Diabetic Uremic Syndrome Presenting Reversible Parkinsonism with Bilateral Basal Ganglia Lesions: A Case Report.

The patient was a 57-year-old man with a 15-year history of diabetes mellitus and a 3-year history of dialysis. He developed a subacute onset of Parkinsonism, including gait disturbance, bradykinesia, cogwheel rigidity, and myoclonus attacks. Magnetic resonance imaging (MRI) of the brain revealed swollen bilateral basal ganglia lesions, which appeared hyperintense with the lentiform fork sign on fluid-attenuated inversion recovery images, indicating vasogenic edematous lesions. He was diagnosed with diabetic uremic syndrome. Dopamine transporter single-photon emission computed tomography revealed no decrease in dopamine transporters. After approximately 4 weeks of continuous hemodialysis, rehabilitation, and supportive therapy, his neurological symptoms and MRI findings markedly improved. Although this disease has been reported in a few cases, its etiology and treatment remain unclear. In this case of diabetic uremic syndrome, dopamine secretion capacity was normal even though the patient had parkinsonian symptoms. This finding might contribute to further elucidation of the pathological mechanism of diabetic uremic syndrome.

Depression and Dementia in Older Adults: A Neuropsychological Review.

Depression and dementia are the most common neuropsychiatric disorders in the older adult population. There are a certain number of depressed patients who visit outpatient clinics because they suspect dementia due to similarities in the clinical symptoms in both disorders. Depressive symptoms associated with dementia may be diagnosed with depression, and treatment with antidepressants is continued for a long time. Depression and dementia differ in their treatment approaches and subsequent courses, and it is necessary to carefully differentiate between the two in the clinical practice of dementia treatment. In this review, I describe the similarities between depression and dementia and how to differentiate depression in dementia treatment based on the differences and emphasize that there is a significant potential to cure depression, in contrast to dementia, for which there is currently no fundamental therapy. Therefore, it is important to recognize that depression and dementia may present with common symptoms and to appropriately differentiate depressed patients who are suspected of having dementia. Dementia is a disorder in which cognitive dysfunction is caused by a variety of causative diseases and conditions, resulting in impairment of activities of daily living. However, current medical science has had difficulty finding a cure for the causative disease. Based on clinical findings, it has also been shown that the degree of symptoms for preexisting psychiatric disorders is alleviated as the brain ages. In the presence of dementia, the speed of the alleviation will increase. The importance of focusing on the positive aspects of aging is also discussed.

Repeated unconsciousness due to chronic carbon monoxide poisoning in an older patient: a case report.

Objective: Although much is known about acute carbon monoxide (CO) poisoning, little is known about chronic CO poisoning. Chronic CO poisoning is often diagnosed based on the patient's living environment and medical history. Herein, we report the case of an older patient who presented with repeated unconsciousness due to chronic CO poisoning. Case presentation: A 90-year-old man was brought to the emergency department after being found at home with a disturbance of consciousness. Arterial blood gas measurements in room air revealed a carboxyhemoglobin level of 18.0%. Impaired consciousness was caused by chronic CO poisoning. The patient received high-flow oxygen therapy, which promptly improved his condition. According to his family, briquette kotatsu was the cause of chronic CO poisoning. Conclusion: Although high-flow oxygen therapy has been said to be less effective than hyperbaric oxygen therapy in CO poisoning treatment, recent studies have demonstrated that high-flow oxygen has similar effects and benefits. Thus, in institutions that do not have hyperbaric oxygen, high-flow oxygen may be sufficient to treat patients with CO poisoning, as seen in the present case. It should be noted that briquette kotatsu can lead to CO poisoning. This case highlights the need for clinicians to consider patients' living conditions.

Encephalopathy Associated with Severe Cytomegalovirus Infection in an Immunocompetent Young Woman.

Primary cytomegalovirus (CMV) infection in healthy young adults is usually an asymptomatic or mononucleosis-like syndrome, whereas in immunocompromised patients, CMV can cause significant disease. In this study, we report an unusual case of primary CMV infection wherein the patient, an immunocompetent 21-year-old woman, presented severe encephalopathy, acute hepatitis, retinitis, and reactivation of latent Epstein-Barr virus. She developed confusion, high fever, headache, and tonic-clonic seizures. Brain magnetic resonance imaging showed high-intensity lesions in the medial temporal lobe and basal ganglia. Liver dysfunction was observed, and abdominal computed tomography revealed splenohepatomegaly. After fundus findings, the patient was diagnosed with CMV retinitis. Upon admission, she was treated with intravenous acyclovir and steroid pulse therapy. Considering both her serious clinical condition and elevated serum levels of interleukin-6, we speculated that her condition was similar to cytokine-storm-induced encephalopathy. On day 2 after admission, she showed prompt recovery from these clinical manifestations. Since blood CMV pp65 antigenemia was found to be positive, we administered ganciclovir for 2 weeks. On the basis of her clinical manifestations and the presence of blood CMV DNA and CMV pp65 antigenemia along with IgM kinetics, we finally diagnosed this patient with severe primary CMV infection. She left our hospital without sequelae 20 days after admission. The incidence of severe CMV disease in immunocompetent young adults might be higher than previously recognized. Noninvasive testing for CMV (such as CMV pp65 antigenemia and CMV DNAemia) is widely available and can help early diagnosis. Short-term glucocorticoid therapy might be beneficial in the treatment of encephalopathy in the early stages of primary CMV infection. Considering such a background, clinicians should keep severe primary CMV infection in mind as a differential diagnosis in the clinical setting.

Clinical features, pathogenesis, and management of stroke-like episodes due to MELAS.

Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) is a disease that should be considered as a differential diagnosis to acute ischemic stroke taking into account its onset pattern and neurological symptoms, which are similar to those of an ischemic stroke. Technological advancements in neuroimaging modalities have greatly facilitated differential diagnosis between stroke and MELAS on diagnostic imaging. Stroke-like episodes in MELAS have the following features: (1) symptoms are neurolocalized according to lesion site; (2) epileptic seizures are often present; (3) lesion distribution is inconsistent with vascular territory; (4) lesions are common in the posterior brain regions; (5) lesions continuously develop in adjacent sites over several weeks or months; (6) neurological symptoms and stroke-like lesions tend to be reversible, as presented on magnetic resonance imaging; (7) the rate of recurrence is high; and; (8) brain dysfunction and atrophy are slowly progressive. The m.3243ANG mutation in the MT-TL1 gene encoding the mitochondrial tRNALeu(UUR) is most commonly associated with MELAS. Although the precise pathophysiology is still unclear, one possible hypothesis for these episodes is a neuronal hyperexcitability theory, including neuron-astrocyte uncoupling. Supplementation, such as with L-arginine or taurine, has been proposed as preventive treatments for stroke-like episodes. As this disease is still untreatable and devastating, numerous drugs are being tested, and new gene therapies hold great promise for the future. This article contributes to the understanding of MELAS and its implications for clinical practice, by deepening their insight into the latest pathophysiological hypotheses and therapeutic developments.

Anti-Ro/SSA Antibodies May Be Responsible for Cerebellar Degeneration in Sjogren's Syndrome.

BACKGROUND: Neurological disorders have been identified to be a common extraglandular manifestation of Sjogren's syndrome (SjS). Central nervous system (CNS) symptoms appear in about 5% of patients with SjS. However, so far, only a few incidences of cerebellar degeneration have been reported, and the clinical features and pathological mechanisms associated with SjS remain to be unclear. Intramedullary production of anti-Ro/anti-SjS-related antigen A (SSA) has been observed in some patients with SjS patients who have CNS involvement, suggesting the involvement of anti- Ro/SSA antibodies as antineuronal antibodies in previous studies. METHODS: We recently treated cerebellar degeneration in a patient with SjS. We analyzed the serum and cerebrospinal fluid (CSF) in order to detect anti-Ro/SSA and anti-La/anti-SjS-related antigen B (SSB) antibodies. We also searched the literature for previous case reports to evaluate the characteristics of cerebellar degeneration in patients with SjS. First, we have studied in mouse brain tissue and examined whether the Ro/SSA (Ro52/tripartite motif protein (TRIM)21) protein was expressed in the cerebellum of mice using immunohistochemistry. RESULTS: Although all patients that we found in the literature review and our patient 1 were positive for anti-Ro/SSA antibodies, some patients were also negative for anti-La/SSB antibodies. Anti-Ro/SSA antibodies were observed in both serum and CSF; however, anti-Ro/SSA antibodies were negative in the CSF of patients with SjS without CNS involvement. Cerebellar atrophy was observed, and sequelae remained in the majority of patients. Autopsy findings indicated a selective loss of Purkinje cells. Ro52/TRIM21 expression was also detected throughout murine brains, including the hippocampus, cerebral cortex and cerebellum. High Ro52/TRIM21 expression was observed in the Purkinje cells. CONCLUSIONS: We described the characteristics of cerebellar degeneration in patients with SjS and Ro52/TRIM21 expression in the Purkinje cells of murine cerebellar tissue sections. These outcomes indicate that anti-Ro/SSA antibodies were likely responsible for cerebellar degeneration in patients suffering from SjS.

Spinal Epidural Abscess: A Review Highlighting Early Diagnosis and Management.

Spinal epidural abscess (SEA) is still an uncommon but devastating infection of the spine. In recent years, a number of reported cases have risen. The most important prognostic factor for a favorable outcome is early diagnosis and appropriate treatment. However, a diagnosis of SEA is often delayed, particularly in the early stages of the disease before patients present with neurological symptoms. With enough knowledge of risk factors, clinical features, and appropriate diagnostic procedures, it may be possible to reduce diagnostic delay in the early stages of the disease. This review focuses on early diagnosis of SEA based on risk factors, presenting symptoms, and characteristic findings on magnetic resonance imaging (MRI), and also discusses the timing of surgical interventions. Traditionally, the symptoms of SEA are characterized by fever, back pain, and neurological symptoms, which are described as a classical triad of symptoms for this type of infection; but this collection of symptoms is seen in only about 10% of cases. However, most patients complain of severe localized lower back pain. Gadolinium-enhanced MRI is the most sensitive, specific, and beneficial imaging modality for establishing a diagnosis of SEA. Patients diagnosed prior to neurological deficits with a known causative microbial organism can be safely treated with antimicrobial therapy alone. However, about 30%-40% of the patients fail in conservative management without surgery. The best management and timing for surgical decompression in patients with or without mild neurological deficits should be established in the near future. Early diagnosis and management, before the occurrence of serious neurological symptoms, are the most important prognostic factors for good outcomes in patients with SEA. We proposed a simple algorithm for early diagnosis of SEA by selecting patients with severe back pain, leading to emergent MRI.

Reversible lesion in the splenium of the corpus callosum in a patient with chronic alcoholism.

Marchiafava-Bignami disease (MBD) is often diagnosed in chronic alcoholics. The disease processes typically involve the corpus callosum and clinically presents with various manifestations on the basis of clinical condition, extent of the splenium of the corpus callosum involvement at brain magnetic resonance imaging (MRI), and prognosis. We report a patient affected by MBD, who presented an isolated reversible splenial lesion at brain MRI and achieved a favorable recovery.

An Autopsy Case of Varicella Zoster Virus Encephalitis with Multiple Brain Lesions.

Varicella-zoster virus (VZV) encephalitis in the absence of vasculopathy may rarely occur in association with herpes zoster. We herein report the case of a 67-year-old woman with non-Hodgkin's lymphoma undergoing chemotherapy who presented with an acute alteration in consciousness. Magnetic resonance imaging of the brain revealed multiple and nonspecific lesions of hyperintensity with mild edema in the cortex and subcortex. She was treated with intravenous acyclovir. However, two days after admission, the patient died and was diagnosed with VZV encephalitis. This case highlights the risk of VZV reactivation with severe neurological complications in patients undergoing immunosuppressive therapy.

Central nervous system tuberculoma with miliary tuberculosis in the elderly.

The aging phenomenon of tuberculosis (TB) patients is recognized all over the world, but no country is as prominent as Japan. Central nervous system (CNS) TB includes clinical entities: tuberculous meningitis, intracranial tuberculoma, and clinical features of CNS TB in the elderly may be atypical, non-specific, and confused with concomitant age-related diseases. Atypical clinical manifestations of TB in older persons can result in delay in diagnosis and initiation of treatment. A 91-year-old woman was brought to our emergency department after her family noted her altered mental status. Chest computed tomography confirmed miliary opacities. The cerebrospinal fluid (CSF) analysis showed elevated protein level, low glucose level, and a lymphocytic pleocytosis. Brain magnetic resonance imaging (MRI) showed multiple well­defined enhancing lesions in the cerebral and cerebellar hemispheres and the pons, suggestive of tuberculomas. Smear, culture, and polymerase chain reaction (PCR) tests confirmed Mycobacterium tuberculosis in the sputum and aspirate. Based on the CSF and brain MRI findings and the sputum microbiology results indicating the presence of M. tuberculosis in the sputum and gastric aspirate, the patient was diagnosed with CNS tuberculoma. The onset of TB is mainly associated with decreased immunity; however, several other factors such as comorbidities, decreased activity, dysphagia, and malnutrition, which influence one another, also influence the development of TB in the elderly. Because the mortality rate of TB increases rapidly with age, reaching approximately 30 % among the elderly, early diagnosis is critical.

Reversible lesion in the splenium of the corpus callosum.

AIM OF REVIEW: The presence of isolated, reversible lesions in the splenium of the corpus callosum (SCC) is essential to confirm the diagnosis of mild encephalitis/encephalopathy. The lesions usually heal within a month after the onset of neurological symptoms. Magnetic resonance imaging (MRI) has increasingly been used as a diagnostic tool, which has led to the publication of an increasing number of case reports. These have highlighted some inconsistencies about encephalitis/encephalopathy. First, the condition is not always mild and may be severe. Second, reversible lesions in the SCC have been identified in various diseases and conditions other than viral encephalitis/encephalopathy. Third, lesions in SCC are not always completely reversible. On this note, this review describes the specific clinical and radiological features of encephalitis/encephalopathy. FINDINGS: The reversible lesion in SCC is an MRI finding observable in a wide variety of diseases and conditions. Thus, it should be considered as a secondary change rather than a peculiar feature associated with mild encephalitis/encephalopathy. If reversible lesions are present in the SCC, the symptoms and prognosis are not necessarily favorable, with manifestations of encephalitis/encephalopathy varying from absent to severe. Neuroradiological features that appear as isolated high-intensity signals on diffusion-weighted images and a decreased apparent diffusion coefficient of the lesion might indicate a diagnosis of cytotoxic edema. Findings of previous studies suggest that cytokine-mediated cytotoxic edema of the SCC may be an important pathophysiological manifestation of this condition. CONCLUSION: The reversible lesions in the SCC found on MRI are not exclusive to encephalitis/encephalopathy but may be secondary to other disorders.

Slightly Symptomatic Cerebral Amyloid Angiopathy-Related Inflammation with Spontaneous Remission in Four Months.

Cerebral amyloid angiopathy-related inflammation (CAA-ri) is a rare variant of CAA with autoimmune inflammation. A 77-year-old female experienced light-headedness during walking and mild ataxic gait without any other objective neuropsychological deficits. Brain magnetic resonance imaging (MRI) revealed an area of abnormal signal and mild parenchymal swelling in the right parietal lobe, indicating vasogenic edema. T2⁎-weighted gradient echo imaging revealed some subcortical microbleeds in the same lesion. Based on the proposed criteria for CAA-ri, she was diagnosed with probable CAA-ri. After 4 months, the spontaneous improvement was noted in the patient's clinical and radiological findings. This report presents a rare and atypical case of CAA-ri in which the diagnosis was established after the patient underwent neuroimaging for only mild neurological symptoms, and the patient's clinical and radiological findings displayed spontaneous improvement. Despite typical and striking MRI findings of CAA-ri, this patient only presented a minimal symptom; this dissociation could highlight the significance of not misinterpreting any new neurological symptoms. Thus, increased availability of MRI and growing awareness of CAA-ri might result in more incidentally diagnosed cases in the future. Furthermore, this case suggests that it would be better to strictly monitor the clinical-radiological findings of patients with probable CAA-ri who only present with minimal symptoms without the initiation of immunosuppressive therapy.

Posterior reversible encephalopathy syndrome: A review with emphasis on neuroimaging characteristics.

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological condition that involves the acute onset of headache, confusion, optical impairments, and seizures with accompanying vasogenic edema on brain imaging. PRES is a complex disorder with many causative factors, including underlying conditions such as hypertensive encephalopathy, eclampsia, collagen disease, and severe infection. Although the exact pathophysiological mechanism is not completely understood and remains controversial, the predominant proposed mechanism is endothelial dysfunction, which is preceded by hypertension, immunosuppressive agents, or cytotoxic medication. Magnetic resonance imaging (MRI) facilitates prompt diagnosis and treatment and leads to good outcomes. Findings are characterized by the following: hyperintensity on fluid-attenuated inversion recovery images and apparent diffusion coefficient mapping, and isointensity on diffusion weighted images involving the parieto-occipital or posterior frontal cortical-subcortical regions that are recognized in >90% of patients, and reversibility of neuroimaging abnormalities, with the latter being the most important. As an algorithm to standardize the diagnosis of PRES has not yet been developed, this review presents a diagnostic algorithm based on the types of MRI findings. This algorithm may provide a better understanding of the characteristics that compose PRES and bring us one step closer to the standardization of PRES diagnosis, helping clinicians evaluate individual features while also considering competing differential diagnoses.

Importance of Distinguishing Between Mitochondrial Encephalomyopathy With Elderly Onset of Stroke-Like Episodes and Cerebral Infarction.

The most common disease-causing mitochondrial DNA (mtDNA) mutation in mitochondrial encephalomyopathy (ME) with lactic acidosis and stroke-like episodes (MELAS) is m.3243A>G. In the future, the incidence of patients with cerebral infarction and diabetes mellitus is expected to increase tremendously. Additionally, the A3243G mutation typical of diabetes is estimated to be present in approximately 2% of all diabetes patients, which suggests that the potential disease population with a mitochondrial disorder is greater than previously thought, and there may have been many cases among the elderly that were misdiagnosed. Considering this background, MELAS with the onset of stroke-like episodes should be considered an important differential diagnosis for elderly patients with cerebral infarction, although it might have been overlooked until now. A 68-year-old Japanese female developed convulsive seizures and was admitted to Hospital of International University of Health and Welfare for epilepsy. She had been hospitalized twice in the previous year for cerebral infarction and seizures. She experienced sensorineural hearing loss at a young age. Thus, although she was elderly, we suspected MELAS and detected elevations of pyruvic and lactic acid. A genetic test revealed a point mutation in the mtDNA (m.3243A>G) that led to a definitive diagnosis of MELAS. To date, MELAS has been regarded as a disease of the relatively young. The incidence of patients with cerebral infarction and diabetes mellitus is expected to greatly increase. Thus, we should evaluate cerebral infarction in the elderly with caution to prevent missed diagnoses of MELAS.

Difficulty in determining the association of a single nucleotide polymorphism in the ZNF512B gene with the risk and prognosis of amyotrophic lateral sclerosis.

The advent of next-generation sequencing technology is expected to accelerate the identification of novel genes, and this technology will likely supersede Sanger sequencing. Thus, genome-wide association studies (GWASs) are performed more routinely in an effort to identify disease-susceptibility genes for sporadic amyotrophic lateral sclerosis (ALS). Previously, a Japanese team conducted a large-scale GWAS with 1,305 Japanese ALS patients and discovered a new single nucleotide polymorphism (SNP) rs2275294 associated with susceptibility to sporadic ALS (sALS) in the ZNF512B gene on chromosome 20q13.33. Ju et al. recently performed a case-control study to examine the possible association of rs2275294 with the risk of sALS. Their results, however, indicated that the SNP in ZNF512B is not associated with sALS susceptibility in the Chinese population. A precise diagnosis of neurodegenerative diseases, especially ALS, is highly challenging. For GWASs and other clinical research studies that require a large sample size, if true ALS patients are not selected initially, then all subsequent research is futile. Here, I evaluate the factors that are likely responsible for the inconsistent results obtained by GWASs and propose the development of a new classification system and diagnostic criteria for ALS as the first step towards conducting better clinical studies on ALS. I have attempted to explain the reasons for the inconsistent association between rs2275294 and ALS progression by listing the gene-gene/gene-environment interactions, age of onset, sample size, odds ratio, and inappropriate ALS diagnosis criteria for stratifying this heterogeneous disease in this review.

Importance of correctly interpreting magnetic resonance imaging to diagnose posterior reversible encephalopathy syndrome associated with HELLP syndrome: a case report.

BACKGROUND: Severe haemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome in pregnancy are possible underlying trigger factors for posterior reversible encephalopathy syndrome (PRES). Magnetic resonance imaging (MRI) shows diffuse signal abnormalities involving the subcortical white matter in the parieto-occipital lobes. Although the diagnosis of RPES was clearly established by the distinctive reversibility of clinical and radiological abnormalities, it is difficult to distinguish from differential diagnosis. Thus, it is important to correctly interpret MRI. CASE PRESENTATION: We describe a case of HELLP syndrome with PRES. A 38-year-old pregnant woman was admitted to our hospital as an emergency case with a complaint of upper abdominal pain and headache at 29 weeks of pregnancy and the development of HELLP syndrome. An emergency caesarean section was immediately performed. After the operation, the patient received intravenous corticosteroids, and her blood pressure was controlled. Thereafter, she showed an altered mental status. MRI showed hypersignal intense lesions in the cortical and subcortical white matter in the occipital lobes, basal ganglia and callosal splenium in both the fluid-attenuated inversion recovery (FLAIR) sequence and apparent diffusion coefficient (ADC), but these lesions were not recognized in diffusion-weighted imaging (DWI). These images were suggestive of PRES. The patient was kept in the hospital and received the appropriate treatment, after which the patient's level of consciousness improved and all laboratory tests and imaging examinations returned normal. CONCLUSION: The MRI findings were useful for the prompt diagnosis of PRES, characterized by hypersignals in FLAIR and ADC, but not in DWI. Additionally, there was an "atypical" MRI appearance of basal ganglial and callosal splenial involvement in this case, which may mistakenly lead clinicians to diagnose other aetiologies than typical PRES. It is considered that vasogenic oedema is the main pathology of PRES according to the MRI image findings. MRI is the gold standard for diagnosing PRES because it can provide information about cerebral involvement earlier than CT; further, it can be a useful tool in the differential diagnosis. This technique facilitated the prompt diagnosis and treatment of the said patient, ultimately resulting in a good outcome.

Diagnosis of a subarachnoid hemorrhage with only mild symptoms using computed tomography in Japan.

BACKGROUND: Japan is currently an aging society, with a huge proportion of elderly citizens. Consequently, the incidence and severity of subarachnoid hemorrhage (SAH) is predicted to increase in the future. Computed tomography (CT) is very important in the initial diagnosis of SAH. The proportion of hospitals owning CT systems in Japan is around four times greater than the mean number of systems owned by hospitals in other countries belonging to the Organisation for Economic Co-operation and Development. Because CT is readily available in Japan, it follows that this technique, with its impressive diagnostic power, might be more in demand in Japan compared to other countries. However, misdiagnosis of SAH is a relatively common problem and is associated with increased mortality and morbidity, even in individuals who initially present in good condition. CASE PRESENTATION: We describe a patient with subtle clinical and CT signs of SAH. A 39-year-old Japanese man visited our hospital with a 3-day history of mild headache, shoulder stiffness, and a feeling of dizziness. His physical examination was normal aside from mild neck stiffness. Although CT did not reveal obvious abnormalities, we noticed subtle signs of SAH on CT images, which have been observed in SAH patients with mild symptoms. Thus, we diagnosed our patient with SAH and provided appropriate treatment (aneurysm clipping). Following this, the patient progressed without development of the initial complications, and he was subsequently discharged from our hospital without sequela. CONCLUSION: Thus, physicians should be able to recognize subtle characteristics of CT imaging in case of SAH patients with low grade symptoms, as this can facilitate early diagnosis.

Hepatitis C virus (HCV) reactivation during fingolimod treatment for relapsing and remitting multiple sclerosis.

We here report a case involving a 38-year-old female with relapsing and remitting multiple sclerosis who developed reactivation of hepatitis C virus (HCV) during administration of fingolimod for 16 months. She had been previously treated for chronic hepatitis C with pegylated interferon and ribavirin, and kept an undetectable HCV-RNA state for more than 4 years before fingolimod starting. Although the increased risk for viral reactivation, for example of herpes zoster virus and varicella-zoster virus, during fingolimod treatment is known, this is, to our knowledge, the first case report of HCV reappearance.

Prevalence of elevated serum anti-N-methyl-D-aspartate receptor antibody titers in patients presenting exclusively with psychiatric symptoms: a comparative follow-up study.

BACKGROUND: Increasing numbers of patients with elevated anti-N-methyl-D-aspartate (NMDA) receptor antibody titers presenting exclusively with psychiatric symptoms have been reported. The aim of the present study was to clarify the prevalence of elevated serum anti-NMDA receptor antibody titers in patients with new-onset or acute exacerbations of psychiatric symptoms. In addition, the present study aimed to investigate the association between elevated anti-NMDA receptor titers and psychiatric symptoms. METHODS: The present collaborative study included 59 inpatients (23 male, 36 female) presenting with new-onset or exacerbations of schizophrenia-like symptoms at involved institutions from June 2012 to March 2014. Patient information was collected using questionnaires. Anti-NMDA receptor antibody titers were measured using NMDAR NR1 and NR2B co-transfected human embryonic kidney (HEK) 293 cells as an antigen (cell-based assay). Statistical analyses were performed for each questionnaire item. RESULTS: The mean age of participants was 42.0 ± 13.7 years. Six cases had elevated serum anti-NMDA antibody titers (10.2 %), four cases were first onset, and two cases with disease duration >10 years presented with third and fifth recurrences. No statistically significant difference in vital signs or major symptoms was observed between antibody-positive and antibody-negative groups. However, a trend toward an increased frequency of schizophrenia-like symptoms was observed in the antibody-positive group. CONCLUSION: Serum anti-NMDA receptor antibody titers may be associated with psychiatric conditions. However, an association with specific psychiatric symptoms was not observed in the present study. Further studies are required to validate the utility of serum anti-NMDA receptor antibody titer measurements at the time of symptom onset.

Prevention of cerebral embolism progression by emergency surgery of the left atrial myxoma.

A 21-year-old woman developed left hemiparesis during work and was hospitalized. Her National Institutes of Health Stroke Scale score was 4. Hyperintense areas in the left basal ganglia, corona radiata, and cortex of the temporal lobe were found by brain diffusion-weighted magnetic resonance imaging, indicating acute cerebral infarction. Echocardiography showed a giant mass of diameter 7 × 4 cm in the left atrium. Therefore, she was diagnosed with cerebral embolism due to a left atrial myxoma. Currently, thrombolytic therapy may continue to be effective because the embolic source may be composed of tumor tissue itself. In case of atrial myxoma, we considered that the use of tPA as emergency treatment in all patients with infarction by atrial myxoma may be questioned. Thus, cardiac tumor extraction was performed the next day after hospitalization without thrombolytic therapy. The excised myxoma measured 7 × 6 × 4 cm. The patient recovered and her neurological symptoms also improved. Furthermore, her National Institutes of Health Stroke Scale score improved to 0. Thirteen days after admission, the patient was discharged from our hospital. Cardiac myxoma is often associated with a high risk of embolic episodes, which emphasizes the need for prompt surgical excision as soon as the diagnosis is confirmed.