Hemorrhagic fever with renal syndrome

The authors describe the illness of a Czech soldier who while serving in the UNPROFOR forces in an area with the endemic occurrence of hantaviruses became infected with this agent and developed haemorrhagic fever with renal syndrome. The severe clinical course which called for seven haemodialyzation procedures led to the patient's recovery. The authors describe the course of the disease and epidemiological circumstances.     

Isolated musculocutaneous nerve palsy in a spinal cord injury

Isolated musculocutaneous nerve palsy is rare. We report one case of a bilateral palsy of this nerve following a road accident which led to a complete thoracic level paraplegia.     

Isolated third nerve palsy due to sarcoidosis

We present a 28-year-old man with isolated third nerve palsy as the initial manifestation of sarcoidosis. MRI demonstrated abnormal enhancement of the cisternal portion of the right third nerve. One month after steroid therapy, he showed almost complete recovery with resolution of the contrast enhancement on MRI. This patient illustrates the usefulness of enhanced MRI for detection of cranial nerve lesions of sarcoidosis.     

Isolated vagal nerve palsy associated with a dissection of the extracranial internal carotid artery

A 40-year-old man had paralysis of the right vocal cord. Imaging showed a dissection of the extracranial internal carotid artery, and physical examination disclosed paresis of the right side of the soft palate. To our knowledge, this is only the second report of carotid dissection presenting as an isolated vagal neuropathy. Most often, multiple lower cranial nerves are involved. The CT, MR imaging, and MR angiographic findings are presented and the topic is reviewed.     

Acute renal insufficiency in hemorrhagic fever with renal syndrome

PURPOSE: Propranolol, a beta-adrenergic antagonist, has been shown to block hyperthermically-induced ocular recurrence of HSV-1 in mice and reduce spontaneous ocular viral shedding and herpetic corneal lesions in latently infected rabbits. The present study was performed to determine the effect of propranolol on epinephrine iontophoresis-induced ocular recurrence and immunosuppression-induced ocular recurrence in the rabbit eye model. METHODS: New Zealand white rabbits were infected with HSV-1 strain 17Syn+ or McKrae. After latency was established, the animals were injected intramuscularly with saline (placebo), or propranolol (5-200 mg/kg) twice daily, and then induced with epinephrine iontophoresis or cyclophosphamide and dexamethasone administration. Tear film swabs were cultured to determine the frequency of viral shedding. RESULTS: Propranolol administered at a range of doses did not affect the frequency or duration of viral shedding following epinephrine or cyclophosphamide/dexamethasone induction as compared to saline treatment. CONCLUSION: These results demonstrate that propranolol does not significantly reduce ocular HSV-1 shedding following induction by epinephrine iontophoresis or immunosuppression. By inference, these results suggest two possibilities: (1) that viral pathways leading to spontaneous and induced shedding of virus are under separate control mechanisms or (2) in rabbits, these inducers are of such potency that propranolol is ineffectual.     

Syringohydromyelia as a complication of Goldenhar syndrome

Goldenhar syndrome is a multifocal developmental disorder consisting of ocular, auricular and vertebral anomalies. A case of Goldenhar syndrome is presented with a previously undescribed association with syringohydromelia. The pertinent literature is reviewed and possible mechanisms of the pathogenesis of syringohydromyelia in this syndrome are discussed.     

Isolated fourth nerve palsy from midbrain hemorrhage: case report

There is accumulating evidence for the efficacy of lamotrigine in the treatment of bipolar disorder, including bipolar depression, both as monotherapy and in combination with sodium valproate. We present the cases of 3 female patients admitted to our hospital with the diagnosis of schizoaffective disorder who were treated with lamotrigine. While dosages up to 200 mg/day, resulting in serum concentrations of less than 5 mg/l, were only partially effective, 400 mg/day (with serum concentrations >10 mg/l) led to considerable mood stability, with complete remission from paranoid symptoms. We suggest that lamotrigine might be helpful in the treatment of schizoaffective disorder, probably with serum concentrations of more than 5 mg/l.     

Peripheral nerve injury as a complication from orthopedic operation

We report a case of pulmonary carcinosarcoma. Surgery is required for this rare mixed type, biphasic tumor. It is generally considered to be a malignant formation issuing from a single cell line but with a two-way differentiation into epithelial and conjunctive components. There is a differentiation continuum between spindle-cell carcinomas (also called monophasic sarcomatoid carcinoma) and carcinosarcoma (or biphasic sarcomatoid carcinoma) leading to debate concerning the immunohistochemical and ultrastructural features.     

Nontuberculous mycobacteriosis as a complication of the Swyer-James syndrome

The chest radiograph of a 35-year-old man with fatigue, exertional dyspnoea and haemoptyses revealed a cavity in the left upper lobe and a shrunken left lung with radiolucency greater than that on the right. Acid-fast rods in sputum were identified as Mycobacterium kansasii on culture. Scintigraphy showed a 9% residual perfusion on the left and abnormal ventilation, compatible with Swyer-James syndrome. This had favoured the development of a mycobacterial infection. There was also a decrease in ciliary function (rate of 4-7 Hz, normal: 10-11). Treatment, begun when tuberculosis had been suspected, was after sensitivity tests changed to a combination of rifampicin (600 mg), ethambutol (1600 mg) and protionamide (500 mg) daily. There was marked regression of the findings within 4 weeks, but treatment was prematurely stopped after 11 months. Two years later there was a recurrence which again responded well to the same drug regimen with additional sulphamethoxazole (1600 mg/d).     

Serotonin concentration in the blood of patients with hemorrhagic fever with renal syndrome

Differences in the concentrations of serotonin in whole blood and plasma of patients with hemorrhagic fever with the renal syndrome prompted measurements of serotonin in different components of the blood. The concentration of serotonin in whole blood was found to depend on its hemoconcentration: the higher is the hematocrit, the greater is the difference between serotonin content in the plasma and whole blood. In case of hemoconcentration or hemodilution it is impossible to assess serotoninemia from the level of serotonin in whole blood.     

An epidemic of hemorrhagic fever with renal syndrome in Croatia in 1995

In the spring of 1995, the largest outbreak of hemorrhagic fever with renal syndrome (HFRS) so far was recorded in Croatia. There were 125 patients reported to the National Croatian Institute of Public Health, Department of Epidemiology. The disease occurred simultaneously in several localities, some of them close to the previously known natural foci (Mala Kapela, western Slavonia); the focus on Dinara was newly discovered. War circumstances in Croatia were closely related to this outbreak. There were 50 patients hospitalized in the University Hospital of Infectious Diseases in Zagreb; 5 of them were civilians from Zagreb area and 45 soldiers (Mala Kapela 33, Dinara 7, western Slavonia 5). In all patients the disease was serologically proven (in 6 by indirect immunofluorescence method and in 44 by ELISA-test). Both previously known types of viruses--Hantaan and Puumala were diagnosed in each locality. In general, the illness was more severe in patients with Hantaan virus infection. Two patients died, the illness was severe in 25, moderately severe in 11 and mild in 12 patients. For the first time inflammatory lung changes were recorded in 13 out of 37 (35.1%) patients who were examined by X-ray in the early stage of the disease.     

Metabolic encephalopathy as a complication of renal failure: mechanisms and mediators

Among patients with end-stage renal disease, nervous system dysfunction remains a major cause of disability. Patients with chronic renal failure who have not yet received dialysis may develop symptoms ranging from mild sensorial clouding to delirium and coma. Dialysis itself is associated with at least three distinct disorders of the CNS: dialysis disequilibrium syndrome; dialysis dementia; and progressive intellectual dysfunction. Peripheral neuropathy is also a major cause of disability in uremic subjects. It is believed that aluminum contributes to the pathogenesis of dialysis dementia. Biochemically, brain calcium is elevated in patients with renal failure, probably because of actions of parathyroid hormone on the brain. The diagnosis of dialysis disequilibrium syndrome, intellectual dysfunction, dialysis dementia, and uremic neuropathy can be made by the characteristic clinical pictures of these syndromes and the exclusion of other causes of nervous system dysfunction.     

Isolated jejunal Crohn's disease in a young adult presenting as fever of unknown origin

A 27-yr-old man was referred for fever, weight loss, fatigue, and occasional mild epimesogastric pain without diarrhea or vomiting. Laboratory tests were suggestive of an active inflammatory disease but serological, bacteriological, viral searches, markers of autoimmunity, and neoplasia were all negative. The following were also negative: ultrasonography; conventional x-rays; CT scans; esophagogastroduodenoscopy, pancolonoscopy with ileoscopy; cytohistology including duodenum and ileocolon. Empiric antibiotic regimens failed to control the temperature. Small bowel enema disclosed multiple proximal jejunal strictures. Jejunoscopy revealed erythema, friability, linear ulcerations, stenosis, and dilation in the proximal jejunum. Multiple directed biopsies showed inflammatory changes devoid of any specific features. The patient received steroid treatment and his temperature normalized. Six months later, he was readmitted on account of intestinal subocclusion that was managed conservatively. A few days later urgent laparotomy was performed with peritoneal lavage, repair of double perforated proximal jejunal ulcers, and stricturoplasty. Surgical jejunal biopsy confirmed the results of enteroscopic biopsies. The patient is presently without fever, in the absence of steroid treatment. There have been no reports of cryptogenic fever due to isolated jejunal Crohn's disease in the recent literature. Our patient's clinical picture resembled disease as seen in older children and adolescents, in whom it is a difficult diagnosis owing to the absence of diarrhea. In adults with Crohn's disease isolated jejunal involvement represents approximately 1% of cases. A thorough small bowel investigation is warranted in young adults with cryptogenic fever and low serum protein levels, even in the absence of major gastrointestinal complaints.