RESUMO
PURPOSE: T cells can be genetically modified to express an anti-CD19 chimeric antigen receptor (CAR). We assessed the safety and efficacy of administering autologous anti-CD19 CAR T cells to patients with advanced CD19(+) B-cell malignancies. PATIENTS AND METHODS: We treated 15 patients with advanced B-cell malignancies. Nine patients had diffuse large B-cell lymphoma (DLBCL), two had indolent lymphomas, and four had chronic lymphocytic leukemia. Patients received a conditioning chemotherapy regimen of cyclophosphamide and fludarabine followed by a single infusion of anti-CD19 CAR T cells. RESULTS: Of 15 patients, eight achieved complete remissions (CRs), four achieved partial remissions, one had stable lymphoma, and two were not evaluable for response. CRs were obtained by four of seven evaluable patients with chemotherapy-refractory DLBCL; three of these four CRs are ongoing, with durations ranging from 9 to 22 months. Acute toxicities including fever, hypotension, delirium, and other neurologic toxicities occurred in some patients after infusion of anti-CD19 CAR T cells; these toxicities resolved within 3 weeks after cell infusion. One patient died suddenly as a result of an unknown cause 16 days after cell infusion. CAR T cells were detected in the blood of patients at peak levels, ranging from nine to 777 CAR-positive T cells/µL. CONCLUSION: This is the first report to our knowledge of successful treatment of DLBCL with anti-CD19 CAR T cells. These results demonstrate the feasibility and effectiveness of treating chemotherapy-refractory B-cell malignancies with anti-CD19 CAR T cells. The numerous remissions obtained provide strong support for further development of this approach.
Assuntos
Antígenos CD19/imunologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Imunoterapia Adotiva/métodos , Linfoma de Células B/terapia , Linfoma Difuso de Grandes Células B/terapia , Receptores de Antígenos de Linfócitos T/imunologia , Linfócitos T/transplante , Adulto , Idoso , Terapia Combinada , Ciclofosfamida/administração & dosagem , Feminino , Humanos , Linfoma de Células B/tratamento farmacológico , Linfoma de Células B/imunologia , Linfoma Difuso de Grandes Células B/tratamento farmacológico , Linfoma Difuso de Grandes Células B/imunologia , Masculino , Pessoa de Meia-Idade , Linfócitos T/imunologia , Condicionamento Pré-Transplante/métodos , Vidarabina/administração & dosagem , Vidarabina/análogos & derivadosAssuntos
Síndrome da Imunodeficiência Adquirida/complicações , Neoplasias do Sistema Nervoso Central/complicações , HIV/patogenicidade , Síndrome Inflamatória da Reconstituição Imune/etiologia , Linfoma Relacionado a AIDS/complicações , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Síndrome da Imunodeficiência Adquirida/patologia , Neoplasias do Sistema Nervoso Central/tratamento farmacológico , Neoplasias do Sistema Nervoso Central/patologia , Quimioterapia Combinada , Humanos , Síndrome Inflamatória da Reconstituição Imune/tratamento farmacológico , Síndrome Inflamatória da Reconstituição Imune/patologia , Linfoma Relacionado a AIDS/tratamento farmacológico , Linfoma Relacionado a AIDS/patologia , Masculino , Pessoa de Meia-Idade , PrognósticoRESUMO
BACKGROUND: Identifying genetic syndromes that lead to significant atopic disease can open new pathways for investigation and intervention in allergy. OBJECTIVE: We sought to define a genetic syndrome of severe atopy, increased serum IgE levels, immune deficiency, autoimmunity, and motor and neurocognitive impairment. METHODS: Eight patients from 2 families with similar syndromic features were studied. Thorough clinical evaluations, including brain magnetic resonance imaging and sensory evoked potentials, were performed. Peripheral lymphocyte flow cytometry, antibody responses, and T-cell cytokine production were measured. Whole-exome sequencing was performed to identify disease-causing mutations. Immunoblotting, quantitative RT-PCR, enzymatic assays, nucleotide sugar, and sugar phosphate analyses, along with matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry of glycans, were used to determine the molecular consequences of the mutations. RESULTS: Marked atopy and autoimmunity were associated with increased T(H)2 and T(H)17 cytokine production by CD4(+) T cells. Bacterial and viral infection susceptibility were noted along with T-cell lymphopenia, particularly of CD8(+) T cells, and reduced memory B-cell numbers. Apparent brain hypomyelination resulted in markedly delayed evoked potentials and likely contributed to neurologic abnormalities. Disease segregated with novel autosomal recessive mutations in a single gene, phosphoglucomutase 3 (PGM3). Although PGM3 protein expression was variably diminished, impaired function was demonstrated by decreased enzyme activity and reduced uridine diphosphate-N-acetyl-D-glucosamine, along with decreased O- and N-linked protein glycosylation in patients' cells. These results define a new congenital disorder of glycosylation. CONCLUSIONS: Autosomal recessive hypomorphic PGM3 mutations underlie a disorder of severe atopy, immune deficiency, autoimmunity, intellectual disability, and hypomyelination.
Assuntos
Doenças Autoimunes/genética , Transtornos Cognitivos/genética , Imunodeficiência de Variável Comum/genética , Doenças Genéticas Inatas/genética , Hipersensibilidade/genética , Mutação , Fosfoglucomutase/genética , Doenças Autoimunes/enzimologia , Doenças Autoimunes/imunologia , Doenças Autoimunes/patologia , Linfócitos B/enzimologia , Linfócitos B/imunologia , Linfócitos B/patologia , Linfócitos T CD8-Positivos/enzimologia , Linfócitos T CD8-Positivos/imunologia , Linfócitos T CD8-Positivos/patologia , Criança , Pré-Escolar , Transtornos Cognitivos/enzimologia , Transtornos Cognitivos/imunologia , Transtornos Cognitivos/patologia , Imunodeficiência de Variável Comum/enzimologia , Imunodeficiência de Variável Comum/imunologia , Imunodeficiência de Variável Comum/patologia , Família , Feminino , Doenças Genéticas Inatas/enzimologia , Doenças Genéticas Inatas/imunologia , Doenças Genéticas Inatas/patologia , Humanos , Hipersensibilidade/enzimologia , Hipersensibilidade/imunologia , Hipersensibilidade/patologia , Imunoglobulina E/genética , Imunoglobulina E/imunologia , Masculino , Linhagem , Fosfoglucomutase/imunologia , Fosfoglucomutase/metabolismo , Células Th17/enzimologia , Células Th17/imunologia , Células Th17/patologia , Células Th2/enzimologia , Células Th2/imunologia , Células Th2/patologia , Adulto JovemAssuntos
Infecções Bacterianas do Sistema Nervoso Central/patologia , Nocardiose/patologia , Nocardia/patogenicidade , Adolescente , Antibacterianos/uso terapêutico , Infecções Bacterianas do Sistema Nervoso Central/diagnóstico , Infecções Bacterianas do Sistema Nervoso Central/tratamento farmacológico , Infecções Bacterianas do Sistema Nervoso Central/microbiologia , Lobo Frontal/microbiologia , Lobo Frontal/patologia , Humanos , Interferon gama/uso terapêutico , Imageamento por Ressonância Magnética , Masculino , Nocardia/efeitos dos fármacos , Nocardia/isolamento & purificação , Nocardiose/diagnóstico , Nocardiose/tratamento farmacológico , Nocardiose/microbiologia , Medula Espinal/microbiologia , Medula Espinal/patologiaRESUMO
The abnormal movements seen in motor conversion disorder are affected by distraction and entrainment, similar to voluntary movement. Unlike voluntary movement, however, patients lack a sense of control for the abnormal movements, a failure of "self-agency." The action-effect binding paradigm has been used to quantify the sense of self-agency, because subjective contraction of time between an action and its effect only occurs if the patient feels that they are the agent responsible for the action. We used this paradigm, coupled with emotional stimuli, to investigate the sense of agency with voluntary movements in patients with motor conversion disorder. Twenty patients with motor conversion disorder and 20 age-matched and sex-matched healthy volunteers used a rotating clock to judge the time of their own voluntary key presses (action) and a subsequent auditory tone (effect) after they completed conditioning blocks in which high, medium, and low tones were coupled to images of happy, fearful, and neutral faces. The results replicated those produced previously: it was reported that an effect after a voluntary action occurred earlier, and the preceding action occurred later, compared with trials that used only key presses or tones. Patients had reduced overall binding scores relative to healthy volunteers, suggesting a reduced sense of agency. There was no effect of the emotional stimuli (faces) or other interaction effects. Healthy volunteers with subclinical depressive symptoms had higher overall binding scores. We demonstrate that patients with motor conversion disorder have decreased action-effect binding for normal voluntary movements compared with healthy volunteers, consistent with the greater experience of lack of control.
Assuntos
Conscientização , Transtorno Conversivo/complicações , Transtorno Conversivo/psicologia , Comportamento Cooperativo , Transtornos do Humor/etiologia , Adulto , Idoso , Estudos de Casos e Controles , Discinesias , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desempenho Psicomotor , Análise de Regressão , Adulto JovemRESUMO
OBJECTIVE: To determine whether severe recurrent headache is a risk factor for neurovascular events in children who received radiation for brain tumors. METHODS: This is a retrospective cohort study of children with brain tumors who received cranial irradiation at a large tertiary care center, aged 0-21 years at diagnosis, with initial treatment between January 1, 1993 and December 31, 2002, and 2 or more follow-up visits. Patients were considered to have severe recurrent headache if this appeared as a complaint on 2 or more visits. Headaches attributed to tumor progression, shunt malfunction, or infection, or appearing at the end of life, were excluded. Medical records were reviewed for events of stroke or TIA. RESULTS: Of 265 subjects followed for a median of 6.0 years (interquartile range 1.7-9.2 years), stroke or TIA occurred in 7/37 (19%) with severe headaches compared to 6/228 (3%) without these symptoms (hazard ratio 5.3, 95% confidence interval 1.8-15.9, p = 0.003). Adjusting for multiple variables did not remove the significance of this risk. Median time to first neurovascular event for the entire cohort was 4.9 years (interquartile range 1.7-5.5 years). CONCLUSIONS: Severe recurrent headache appears to be a risk factor or predictor for subsequent cerebral ischemia in pediatric brain tumor survivors treated with radiation. This finding has clinical implications for both monitoring survivors and targeting a specific population for primary stroke prevention.
Assuntos
Neoplasias Encefálicas/complicações , Neoplasias Encefálicas/radioterapia , Transtornos Cerebrovasculares/complicações , Cefaleia/etiologia , Radioterapia/efeitos adversos , Adolescente , Isquemia Encefálica/complicações , Isquemia Encefálica/epidemiologia , Transtornos Cerebrovasculares/epidemiologia , Criança , Pré-Escolar , Círculo Arterial do Cérebro/efeitos da radiação , Estudos de Coortes , Terapia Combinada , Intervalo Livre de Doença , Feminino , Seguimentos , Cefaleia/epidemiologia , Humanos , Ataque Isquêmico Transitório/complicações , Ataque Isquêmico Transitório/epidemiologia , Estimativa de Kaplan-Meier , Imageamento por Ressonância Magnética , Masculino , Doses de Radiação , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/epidemiologiaRESUMO
OBJECTIVE: To describe the presentation and management of encephalitis due to human herpes 6 virus (HHV-6) in patients who underwent allogeneic hematopoietic stem cell transplant (alloHSCT), via retrospective chart review. METHODS: Of the 243 patients who underwent alloHSCT at the NIH Clinical Center during 2009 to 2011, we retrospectively analyzed 9 diagnosed with HHV-6 encephalitis post-alloHSCT. RESULTS: Eight men and 1 woman (aged 19-60 years) met diagnostic criteria for study inclusion. The median time from HSCT to initial symptoms was 21 days. All patients presented with altered mental status and headaches. Seven patients had amnesia and 2 presented with fever of unknown etiology. Four patients had clinical seizures during the disease course. Brain MRI within 7 days was normal in all patients. Repeat MRI after 7 days showed hyperintensity in the limbic area in 3 patients. On initial testing, CSF analysis indicated acellularity and normal or minimally elevated protein; presence of HHV-6 was detected by PCR. After 7 days, mildly elevated protein and minimal pleocytosis were noted. Ganciclovir, foscarnet, or valganciclovir alone or in combination was initiated with subsequent improvement. Four patients remained alive at 1 year posttransplant; 2 had persistent memory deficits. Presence of encephalitis was associated with higher mortality post-alloHSCT. CONCLUSION: High clinical suspicion and CSF PCR testing are important for early diagnosis of HHV-6 encephalitis post-HSCT. Abnormalities on brain MRI or CSF testing may be minimal and delayed. Diagnosis and management of HHV-6 encephalitis is challenging, and a larger prospective study is needed for further research.
Assuntos
Transplante de Células-Tronco Hematopoéticas/métodos , Herpesvirus Humano 6 , Infecções por Roseolovirus/complicações , Adulto , Idoso , Antivirais/uso terapêutico , Encéfalo/patologia , Progressão da Doença , Feminino , Seguimentos , Cefaleia/etiologia , Neoplasias Hematológicas/complicações , Neoplasias Hematológicas/terapia , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/mortalidade , Humanos , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuroimagem , Prognóstico , Estudos Retrospectivos , Infecções por Roseolovirus/tratamento farmacológico , Infecções por Roseolovirus/virologia , Convulsões/etiologia , Sobrevida , Carga Viral , Adulto JovemRESUMO
Neurological disorders of volition may be characterized by deficits in willing and/or agency. When we move our bodies through space, it is the sense that we intended to move (willing) and that our actions were a consequence of this intention (self-agency) that gives us the sense of voluntariness and a general feeling of being "in control." While it is possible to have movements that share executive machinery ordinarily used for voluntary movement but lack a sense of voluntariness, such as psychogenic movement disorders, it is also possible to claim volition for presumed involuntary movements (early chorea) or even when no movement is produced (anosognosia). The study of such patients should enlighten traditional models of how the percepts of volition are generated in the brain with regard to movement. We discuss volition and its components as multi-leveled processes with feedforward and feedback information flow, and dependence on prior expectations as well as external and internal cues.
Assuntos
Agnosia/psicologia , Encéfalo/fisiologia , Intenção , Volição/fisiologia , Humanos , Movimento/fisiologiaRESUMO
PURPOSE OF REVIEW: Neurologic complications of HIV infection are unfortunately common, even in the era of effective antiretroviral treatment (ART). The consulting neurologist is often asked to distinguish among neurologic deterioration due to opportunistic infection (OI), immune reconstitution, or the effect of the virus itself, and to comment on the role of immunomodulatory agents in patients with HIV infection. Additionally, as successful virologic control has extended the life span of patients with HIV infection, neurologists are called upon to manage long-term complications, such as neurocognitive disorders and peripheral neuropathy. RECENT FINDINGS: Despite the use of ART, significant numbers of patients continue to be affected by HIV-associated neurocognitive disorders, although with milder forms compared to the pre-ART era. Regimens of ART have been ranked according to CNS penetration and are being studied with regard to neuropsychological outcomes. Nucleoside analogs with the greatest potential for peripheral neurotoxicity are no longer considered first-line agents for HIV treatment. Efavirenz, a non-nucleoside reverse transcriptase inhibitor, has the greatest frequency of neurologic side effects among newer ART regimens. The spectrum of clinical manifestations of immune reconstitution inflammatory syndrome (IRIS) continues to grow, including IRIS without underlying OI. A greater understanding of pathophysiology and risk factors has shown that while HIV should be treated early to prevent severe immunocompromise, delayed initiation of ART may be helpful while treating OIs. SUMMARY: This article reviews the neurologic complications of HIV infection, or its treatment, most commonly encountered by neurologists.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Viroses do Sistema Nervoso Central/virologia , Infecções por HIV/tratamento farmacológico , HIV-1 , Infecções Oportunistas Relacionadas com a AIDS/virologia , Fármacos Anti-HIV/efeitos adversos , Anticonvulsivantes/uso terapêutico , Infecções Bacterianas do Sistema Nervoso Central/tratamento farmacológico , Infecções Bacterianas do Sistema Nervoso Central/virologia , Infecções Fúngicas do Sistema Nervoso Central/tratamento farmacológico , Infecções Fúngicas do Sistema Nervoso Central/virologia , Infecções Parasitárias do Sistema Nervoso Central/tratamento farmacológico , Infecções Parasitárias do Sistema Nervoso Central/virologia , Viroses do Sistema Nervoso Central/tratamento farmacológico , Transtornos Cognitivos/tratamento farmacológico , Transtornos Cognitivos/virologia , Quimioterapia Combinada , Feminino , Infecções por Herpesviridae/tratamento farmacológico , Infecções por Herpesviridae/virologia , Humanos , Síndrome Inflamatória da Reconstituição Imune/tratamento farmacológico , Síndrome Inflamatória da Reconstituição Imune/virologia , Fatores Imunológicos/uso terapêutico , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Polineuropatias/tratamento farmacológico , Polineuropatias/virologia , Inibidores da Transcriptase Reversa/efeitos adversos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND AND PURPOSE: The purposes of this study were to determine the incidence of neurovascular events as late complications in pediatric patients with brain tumor and to evaluate radiation as a risk factor. METHODS: Patients were ascertained using the tumor database of a pediatric tertiary care center. Included patients had a primary brain tumor, age birth to 21 years, initial treatment January 1, 1993, to December 31, 2002, and at least 2 visits with neuro-oncology. Radiation exposure included: whole brain, whole brain plus a focal boost, or focal brain. The primary outcome was stroke or transient ischemic attack. RESULTS: Of 431 subjects, 14 had 19 events of stroke or transient ischemic attack over a median follow-up of 6.3 years. The incidence rate was 548/100 000 person-years. Overall, 61.5% of subjects received radiation, including 13 of 14 subjects with events. Median time from first radiation to first event was 4.9 years. The stroke/transient ischemic attack hazard ratio for any brain irradiation was 8.0 (95% CI, 1.05-62; P=0.045); for the circle of Willis, radiation was 9.0 (95% CI, 1.2-70; P=0.035); and for focal noncircle of Willis, radiation was 3.4 (95% CI, 0.21-55; P=0.38). CONCLUSIONS: The incidence of neurovascular events in this population is 100-fold higher than in the general pediatric population and cranial irradiation is an important risk factor. By defining the incidence of this late effect, physicians are better able to counsel parents regarding treatment, monitor patients at risk, and target a population for primary stroke prevention in future studies.
Assuntos
Neoplasias Encefálicas/radioterapia , Irradiação Craniana/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Sobreviventes/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
Psychogenic movement disorders (PMD) and other conversion disorders (CD) with apparent neurologic signs (neurologic CD) plague patients and perplex physicians. Due to a lack of objective evidence of underlying brain lesions, CD were largely abandoned by neurologists and remained poorly understood psychiatric diagnoses throughout most of the 20th century. Modern neuroscience now supports increasingly comprehensive biological models for these complex disorders, definitively establishing their place in both neurology and psychiatry. Although it is often clinically useful to distinguish a movement disorder as either "organic" or "psychogenic," this dichotomy is difficult to defend scientifically. Here we describe the neuroimaging and neurophysiologic evidence for dysfunctional neural networks in PMD, explain the diagnostic potential of clinical neurophysiologic testing, discuss the promising if increasingly complex role of neuropsychiatric genetics, and review current treatment strategies.
Assuntos
Transtorno Conversivo/psicologia , Transtornos dos Movimentos/psicologia , Doenças do Sistema Nervoso/psicologia , Transtorno Conversivo/fisiopatologia , Transtorno Conversivo/terapia , Humanos , Transtornos Mentais , Modelos Neurológicos , Transtornos dos Movimentos/fisiopatologia , Transtornos dos Movimentos/terapia , Doenças do Sistema Nervoso/fisiopatologia , Doenças do Sistema Nervoso/terapia , Neurologia , Testes Neuropsicológicos , Escalas de Graduação Psiquiátrica , PsiquiatriaRESUMO
BACKGROUND: There are a host of vague terms to describe psychologically-mediated symptoms that mimic neurological disease, such as "functional," "non-organic," "psychogenic," or "medically unexplained." None of these terms has a direct translation in psychiatric classification, and psychiatrists are often faced with patients who do not believe in a psychological origin for their symptoms. OBJECTIVE: Within the framework of psychogenic movement disorders, we discuss the roadblocks to effective collaboration and treatment in these patients and the current state of the literature regarding diagnosis and treatment. RESULTS: We describe the approach to these patients from the perspective of neurology and psychiatry, illustrating the differences in terminology and categorization. CONCLUSION: Psychogenic movement disorders represent a unique opportunity for these fields to collaborate in the care of a potentially curable but significantly disabling disorder.
Assuntos
Transtorno Conversivo/diagnóstico , Transtorno Conversivo/psicologia , Transtorno Conversivo/terapia , Equipe de Assistência ao Paciente , Transtornos Psicomotores/diagnóstico , Transtornos Psicomotores/psicologia , Transtornos Psicomotores/terapia , Comportamento Cooperativo , Humanos , Relações Interprofissionais , Neurologia , Psiquiatria , Terminologia como AssuntoRESUMO
Pregnant patients are rarely encountered in the movement disorders clinic, but they present significant dilemmas regarding treatment and counseling for neurologists. While movement disorders in pregnancy once described those disorders arising de novo during pregnancy, such as chorea gravidarum or restless leg syndrome, advancing maternal age in Western countries will likely increase the number of women in whom pregnancy complicates a pre-existing movement disorder. Physicians treating these women must be aware of the impact of the movement disorder and its treatment on fertility, pregnancy, fetal development, lactation, and infant care. This review summarizes retrospective series and case reports to both guide clinicians and to stimulate and direct the design of prospective studies.
Assuntos
Transtornos dos Movimentos/complicações , Complicações na Gravidez/fisiopatologia , Coreia Gravídica , Distonia/complicações , Feminino , Humanos , Transtornos dos Movimentos/fisiopatologia , Doença de Parkinson/complicações , GravidezRESUMO
Prolonged status epilepticus (SE) can be refractory to conventional interventions, with high rates of subsequent morbidity and mortality. A high fat, low protein, low carbohydrate ketogenic diet (KD) has been used successfully to treat intractable epilepsy. However, its possible role in prolonged SE has not been well described. We report successful use of the KD in two adult patients with prolonged nonconvulsive SE (NCSE) refractory to multiple other interventions. Our observations suggest induction of ketosis may be a novel strategy to safely and effectively treat status in adults even after weeks to months of refractory seizures. Although there are few data regarding the use of the ketogenic diet in the treatment of adult epilepsy syndromes, it may be an option for the treatment of adults with refractory, prolonged SE.
Assuntos
Dieta Cetogênica/métodos , Estado Epiléptico/dietoterapia , Adulto , Feminino , Humanos , Masculino , Estado Epiléptico/fisiopatologia , Fatores de Tempo , Resultado do TratamentoAssuntos
Calcinose/complicações , Calcinose/patologia , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/patologia , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/patologia , Encéfalo/irrigação sanguínea , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Infarto Encefálico/patologia , Calcinose/diagnóstico por imagem , Angiografia Cerebral , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/patologia , Humanos , Hipestesia/etiologia , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/patologia , Midodrina/uso terapêutico , Valva Mitral/diagnóstico por imagem , Valva Mitral/patologia , Valva Mitral/fisiopatologia , Paresia/etiologia , Inibidores da Agregação Plaquetária/uso terapêutico , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVE: To describe a case of Propionibacterium acnes infection arising 10 years after neurosurgery and to review the literature regarding similar cases and their treatment. DESIGN: Case report. SETTING: Hospital of the University of Pennsylvania. PATIENT: A 70-year-old man with an intracerebral abscess and 2 biopsies culture positive for P acnes 10 years after subdural hematoma evacuation. Intervention Surgical biopsy followed by 6 weeks of intravenous vancomycin. MAIN OUTCOME MEASURES: Magnetic resonance imaging, neurologic examination, and microbiology culture results. RESULTS: Biopsies obtained from abscesses grew only P acnes. Magnetic resonance imaging and serial neurological examinations showed marked improvement after 6 weeks of intravenous vancomycin. CONCLUSIONS: Infection by P acnes can complicate neurosurgical procedures as late as 10 years after surgery and therefore should be considered in the evaluation of patients presenting with neurologic signs and symptoms with a history of neurosurgery.
Assuntos
Abscesso Encefálico/microbiologia , Encéfalo/microbiologia , Infecções por Bactérias Gram-Positivas/microbiologia , Procedimentos Neurocirúrgicos/efeitos adversos , Propionibacterium acnes , Infecção da Ferida Cirúrgica/microbiologia , Idoso , Antibacterianos/uso terapêutico , Biópsia , Encéfalo/patologia , Abscesso Encefálico/tratamento farmacológico , Abscesso Encefálico/patologia , Craniotomia/efeitos adversos , Progressão da Doença , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/patologia , Hematoma Subdural/cirurgia , Humanos , Imageamento por Ressonância Magnética , Masculino , Infecção da Ferida Cirúrgica/patologia , Infecção da Ferida Cirúrgica/fisiopatologia , Tempo , Fatores de Tempo , Vancomicina/uso terapêuticoAssuntos
Hemiplegia/etiologia , Processamento de Imagem Assistida por Computador , Infarto da Artéria Cerebral Média/diagnóstico , Imageamento por Ressonância Magnética , Transtornos da Percepção/etiologia , Artéria Carótida Interna/patologia , Dissecação da Artéria Carótida Interna/diagnóstico , Diagnóstico Diferencial , Dominância Cerebral/fisiologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Artéria Cerebral Média/patologia , Exame NeurológicoRESUMO
Prior to the onset of the cardinal motor features of idiopathic Parkinson's disease (PD), other manifestations of neurodegeneration such as olfactory dysfunction are often apparent. Characterizing these potential biomarkers of preclinical PD is particularly important in identifying individuals who will go on to develop disabling symptoms, and thus be good candidates for new neuroprotective strategies. As shown by the Braak neuropathologic staging of PD, the olfactory system is among the first neuronal populations to display Lewy body pathology. Clinically, loss of smell can be easily tested in the office using several validated techniques and is often helpful to the physician in distinguishing idiopathic PD from other forms of parkinsonism. Recent findings have indicated that a decline in olfaction may be observed in selected at-risk patients, which has significant implications for identifying potential study populations. Ongoing studies of olfactory dysfunction may also reveal potential for use as a medication-independent biomarker of disease progression in addition to use as a biomarker for the diagnosis of PD.