Recurrent Chagas' disease meningomyelitis in an HIV-infected patient.

Chagas' disease reactivation leading to monophasic acute or subacute meningoencephalitis or space-occupying lesions is a well-described AIDS-defining condition in Latin America. We report a 59-year-old man native from the Northeast region of Brazil, with a second episode of subacute chagasic meningomyelitis. He had long-term multidrug-resistant HIV and had abandoned combined antiretroviral therapy (CD4+ lymphocyte count, 16 cells/mm³, and HIV viral load 169 403 copies/mL). He initially received benznidazole but switched to nifurtimox after developing myelotoxicity. He was discharged home having made a partial neurological improvement. Chagas' disease should be included in the differential diagnosis of meningomyelitis in people living with HIV/AIDS who are from endemic areas of this parasitic disease.

Peculiar aetiology for orbital apex syndrome: Wyburn-Mason syndrome as orbital apex lesion.

Background: Wyburn-Mason syndrome is a rare, non-hereditary congenital disease, belonging to the group of neurocutaneous syndromes with fewer than 100 cases reported since its first description in 1937. Case report: A young adult man was initially evaluated at the age of 2 years for proptosis and progressive visual impairment of the right eye, followed by impairment in ocular abduction, adduction and elevation as well as amaurosis. MRI revealed an expansive formation centred in the right orbit compromising conal spaces with distortion of eye muscles and optic nerve. The lesion extended through the superior orbital fissure into the right cavernous sinus and to the contralateral orbit. Despite embolisation, proptosis and oedema of the periorbital tissue continued to worsen. The combination of facial, ocular and intracranial vascular malformations and the exclusion of alternative aetiologies led to a diagnosis of cerebrofacial arteriovenous metameric syndrome (CAMS) 1 (Wyburn-Mason syndrome). Discussion: Important differential diagnoses are other CAMS, such as Sturge-Weber syndrome, as well as other conditions such as retinal cavernous haemangioma and vasoproliferative tumours. The optimal treatment regimen for severe cases of this syndrome is still unclear. Wyburn-Mason syndrome should be considered in patients presenting multiple arteriovenous malformations with orbital apex lesions.

Neurological gait assessment.

Gait disorders are a common feature of neurological disease. The gait examination is an essential part of the neurological clinical assessment, providing valuable clues to a myriad of causes. Understanding how to examine gait is not only essential for neurological diagnosis but also for treatment and prognosis. Here, we review aspects of the clinical history and examination of neurological gait to help guide gait disorder assessment. We focus particularly on how to differentiate between common gait abnormalities and highlight the characteristic features of the more prevalent neurological gait patterns such as ataxia, waddling, steppage, spastic gait, Parkinson's disease and functional gait disorders. We also offer diagnostic clues for some unusual gait presentations, such as dystonic, stiff-person and choreiform gait, along with red flags that help differentiate atypical parkinsonism from Parkinson's disease.

New-onset refractory status epilepticus (NORSE) in paediatric patients: causes, characteristics and outcomes.

Background: New-onset refractory status epilepticus (NORSE) refers to patients without a previous history of seizures who have refractory status epilepticus for at least 72 hours without an identified aetiology. Despite the severe neurological sequelae of NORSE, little is known about this condition in paediatric patients. Objective: To describe the profile of paediatric patients with NORSE, the profile of seizures, possible causes attributed to this condition, treatments offered to patients and the outcomes at discharge from the paediatric intensive care unit (PICU). Methods: This retrospective, multicentre, descriptive study (case series) was conducted in the PICUs of three tertiary hospitals. We reviewed the medical records of all patients aged 0-16 years admitted to the participating PICUs between December 2013 and December 2017 with refractory status epilepticus, without a previous history of seizures or neurological disease. Results: Fifteen patients (2.4%) had NORSE. The median age of patients was 62.3 (IQR 26.2-75.4) months. All patients experienced prodromes before progressing to refractory status epilepticus. Twelve patients (80%) had fever up to 24 hours before seizures. NORSE was classified as cryptogenic in 66% of patients. Twelve patients were treated with complementary therapies, in addition to anticonvulsants. There was no standardisation in the treatment of patients. The overall mortality rate was 20%. Conclusions: NORSE is associated with high morbidity and mortality, without an identified aetiology in most cases and with a wide range of proposed therapies.

Olfactory nerve: from ugly duckling to swan / Nervo olfatório: de patinho feio a cisne

ABSTRACT Background: The olfactory nerve has never been the shining star of neurological examination. Quite the contrary, examining the first cranial nerve is often an overlooked step. As cases of anosmia secondary to COVID-19 infection continue to rise, the 2020 pandemic has shed new light on this much-forgotten nerve, its value as an aid to diagnosis of several diseases and its central role in our daily lives. Objective: We aimed to emphasize how essential and simple clinical examination of the olfactory system can be by highlighting practical techniques and clinical tips for its assessment. We also share pearls and pitfalls in localization and differential diagnosis, which may prove valuable to busy clinicians. Methods: A broad review of the literature was conducted by searching PubMed, Cochrane and Google Scholar for articles and books containing topics regarding examination of the olfactory nerve and its anatomy, physiology and pathology. No particular inclusion or exclusion criteria were used. Results: Forty different works were found, between books and articles, from which 20 were selected after careful analysis. Conclusions: Despite the tragedy and adversity that followed the COVID-19 pandemic, its legacy has taught us a crystal-clear lesson: olfaction should no longer be neglected in clinical practice.

RESUMO Antecedentes: O nervo olfatório nunca foi a estrela do exame neurológico. Pelo contrário, o exame desse nervo craniano é um passo frequentemente ignorado. No entanto, o aumento exponencial de casos de anosmia secundária a COVID-19 o colocou sob os holofotes, tanto em relação á sua função para o ser humano em sociedade, como seu papel no auxílio do diagnóstico de diversas patologias. Objetivos: Enfatizar quão importante é examinar o nervo olfatório e compreender as desordens do seu sistema. Ressaltamos pérolas clínicas e erros comuns no exame deste nervo, além dicas que possam auxiliar no diagnóstico de uma série de doenças neurológicas e sistêmicas. Métodos: Uma ampla revisão da literatura foi conduzida por meio de busca no PubMed, Cochrane e Google Acadêmico por artigos e livros relacionados aos tópicos do exame físico, fisiologia, anatomia e patologia do nervo olfatório. Não foram utilizados critérios específicos de inclusão ou exclusão. Resultados: Foram encontrados 40 artigos itens relacionados na língua inglesa, dentre os quais livros e artigos, tendo sido analisados e selecionados um a um até o total de 20 referências. Conclusões: Apesar da tragédia e adversidade trazidas pela pandemia de COVID-19, uma lição clara permanece: o olfato não deve mais ser negligenciado na prática clínica.

Myelopathy associated with intrathecal methotrexate.

A 21-year-old man developed progressive and bilateral lower limb numbness, gait impairment and urinary incontinence over 10 days. He had received intrathecal methotrexate 20 days previously for acute lymphoblastic B-cell leukaemia, following 7 months of systemic chemotherapy. MR scan of the spinal cord showed bilateral symmetric and extensive T2/fluid attenuated inversion recovery (FLAIR) increased signal involving the dorsal columns in the thoracic cord. His serum folate concentration was at the lower end of the normal range. We stopped the intrathecal chemotherapy and gave folate; after a few days, he progressively improved. Myelopathy is an important adverse effect of intrathecal methotrexate, which may cause clinical and imaging features resembling subacute combined degeneration of the spinal cord. CNS infiltration must be excluded, intrathecal chemotherapy stopped and deficiency of folate or vitamin B12 treated as appropriate.

Aspectos terapêuticos de cães com diagnóstico presuntivo de epilepsia idiopática / Therapeutic aspects of dogs with presumptive diagnosis of idiopathic epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects. Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between 1.4 and 12 mg kg-1 and the median of serum concentration was 26.41 μg kg-1. There was significant reduction in the frequency of the seizure after start the treatment. There was refractory to antiepileptic drugs in two dogs (9.5%). In blood analysis, there was increase serum activities of AP (23.81%) and ALT (14.20%), decrease total protein (42.29%), hypoalbuminemia (9.5%) and it was not increased AST activities. The main adverse effects were nodularliver damage and hypothyroidism. [...](AU)

Therapeutic Aspects of Dogs with Presumptive Diagnosis of Idiopathic Epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects.Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between

Aspectos terapêuticos de cães com diagnóstico presuntivo de epilepsia idiopática / Therapeutic aspects of dogs with presumptive diagnosis of idiopathic epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects. Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between 1.4 and 12 mg kg-1 and the median of serum concentration was 26.41 μg kg-1. There was significant reduction in the frequency of the seizure after start the treatment. There was refractory to antiepileptic drugs in two dogs (9.5%). In blood analysis, there was increase serum activities of AP (23.81%) and ALT (14.20%), decrease total protein (42.29%), hypoalbuminemia (9.5%) and it was not increased AST activities. The main adverse effects were nodularliver damage and hypothyroidism. [...]

Therapeutic Aspects of Dogs with Presumptive Diagnosis of Idiopathic Epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects.Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between

Therapeutic Aspects of Dogs with Presumptive Diagnosis of Idiopathic Epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects.Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between

Therapeutic Aspects of Dogs with Presumptive Diagnosis of Idiopathic Epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects.Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between

Therapeutic Aspects of Dogs with Presumptive Diagnosis of Idiopathic Epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects.Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between

Therapeutic Aspects of Dogs with Presumptive Diagnosis of Idiopathic Epilepsy

Background: Epilepsy is a chronic neurological condition characterised by recurrent epileptic seizures. Various antiepileptic drugs are used for the management of canine idiopathic epilepsy. Phenobarbital is the drug of choice for long-term treatment in dogs. Although it is well tolerated, phenobarbital can cause liver injury if administered alone or in combination with other drugs. Therefore, the main of this study was to identify dogs with presumptive diagnosis of idiopathic epilepsy and information about the antiepileptic drugs, the dose and frequency of administration, period of treatment, frequency of the seizure before and after start the treatment, complementary exams and adverse effects.Materials, Methods & Results: In this study were included 21 dogs with idiopathic epilepsy. All dogs were examined and having blood taken for blood count, biochemical tests (ALT, AST, AP, total protein, albumin, creatinine, urea, amylase, lipase, cholesterol and triglycerides), measurement of serum phenobarbital and/or potassium bromide and, some dogs, free T4 by dialysis and canine TSH. In this study, it was observed monotherapy (phenobarbital) in 76.19% (16/21), double therapy (phenobarbital and potassium bromide) in 19.05% (4/21) and triple therapy (phenobarbital, potassium bromide and gabapentin) in 4.76% (1/21) of dogs. The phenobarbital was used as monotherapy with dose between