RESUMO
A 69-year-old woman presented with acute bilateral ptosis, ophthalmoplegia, ataxia, and hyporeflexia in the extremities following an antecedent upper respiratory infection. We suspected that she had Miller Fisher syndrome (MFS) and performed an edrophonium test (ET) to rule out myasthenia gravis (MG). Edrophonium chloride improved the patient's bilateral ptosis, but not her ophthalmoplegia. Given the absence of the waning phenomenon on electrophysiological examination, the anti-acetylcholine receptor antibody, and a diurnal variation of symptoms, we concluded that the ET result was a false-positive. A diagnosis of MFS was confirmed by the presence of a positive anti-GQ1b antibody. To our knowledge, this is the first case report of MFS with a false-positive ET.
Assuntos
Edrofônio , Gangliosídeos/imunologia , Síndrome de Miller Fisher/diagnóstico , Síndrome de Miller Fisher/tratamento farmacológico , Idoso , Autoanticorpos/sangue , Biomarcadores/sangue , Diagnóstico Diferencial , Reações Falso-Positivas , Feminino , Humanos , Miastenia GravisRESUMO
A 68-year-old right-handed woman with acute-onset inability to stand was admitted to our department. Although left hemiparesis was minor, the neurological examination on admission showed marked body lateropulsion (BL) to the left when she stood or stepped with eyes open and feet closed. Neither ataxia nor sensory disturbance was present. Brain MRI and 3D-CT angiography revealed infarction of the right posterior cingulate and the precuneus due to dissection of the right anterior cerebral artery. BL improved on day 10 and she was discharged without sequelae on day 26. BL caused by cerebral lesions is rare, and we should recognize that infarction of the posterior cingulate and/or the precuneus can cause BL.
Assuntos
Infarto Cerebral/complicações , Giro do Cíngulo/irrigação sanguínea , Lobo Parietal/irrigação sanguínea , Equilíbrio Postural/fisiologia , Transtornos de Sensação/etiologia , Transtornos de Sensação/fisiopatologia , Doença Aguda , Idoso , Artéria Cerebral Anterior/diagnóstico por imagem , Angiografia Cerebral , Doenças Arteriais Cerebrais/complicações , Doenças Arteriais Cerebrais/diagnóstico por imagem , Infarto Cerebral/diagnóstico por imagem , Feminino , Humanos , Imageamento Tridimensional , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios XRESUMO
We describe a case of 20-year-old woman with visual impairment in her left eye. Her left visual acuity was 0.07 and an ophthalmoscopic examination demonstrated bilateral intermediate uveitis (IU). A neurological examination on admission revealed lower nasal quadrantanopsia in her left eye and an exaggerated right patellar tendon reflex. A T2-weighted MRI showed multiple high-intensity lesions in the bilateral periventricular region, corpus callosum, medulla. A short T1 inversion recovery MRI also showed a swollen left retrobulbar optic nerve and posterior thoracic cord lesion at Th 9 level. The latter longitudinal length was approximately 20â mm. Laboratory investigation demonstrated no abnormalities including an anti-aquaporin-4 antibody. A cerebrospinal fluid examination revealed an increased IgG-index (1.21) with oligoclonal IgG babds. Initially, a diagnosis of retrobulbar optic neuritis with IU was made. She received subtenon corticosteroid injection with intravenous methylprednisolone pulse and oral prednisolone therapy. An immediate improvement of her visual symptoms and MRI abnormalities was observed. Approximately 1 year later, a new high-intensity lesion in the right internal capsule was present on a follow-up T2-weighted brain MRI, established a diagnosis of multiple sclerosis (MS) based on the McDonald criteria in 2010. Previous reports in Japan demonstrated few cases of uveitis in patients with MS and this is the first report of MS with IU in Japan.
Assuntos
Esclerose Múltipla/complicações , Uveíte Intermediária/complicações , Adulto , Feminino , HumanosRESUMO
A 66-year-old man was admitted to our hospital with acute paraplegia. He has suffered from hypertension with renal dysfunction for 7 years. Five months before admission, hemodialysis was introduced to him because of chronic renal failure due to renal sclerosis. One week before hospitalization, he noticed dizziness, sensory disturbance below the chest, and a urinary difficulty. Two days prior to admission, he could not walk independently. Spinal MRI revealed a mass at the 7th level of the cervical spine, showing low intensity on T(1)-weighted image and surrounding hypointensity with inner mixed intensity on T(2)-weighted image. An urgent surgery removed the cervical epidural mass and the following pathological evaluation established the diagnosis of ß2-microglobulin amyloidoma. Hemodialysis-related amyloidoma generally emerges after a long duration of hemodialysis, demonstrates an insidious onset of symptoms, and is very rare. The current case indicates that we need to be aware of the possibility of ß2-microglobulin amyloidoma even in patients with a short history of hemodialysis with a rapid presentation.
Assuntos
Amiloidose/etiologia , Paraplegia/etiologia , Diálise Renal/efeitos adversos , Doenças da Coluna Vertebral/etiologia , Microglobulina beta-2 , Doença Aguda , Idoso , Amiloidose/diagnóstico , Amiloidose/cirurgia , Vértebras Cervicais , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Masculino , Doenças da Coluna Vertebral/diagnóstico , Doenças da Coluna Vertebral/cirurgia , Fatores de TempoRESUMO
Three months prior to presentation, a 76-year-old woman suffered from insomnia and was prescribed some antidepressants and hypnotics. At that time, brain MRI showed no cerebral infarcts. Having developed an action tremor of the left hand, bradykinesia, and unstable gait, she visited our hospital. Neurological examination revealed rigidity of the neck and left limbs, clumsiness of the left hand, action tremor, and decreasing swing of the left arm while walking. 123I-metaiodobenzylguanidine scintigraphy showed no decrease of the heart/mediastinum ratio. The second MRI showed an old cerebral infarct located just in the right external segment of the globus pallidus. Since drug-induced parkinsonism was suspected, paroxetine and trazodone were discontinued, but her symptoms did not improve. We concluded that her hemiparkinsonism was due to the cerebral infarct in the right external segment of the globus pallidus, because her symptoms did not respond to dopamine agonist and L-dopa therapy, and the onset of symptoms corresponded with the time of appearance of the cerebral infarct. This is a rare case that is important for understanding the mechanism of parkinsonism.
Assuntos
Infarto Cerebral/complicações , Globo Pálido/irrigação sanguínea , Transtornos Parkinsonianos/etiologia , Idoso , Feminino , HumanosRESUMO
We report the case of a woman who developed limb clumsiness in her fifties and gait disturbance in her sixties. She was bedridden after bone fractures at age 75 and showed disorientation, slow eye movement, gaze palsy, ataxic speech, muscle atrophy and weakness, and areflexia with pathological reflex. She died of respiratory failure at age 85. This patient was diagnosed genetically as having spinocerebellar ataxia type 2 (SCA2), and the number of expanded CAG repeats was 41. At autopsy, the brain weighed 965 g, and the brainstem, cerebellum, frontal convexity and spinal cord were atrophic. Neuronal loss and gliosis were severe in the pontine nucleus, inferior olivary nucleus, cerebellar cortex, gracile and cuneate nuclei and moderate in the substantia nigra, cerebellar dentate nucleus, anterior horns of the spinal cord and dorsal root ganglia. Axonal loss was observed in the middle and inferior cerebellar peduncles, pyramidal tract and posterior column of the spinal cord. Senile plaques and neurofibrillary tangles (NFTs) were diffusely found in the cerebrum (plaque stage C; NFT stage IV). Expanded polyglutamine-immunoreactive inclusions in the neuronal cytoplasm were widely distributed in the CNS, and neuronal intranuclear inclusions were observed in the pontine nucleus and cerebral cortex. This patient in this autopsy case is a late-onset and aged patient with SCA2, and this is the first report of SCA2 combined with Alzheimer's disease (AD) pathology. Neuropathological findings in this patient, except for AD pathology, were consistent with those of reported SCA2 cases. However, the olivo-ponto-cerebellar system of this patient was relatively preserved and the cerebellar dentate nucleus was more involved as compared with previously reported cases. These results suggest that age at onset or the number of CAG repeat expansions could correlate with the distribution pattern of SCA2 neurodegeneration.
Assuntos
Ataxias Espinocerebelares/patologia , Fatores Etários , Idoso de 80 Anos ou mais , Ataxinas , Evolução Fatal , Feminino , Humanos , Proteínas do Tecido Nervoso/genética , Ataxias Espinocerebelares/genética , Expansão das Repetições de Trinucleotídeos/genéticaRESUMO
BACKGROUND: Familial amyloid polyneuropathy (FAP) is distributed worldwide with several endemic foci including two major foci in Japan. OBJECTIVE: To elucidate a nationwide epidemiology of FAP in Japan. DESIGN, SETTING, AND PATIENTS: (i) We analyzed the data of FAP patients registered by the Ministry of Health, Labour, and Welfare, Japan, during 2003-2005. (ii) As Ishikawa prefecture was found to be a novel endemic focus, we examined 27 FAP patients in Ishikawa to characterize their clinical and genetic features in comparison with other endemic foci. RESULTS: (i) The prevalence of familial amyloidosis in Japan was estimated to be 0.87-1.1 per 1,000,000 persons. Nagano prefecture had the highest prevalence (11-15.5), followed by Kumamoto (10.1-10.3), and then Ishikawa (3.5-4.2). (ii) All the FAP patients in Ishikawa had transthyretin (TTR) type FAP; all the families had a TTR Val30Met mutation except one family with a Leu58Arg mutation. FAP with Val30Met mutation in Ishikawa was characterized by late onset, high penetrance, and moderate autonomic dysfunction. CONCLUSIONS: Ishikawa prefecture is the third endemic focus of FAP in Japan. FAP with TTR Val30Met mutation in Japan can be classified to (i) early-onset and endemic (Nagano and Kumamoto), (ii) late-onset and endemic (Ishikawa), and (iii) late-onset and non-endemic types.
Assuntos
Neuropatias Amiloides Familiares/epidemiologia , Neuropatias Amiloides Familiares/genética , Epidemiologia Molecular , Mutação , Pré-Albumina/genética , Adulto , Idade de Início , Idoso , Neuropatias Amiloides Familiares/metabolismo , Amiloidose/metabolismo , Feminino , Humanos , Japão/epidemiologia , Masculino , Metionina/genética , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Valina/genéticaRESUMO
A 31-year-old female patient with headache and nausea was admitted to our hospital, although there were no apparent neurological abnormalities except headache. Cerebrospinal fluid (CSF) pressure was 40 mmH2O on the first lumbar puncture and CT showed some fluid in the left maxillary sinus. She gradually developed orthostatic headache despite antibiotics, hydration and analgesics. MRI showed diffuse meningeal thickening and enhancement. CSF pressure was 0 mmH2O on the second lumbar puncture and RI cisternography demonstrated early excretion to the kidneys. She was diagnosed with intracranial hypotension due to CSF leakage. An autologous 10ml blood patch on the lumbar epidural space did not relieve the orthostatic headache. However, headache disappeared one day after oral intake of 40mg prednisolone. During the next three months, oral prednisolone was tapered off. Three months after the onset of the illness, MRI did not show either meningeal thickening or enhancement. We concluded that oral prednisolone was effective in a case of intracranial hypotension.
Assuntos
Hipotensão Intracraniana/tratamento farmacológico , Prednisolona/administração & dosagem , Administração Oral , Adulto , Feminino , Humanos , Hipotensão Intracraniana/diagnóstico , Hipotensão Intracraniana/etiologia , Imageamento por Ressonância Magnética , Mielografia , Derrame Subdural/complicações , Resultado do TratamentoRESUMO
We report a 38-year-old Japanese woman who had cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) with a novel mutation (TGT to TAT) at nucleotide position 1241 (C388Y) in exon 7 of the Notch3 gene (NOTCH3). Immunostaining of a skin biopsy with a Notch3 monoclonal antibody is a beneficial method for the screening of CADASIL, particularly in the case of rare mutations outside the mutation hotspots in NOTCH3 as shown in this patient.
Assuntos
CADASIL/genética , Éxons , Mutação , Receptores Notch/genética , Adulto , Povo Asiático/genética , Sequência de Bases , Biópsia , CADASIL/diagnóstico , CADASIL/metabolismo , CADASIL/patologia , Feminino , Humanos , Imuno-Histoquímica , Imageamento por Ressonância Magnética , Microscopia Eletrônica , Receptor Notch3 , Pele/metabolismo , Pele/patologiaRESUMO
Dural rupture, cerebrospinal fluid leakage, and spontaneous intracranial hypotension may complicate significant or minimal spinal trauma and cause chronic headache with a positional component. While such cases typically reflect no pre-existing predilection, we encountered a patient whose cervicothoracic anatomy appeared to predispose him to this complication.