Neurologic alterations in an HIV adult patient with pertussis: a case report.

BACKGROUND: Pertussis is a highly contagious disease of public health interest caused by the bacterium Bordetella pertussis. Although its incidence has decreased substantially after the introduction of a vaccination, the burden of the disease remains high. Although the paroxysmal phase is highly disabling, complications are uncommon and more prevalent in children than in adults. The most frequent neurological complication is encephalopathy, but seizures, paresis, paraplegia, ataxias, aphasias, and decerebration postures have also been described. The complication of decerebration postures has not been previously reported in adults. CASE PRESENTATION: We present a video case of an adult HIV patient with severe coughing paroxysms, post-tussive emesis and syncope, whose workup confirmed the diagnosis of a B. pertussis respiratory infection. During hospitalization, he had fluctuant encephalopathy and post-tussive decerebration postures following paroxysms. He was treated with antibiotic therapy and finally sent home without residual neurological deficits. CONCLUSION: This case illustrates the biological plausibility of neurologic complications of pertussis in adults, which, albeit rare, can cause important morbidities. Future research should explore whether there are differences in the clinical presentation, risk factors and pathophysiology of the disease among adults or interventions aimed at preventing or treating pertussis encephalopathy.

[Case of Bickerstaff brainstem encephalitis associated with spindle coma and decorticate posture].

A 25-years-old man experienced fever and diarrhea. Ten days later he noticed difficulty walking (day 1). On admission neurological examination revealed lethargy, dysarthria and weakness of limbs. Oculocephalic response was not be elicited and extensor toe signs were positive. In spite of treatment with aciclovir and methylprednisolone, he continued to show progressive deterioration developing to coma with decorticate posture. Autonomic symptoms (hyperhidrosis, hypersalivation and fever) and groaning were observed. Brain magnetic resonance image and brainstem evoked potential presented no abnormality, but electroencephalographic study showed a spindle pattern indicating spindle coma. Laboratory tests including cerebrospinal fluids showed no specific results. High-dose immunoglobulin was administered from day 6, and his consciousness level improved. External ophthalomoplegia and ataxic gait were observed after he became more alert. Because he had IgG type anti-GQ1b antibodies in the serum, a diagnosis was made of Bickerstaff's brainstem encephalitis (BBE). Six months after discharge he had complete resolution of his symptoms. This is the first report of spindle coma observed in a case of serologically confirmed BBE.

Rigidez de descerebración transitoria en el contexto de hipoxemia y administración de propofol, midazolamflumacenilo y remifentanilo-naloxona / No disponible

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Reversible hepatic decerebration: a case report and review of the literature.

Hepatic encephalopathy is a syndrome of neuropsychiatric dysfunction caused by portosystemic venous shunting with or without the presence of intrinsic liver disease. Clinical presentations are variable ranging from an abnormal sleep pattern to somnolence and deep coma. Decerebrate and decorticate posturing, have been rarely reported with hepatic encephalopathy. We report a case of a 59-year-old-man with a history of Child-Pugh B liver disease secondary to chronic alcoholism who was admitted because of coma. He had a transjugular intrahepatic portosystemic shunt 3 months prior to his presentation. He was found to have decerebrating posture. He was treated for hepatic encephalopathy with complete recovery and resolution of the neurologic findings. The physician should be aware that decerebration and decortication posture can occur with hepatic encephalopathy and can be reversible.

Muscle relaxant and neurotoxic activities of intrathecal baclofen in rats.

Intrathecal baclofen therapy by the continuous intrathecal infusion of baclofen has been shown to be an effective treatment for spasticity in patients with spinal cord injury, cerebral palsy, traumatic brain injury, multiple sclerosis and other disorders. To demonstrate the efficacy and safety of intrathecal baclofen therapy, we investigated the muscle relaxant and neurotoxic activities of intrathecal baclofen in rats, compared with intravenous baclofen. Intrathecal and intravenous administration of baclofen dose-dependently inhibited the anemic decerebrate rigidity with ED(50) values of 0.31microg/animal (=1.1-1.3microg/kg) and 0.43mg/kg, respectively. Intrathecal administration of baclofen induced no noticeable changes in a spontaneous electroencephalogram at 30microg/animal. Intravenous administration of baclofen induced an abnormal electroencephalogram with flat waves in all the animals and the no-observed-effect level was estimated to be 5mg/kg. In some animals, intravenous administration of baclofen induced sporadic spikes or sharp waves with background flat waves, indicating inhibitory and excitatory effects on the central nervous system. In conclusion, intrathecal administration of baclofen dose-dependently inhibited anemic decerebrate rigidity in rats and the effective dose was more than 300 times lower than that of intravenous baclofen. The safety margin of intrathecal baclofen was greater than that of intravenous baclofen (> or =97 versus 12). These results suggest that intrathecal baclofen therapy is superior to systemic baclofen therapy in both efficacy and safety.

Gabapentin for decerebrate rigidity: a case report.

A 48-year-old woman suddenly lost consciousness as a result of a right rostral pontine tegmentum haemorrhage. The patient presented with decerebrate rigidity (DR) and regained full consciousness 5 days after the initial onset. The patient was given gabapentin 1200 mg/day nasogastrically and her DR significantly improved, although other antiepileptic drugs such as phenytoin and carbamazepine were given in larger dosages to decrease muscle hypertonicity. The patients' preserved consciousness and motor-evoked potentials to transcranial magnetic stimulation indicated a derangement of the extrapyramidal tracts with preservation of the pyramidal tracts. This case report discusses the possible mechanisms of action of gabapentin in DR.

Neurotrophic factors promote and enhance locomotor recovery in untrained spinalized cats.

In spinal cats, locomotor recovery without rehabilitation is limited, but weight-bearing stepping returns with treadmill training. We studied whether neurotrophins administered to the injury site also restores locomotion in untrained spinal cats and whether combining both neurotrophins and training further improves recovery. Ordinary rat fibroblasts or a mixture of fibroblasts secreting brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) (Fb-NTF) were grafted into T12 spinal transection sites. Cats with each type of transplant were divided into two groups: one receiving daily training and the other receiving no training. As expected, trained cats with/without neurotrophin-producing transplants could step on the treadmill. Untrained cats without neurotrophin-producing transplants could not locomote. However, untrained cats with neurotrophin-secreting transplants performed plantar weight-bearing stepping at speeds up to 0.8 m/s as early as 2 wk after transection. Locomotor capability and stance lengths in these animals were similar to those in animals receiving training alone, suggesting that administration of BDNF/NT-3 was equivalent to treadmill training in restoring locomotion in chronically spinalized cats. Cats receiving both interventions showed the greatest improvement in step length. Anatomical evaluation indicated that all transections were complete and that axons did not enter the cord caudal to the graft. Thus BDNF/NT-3 secreting fibroblasts were equivalent to training in their ability to engage the locomotor circuitry in chronic spinal cats. Furthermore, the rapid time-course of recovery and the absence of axonal growth through the transplants indicate that the restorative mechanisms were not related to supraspinal axonal growth. Finally, the results show that transplants beneficial in rodents are applicable to larger mammals.

Endogenous opioids support the spinal inhibitory action of an alpha 2-adrenoceptor agonist in the decerebrated, spinalised rabbit.

The present study examined the possible contribution of endogenous opioids to inhibition of spinal reflexes by an alpha(2)-adrenoceptor agonist. In rabbits decerebrated and spinalised under halothane/nitrous oxide anaesthesia, the selective alpha(2)-adrenoceptor agonist dexmedetomidine (3-30 microg intrathecal) induced significant decreases in short- and long-latency reflex responses evoked in medial gastrocnemius (MG) motoneurones by stimulation of the sural nerve. After recovery from dexmedetomidine, the mu-opioid receptor antagonist beta-funaltrexamine (beta-FNA; 100 microg intrathecal) significantly enhanced short-latency but not long-latency MG reflex responses. After beta-FNA, inhibition of all reflexes by dexmedetomidine was significantly weaker than in the control state, whereas the cardiovascular actions of dexmedetomidine were unaffected. These data confirm that activation of spinal alpha(2)-adrenoceptors depresses MG reflexes evoked by all groups of sural nerve afferent fibres, and shows that endogenous opioid tone supports the inhibitory action of alpha(2) agonists, possibly by a synergistic interaction in the spinal cord.

Reversible decerebrate posturing secondary to hypoglycemia.

Two cases of decerebrate posturing that resolved following the administration of dextrose are reported. The literature on hypoglycemia-induced neurologic deficits is reviewed and an explanation for the quick remission of the decerebrate posturing is postulated.

[Use of barbiturates in posttraumatic comas at the mesencephalic level. Apropos of 38 cases]. / Utilisation des barbituriques dans les comas post-traumatiques de niveau mésencéphalique. A propos de 38 cas.

Thirty-eight patients with brain injury and mesencephalic coma, or a Glasgow score of less than 5, were treated routinely with Thiopental administered by electric syringe for a mean duration of 4 days. Follow up review criteria were based on clinical computed tomography and electroencephalographic data, as well as results of monitoring of intracranial pressure and assay of blood barbiturate levels. Global results indicated a mortality of 55.3% and reintegration of 34.2% of the patients. Results as a function of the different parameters of surveillance are discussed.

Changes of hemodynamics and O2 transport associated with the perfluorochemical blood substitute, Fluosol-DA.

Hemodynamic, arterial O2 tension (PaO2) and transcutaneous O2 tension (PtcO2) changes associated with the infusion of 500 ml of Fluosol-DA were evaluated in 14 decerebrated patients. Flow-directed pulmonary artery catheters and the Clark-type oxygen electrode manufactured by Hoffmann-La Roche were utilized. The marked improvement of cardiovascular variables along with marked increases in PaO2 and PtcO2 may indicate a marked increase in skin circulation by the infusion of Fluosol. One patient exhibited a hypotensive episode during the infusion, which lasted only a short time, disappeared spontaneously, and did not prohibit the further infusion of Fluosol. We still consider that Fluosol will be clinically useful for increasing oxygen capacity and improving overall hemodynamic status as well as individual organ circulation.

[Severe head-injury of the child. Medical treatment (author's transl)]. / Le traumatisme crânien grave chez l'enfant Traitement médical.

The child with a severe head injury requires a three component's treatment: against cerebral edema, against restlessness and vegetative trouble, against shock in case of scalp-hemorrage or attendant traumatism. As there is no agreement neither about the treatment of cerebral edema nor that of sedative treatment, we continue to use systematically artificial ventilation, sometimes corticoids, rarely mannitol. Decerebration is treated by a lytic coktail enclosing always diazepam and in case of failure, sodium gamma-hydroxybutyrate.

A comparison of the actions of some drugs on decerebrate rigidity, muscle spindle activity and alpha-adrenoceptors.

1 The relative potencies of methotrimeprazine, (+)-methotrimeprazine, (+/-)-10-(3-dimethylamino-2-methylpropyl)-2-valeroyl phenothiazine hydrochloride (M & B 18,706) and (+)-M & B 18,706 in reducing the pressor action of noradrenaline in the spinal cat, reducing intercollicular decerebrate rigidity, and muscle spindle afferent activity have been studied.2 Methotrimeprazine was eight times as potent as (+)-methotrimeprazine in reducing the pressor action of noradrenaline and six times as potent in reducing decerebrate rigidity. M & B 18,706 was also eight times as potent as (+)-M & B 18,706 in reducing the pressor action of noradrenaline and six times as potent in reducing decerebrate rigidity.3 For the above compounds and chlorpromazine there was a significant correlation between the effective doses for the inhibition of the pressor action of noradrenaline and for the reduction of decerebrate rigidity.4 The doses which reduced decerebrate rigidity were similar to those that reduced muscle spindle afferent discharge. It is likely that these drugs reduce decerebrate rigidity by inhibiting fusimotor activity.5 Desipramine increased decerebrate rigidity and increased spindle afferent discharge.6 It is thought that the phenothiazine derivatives studied reduce decerebrate rigidity and spindle afferent discharge by inhibiting receptors for noradrenaline in the central nervous system.