSIONS: Neurologic complications of IE are frequent during the evolution of the disease, and they still constitute a significant problem in clinical practice because they often are not accurately diagnosed and significantly increase patients' mortality.

[HLA-DRB1 typing in Caucasians patients with neuromyelitis optica]. / HLA-DRB1 en pacientes caucasicos con neuromielitis optica.

INTRODUCTION: The existence of antibodies to aquaporin-4 (AQP-4-ab) has identified neuromyelitis optica (NMO) and multiple sclerosis (MS) as different diseases. Although HLA-DRB1 alleles contribute to MS risk, recent studies suggest that HLA back-ground differs between patients with NMO or MS in non-Caucasians populations. Our study was aimed to analyze HLA-DRB1 distribution in Caucasians NMO patients. SUBJECTS AND METHODS: We recruited a cohort of 22 NMO patients (73% were AQP-4-ab positive), 228 MS patients and 225 healthy controls from Spain and we genotyped the HLA-DRB1 locus. Then, we performed a pool analysis using reported data from 45 NMO patients (53% were AQP-4-ab positive), 156 MS patients and 310 healthy controls from Caucasian French population. RESULTS: In the Spanish cohort, NMO was associated with increased frequency of DRB1*10 allele compared with MS (odds ratio, OR = 15.1; 95% confidence interval, 95% CI = 3.26-69.84; p = 0.012). In the pooled analysis, by comparison with healthy controls, NMO was associated with increased frequency of DRB1*03 allele (OR = 2.27; 95% CI = 1.44-3.58; p < 0.0008) which was related to AQP-4-ab seropositivity (OR = 2.74; 95% CI = 1.58-4.77; p < 0.0008). By contrast, MS was associated with increased frequency of DRB1*15 allele (OR = 2.09; 95% CI = 1.62-2.68; p < 0.0008) and decreased frequency of DRB1*07 allele (OR = 0.58; 95% CI = 0.44-0.78; p < 0.0008). CONCLUSIONS: Caucasian patients with NMO and MS have a different HLA-DRB1 allelic distribution. DRB1*03 allele seems to contribute to NMO seropositivity. Multicenter collaborative efforts are needed to adequately address the genetic contribution to NMO susceptibility.

[Hyperammonaemic encephalopathy due to valproic acid]. / Encefalopatía hiperamoniémica por ácido valproico.

INTRODUCTION: One of the less frequent idiosyncratic side effects of valproic acid (VPA) is encephalopathy. Here we report one case. CASE REPORT: An 83-year-old female with no relevant past history, who received treatment with VPA following a post-traumatic subarachnoid haemorrhage and two convulsive seizures. A few days later, she was admitted to the Emergency Department because of a progressive clinical picture of mental slowness, nauseas and apathy. The systemic examination was normal. Neurologically, the most striking features were inattention and disorientation, despite her having a good level of consciousness, and mental confusion. Levels of VPA were within the below-therapeutic range and the basic lab findings (including hepatic profile) were normal, except for hyperammonaemia. Neuroimaging studies and cerebrospinal fluid analysis were also normal. An electroencephalogram (EEG) showed signs of severe diffuse encephalopathy with slow, triphasic waves and a non-convulsive epileptic status was therefore ruled out. After withdrawing the VPA, the patient's condition improved until her basal situation was reached in 48 hours and the EEG became normal, as did her ammonium levels. CONCLUSION: When faced with a patient who has recently been taking VPA and who presents a clinical picture of mental confusion, the possibility of encephalopathy due to said drug must be taken into consideration.

Síndrome de hiperperfusión cerebral postendarterectomía carotídea / Post-carotid endarterectomy cerebral hyperperfusion syndrome

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Encefalopatía hiperamoniémica por ácido valproicomage / Hyperammonaemic encephalopathy due to valproic acid

Uno de los efectos adversos idiosincrásicos menos frecuentes del ácido valproico (VPA) es la encefalopatía.Presentamos un caso. Caso clínico. Mujer de 83 años sin antecedentes de interés, que tras sufrir una hemorragiasubaracnoidea postraumática y dos crisis epilépticas, recibe tratamiento con VPA. Pocos días después ingresa en Urgencias por cuadro progresivo de torpeza mental, náuseas y apatía. La exploración sistémica era normal. Neurológicamente destacaba la inatención y la desorientación a pesar de un buen nivel de conciencia y la confusión mental. Los niveles de VPA estabanen rango infraterapéutico y la analítica básica (incluido el perfil hepático) era normal, salvo por una hiperamoniemia. También eran normales los estudios de neuroimagen y el análisis del líquido cefalorraquídeo. Un electroencefalograma (EEG) reveló signos de encefalopatía difusa grave con ondas trifásicas y ondas lentas, por lo que se descartó un estado epiléptico noconvulsivo. Tras retirar el VPA, la paciente mejoró hasta su situación basal en 48 horas, y el EEG se normalizó, al igual que los niveles de amonio. Conclusión. Ante cualquier paciente al que se le haya instaurado VPA recientemente, y que presente uncuadro de confusión mental, es preciso considerar una encefalopatía por dicho fármaco

One of the less frequent idiosyncratic side effects of valproic acid (VPA) is encephalopathy. Here wereport one case. Case report. An 83-year-old female with no relevant past history, who received treatment with VPA following a post-traumatic subarachnoid haemorrhage and two convulsive seizures. A few days later, she was admitted to the Emergency Department because of a progressive clinical picture of mental slowness, nauseas and apathy. The systemic examination wasnormal. Neurologically, the most striking features were inattention and disorientation, despite her having a good level of consciousness, and mental confusion. Levels of VPA were within the below-therapeutic range and the basic lab findings (including hepatic profile) were normal, except for hyperammonaemia. Neuroimaging studies and cerebrospinal fluid analysiswere also normal. An electroencephalogram (EEG) showed signs of severe diffuse encephalopathy with slow, triphasic waves and a non-convulsive epileptic status was therefore ruled out. After withdrawing the VPA, the patient’s condition improved untilher basal situation was reached in 48 hours and the EEG became normal, as did her ammonium levels. Conclusion. When faced with a patient who has recently been taking VPA and who presents a clinical picture of mental confusion, the possibility of encephalopathy due to said drug must be taken into consideration

Ceguera cortical transitoria tras la administración de contrastes angiográficos / Transient cortical blindness following the administration of angiographic contrasts

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Paraparesia tras anestesia con monóxido de dinitrógeno / Parapesis following anaesthesia with nitrous oxide

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Manifestaciones neurológicas de la endocarditis infecciosa: un reto diagnóstico y pronóstico / Neurologic manifestations of infective endocarditis: a diagnostic and prognostic challenge

Introducción. La endocarditis infecciosa (EI) es un reto médico actual debido a que todavía presenta gran morbimortalidad. Las complicaciones neurológicas aparecen en el 20-40% de los pacientes, y el cerebro es la principal localización de las complicaciones extracardíacas de las EI. Objetivo. Analizar las características clínicas de los pacientes con manifestaciones neurológicas debidas a EI, y centrarnos en los problemas diagnósticos y pronósticos que presentan. Pacientes y métodos. Se realizó un estudio retrospectivo de todos los pacientes diagnosticados de EI en los hospitales de Valme y de la Merced, entre los años 1998 y 2003. Posteriormente, se compararon los grupos de pacientes con EI y manifestaciones neurológicas con los que no las presentaron. Obtuvimos una muestra de 60 casos de EI. Resultados. Las manifestaciones neurológicas aparecieron en 12 pacientes (20%). La manifestación neurológica más frecuente fue la clínica focal en forma de hemiparesia en siete casos (58,3%); en tres casos apareció un síndrome confusional agudo (25%) y los dos pacientes restantes presentaron síndrome meníngeo. Los hallazgos de neuroimagen fueron: infartos isquémicos en seis casos (50%), seguidos de hemorragia cerebral en dos pacientes (16,6%), y no existieron hallazgos significativos en los restantes. Los pacientes con EI y manifestaciones neurológicas presentaron una mayor mortalidad (p < 0,001) y mayor frecuencia de hemocultivos negativos (p < 0,001) que los que no presentaban clínica neurológica. Conclusiones. Las complicaciones neurológicas de la EI son frecuentes durante la evolución de la enfermedad y todavía constituyen un grave problema en la clínica diaria por sus dificultades diagnósticas y elevada mortalidad

Introduction. Infective endocarditis (IE) is an ongoing challenge in terms of excess morbidity and mortality. Neurologic complications occur in 20-40% of patients, and the brain is the main location of IE extracardiac complications. Aim. To analyse clinical characteristics of the neurologic complications found in patients with IE, focused on the diagnostic and prognostic aspects. Patients and methods. We studied retrospectively the cases of patients with IE admitted to the Hospital de Valme and Hospital de la Merced between 1998 and 2003. Laterly, patients with and without neurologic manifestations were compared. Sixty episodes of IE were evaluated. Results. Neurological complications occurred in 12 patients (20%). The most frequent neurologic manifestation was unilateral hemi paresis, which occurred in seven cases (58.3%), three cases with acute confusional state (25%) and two patients developed meningitis (16.6%). Brain infarction was the most common lesion found in neuroimaging, in 6 patients (50%), followed by 2 cases (16.6%) of brain hemorrhage, and without significant findings in the cases left. Cases with neurologic complications had significantly higher mortality (p < 0.001) and higher frequency of negative blood culture (p < 0.001). Conclusions. Neurologic complications of IE are frequent during the evolution of the disease, and they still constitute a significant problem in clinical practice because they often are not accurately diagnosed and significantly increase patients’ mortality