Fatal case of simply influenza A (H3N2)-associated encephalitis in immunocompetent patient.

Influenza virus-associated encephalopathy/encephalitis is a rare entity in adults that can lead to severe neurological sequelae and even death. The clinical presentation can be quite diverse. This absence of a typical presentation along with the difficulty detecting the virus in the cerebrospinal fluid represents a diagnostic challenge. We present the case of a 79-year-old male with sudden onset of decreased consciousness and signs of right hemisphere damage. The presence of influenza A (H3N2) virus in respiratory sample along with compatible findings in cranial magnetic resonance led to the diagnosis. The patient died without responding to treatment with antivirals and immunomodulators and the anatomopathological study did not detect infectious agent. Early diagnostic suspicion is essential to establish adequate treatment and improve the prognosis.

[Lacunar stroke as a very late complication of radiotherapy: value of nuclear medicine techniques]. / Ictus lacunar como complicación muy tardía de la radioterapia: valor de las técnicas de medicina nuclear.

INTRODUCTION: Radiation therapy is a very useful treatment for central nervous systemS neoplasms. The time range of its complications is very wide; they appear even many years after its completion. These late complications behave clinically and radiologically similar to a relapse; a functional diagnostic study with radioactive isotopes can help to make a therapeutic decision. CASE REPORT: A male suddenly presented deficient neurological symptoms in the same site where he received radiation therapy 25 years earlier for a pilocytic astrocytoma. The MRI findings suggested a lacunar stroke but a finding in the perfusion sequence forced us to be more precise in the diagnosis. A PET-CT 11C-methionine was performed which showed an increased uptake compatible with neoplasia. The spontaneous regressive evolution of the symptoms inclined us to take a conservative attitude. Lacunar ictus was confirmed on MRI three months later. CONCLUSIONS: The reappearance of neurological symptoms years after radiotherapy of a brain neoplasm poses a diagnostic dilemma. Current diagnostic techniques are very accurate but present false positives. The various nuclear medicine techniques, in particular PET-CT 11C-methionine, are a diagnostic aid. With the presentation of this case we intend to draw attention to one of the late complications of radiation therapy and the various differential diagnoses. Diagnostic and therapeutic advances have increased the life expectancy of cancer patients, so these late complications are expected to be more frequent.

TITLE: Ictus lacunar como complicación muy tardía de la radioterapia: valor de las técnicas de medicina nuclear.Introducción. La radioterapia es un tratamiento de gran utilidad en las neoplasias del sistema nervioso central. El rango temporal de sus complicaciones es muy amplio, ya que aparecen incluso muchos años más tarde de haberla finalizado. Estas complicaciones tardías se comportan clínica y radiológicamente de forma similar a una recidiva; un estudio funcional diagnóstico con isótopos radiactivos puede ayudar a tomar una decisión terapéutica. Caso clínico. Varón que presentó de forma brusca sintomatología neurológica deficitaria en la misma localización donde 25 años antes había recibido radioterapia por un astrocitoma pilocítico. La resonancia magnética sugería un ictus lacunar, pero un hallazgo en la secuencia de perfusión obligaba a ser más preciso en el diagnóstico. Una tomografía por emisión de positrones-tomografía computarizada (PET-TC) con C11-metionina mostró un aumento de captación compatible con neoplasia. La evolución espontánea regresiva de los síntomas inclinó a tomar una actitud conservadora. Una resonancia magnética realizada tres meses más tarde confirmó el ictus lacunar. Conclusiones. La reaparición de síntomas neurológicos años más tarde de la radioterapia de una neoplasia cerebral supone un dilema diagnóstico. Las técnicas diagnósticas actuales son muy precisas, pero presentan falsos positivos. Las distintas técnicas de medicina nuclear, en concreto la PET-TC con C11-metionina, suponen una ayuda diagnóstica. Con este caso se pretende llamar la atención sobre una de las complicaciones tardías de la radioterapia y los distintos diagnósticos diferenciales. Los avances diagnósticos y terapéuticos han aumentado la esperanza de vida de los pacientes oncológicos, con lo que estas complicaciones tardías se prevén más frecuentes.

[Metronidazole-induced encephalopathy: description of a case with radiological and anatomopathological findings]. / Encefalopatia inducida por metronidazol: descripcion de un caso con hallazgos radiologicos y anatomopatologicos.

INTRODUCTION: Metronidazole is a widely known and used antibiotic. In exceptional cases, an encephalopathy with characteristic lesions on magnetic resonance imaging (MRI), usually located in the cerebellum and splenium of the corpus callosum, may be an adverse effect. The incidence and pathogenesis are unknown. The suspension of the treatment usually resolves the symptoms and normalizes the MRI in a few weeks. Due to the usual good prognosis, the anatomopathological findings are exceptional. We present a clinical case with the radiological findings suggestive of metronidazole-induced encephalopathy and, exceptionally, we provide the anatomopathological findings. CASE REPORT: A 72 years-old woman with severe Crohn's disease who, months after starting treatment with metronidazole, presented a slowly progressing bradypsychia and difficulty walking until she came to coma. In MRI it showed hyperintense images in T2 in the corpus callosum, red and dentate nuclei. He improved by stopping metronidazole but later developed sepsis and died. At autopsy, softening of the red nucleus was observed and, microscopically, cell necrosis and demyelination. CONCLUSION: With the publication of the clinical, radiological and anatomopathological information of our case we intend to promote the knowledge of this infrequent treatable cause of subacute encephalopathy and provide data that help to clarify its pathogenesis.

TITLE: Encefalopatia inducida por metronidazol: descripcion de un caso con hallazgos radiologicos y anatomopatologicos.Introduccion. El metronidazol es un antibiotico ampliamente conocido y utilizado. En casos excepcionales puede producir como efecto adverso un cuadro de encefalopatia con unas lesiones caracteristicas en la resonancia magnetica, localizadas generalmente en el cerebelo y el esplenio del cuerpo calloso. La incidencia y la patogenia se desconocen. La suspension del tratamiento habitualmente resuelve los sintomas y normaliza la resonancia magnetica en pocas semanas. Debido al habitual buen pronostico, los hallazgos anatomopatologicos son excepcionales. Se presenta un caso clinico con los hallazgos radiologicos sugestivos de la encefalopatia inducida por metronidazol y, de forma excepcional, se aportan los hallazgos anatomopatologicos. Caso clinico. Mujer de 72 años, con enfermedad de Crohn grave, que meses mas tarde de iniciar tratamiento con metronidazol presento de forma lentamente progresiva bradipsiquia y dificultad para caminar hasta llegar al coma. En la resonancia magnetica mostraba caracteristicas imagenes hiperintensas en T2 en el cuerpo calloso, y los nucleos rojos y dentados. Mejoro al suspender el metronidazol, pero posteriormente desarrollo una sepsis y fallecio. En la autopsia se observo reblandecimiento del nucleo rojo y, microscopicamente, necrosis celular y desmielinizacion. Conclusion. Con la publicacion de la informacion clinica, radiologica y anatomopatologica de este caso se pretende fomentar el conocimiento de esta infrecuente causa tratable de encefalopatia subaguda y aportar datos que ayuden a aclarar su patogenia.

[SUNCT-type headache and Rathke's cleft cyst: a controversial relation]. / Cefalea tipo SUNCT y quiste de la bolsa de Rathke: controversias sobre su relación.

INTRODUCTION: SUNCT is a primary headache, although in a small percentage of cases it is associated with intracranial lesions, generally in the pituitary area or in the posterior fossa. CASE REPORT: A 69 years-old woman with SUNCT whose magnetic resonance imaging showed chronic bleeding in a Rathke's cleft cyst. This is the first case report of this association. CONCLUSIONS: We discuss the relation between the two conditions and the utility and risks of surgery to control refractory headache.

Cefalea tipo SUNCT y quiste de la bolsa de Rathke: controversias sobre su relación / SUNCT-type headache and Rathke’s cleft cyst: a controversial relation

Introducción. El SUNCT es una cefalea primaria, aunque en un pequeño porcentaje de casos se asocia a lesiones intracraneales, generalmente en el área hipofisaria o en la fosa posterior. Caso clínico. Mujer de 69 años con SUNCT, en cuya resonancia magnética apareció un sangrado crónico en un quiste de la bolsa de Rathke. Es el primer caso descrito con esta asociación. Conclusiones. Discutimos la relación entre estas entidades, así como la utilidad y los riesgos de la cirugía para el control de la cefalea refractaria (AU)

Introduction. SUNCT is a primary headache, although in a small percentage of cases it is associated with intracranial lesions, generally in the pituitary area or in the posterior fossa. Case report. A 69 years-old woman with SUNCT whose magnetic resonance imaging showed chronic bleeding in a Rathke’s cleft cyst. This is the first case report of this association. Conclusions. We discuss the relation between the two conditions and the utility and risks of surgery to control refractory headache (AU)

Macroadenoma productor de FSH: una enfermedad no tan benigna como indica la histología / FSH producing macroadenoma; a disease that is not as benign as the histology indicates

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[Treatment of transformed refractory migraine with intravenous dihydroergotamine]. / Tratamiento de la migraña transformada refractaria con dihidroergotamina intravenosa.

In this work we present our experience with a seven-day protocol of i.v. dihydroergotamine (DHE) in the treatment of 6 patients (7 treatments) suffering from intractable transformed migraine. All of them were admitted to hospital and treated for one week with a protocol which included DHE doses between 0.5-1 mg/8 h. One patient did not respond. The remaining 6 became free of pain in under 48 hours after the beginning of treatment. This positive effect remained for between 15 days and 3 months. All patients experienced adverse events; however, these were slight and ceased when the DHE dose was reduced. DHE is an effective and quick option for the short-term treatment of patients with severe transformed migraine resistant to other medications.