Rumination in a 7-year-old child

Regurgitation of food by rumination has rarely been reported in latency-age children. A 7-year-old boy had symptoms of rumination, gagging, bruxism, and enuresis. During the oppositional stage of development many unresolved conflicts had developed between the patient and his parents. Short-term psychotherapy which focused on resolution of the power struggles produced rapid remission of the symptoms. A two-year follow-up showed no recurrence of difficulty.     

Intractable vomiting due to a brainstem lesion in the absence of neurological signs or raised intracranial pressure

The case of a 30 year old man who was believed to have a gastrointestinal motility disorder causing his chronic vomiting is reported. He had been well until 21 months previously when he had developed recurrent vomiting which would occur up to 10 times in a 24 hour period. Vomiting was not precipitated by eating and was not associated with any other symptoms. He had lost 25 kg in weight. A psychiatric assessment did not reveal a psychogenic cause for his vomiting. A brainstem magnetic resonance imaging scan revealed an area of low signal in the low midbrain just above the pons to the left of the midline. After gadolinium contrast injection the area enhanced. There was little or no mass effect, that is minimal displacement of normal structures, and minimal oedema. The appearance was that of a low grade or early brainstem tumour. There were no features of haemorrhage or infarct. The patient was managed with oral dexamethasone, resulting in prompt resolution of his symptoms. A search for a central neurological cause is recommended in a patient with unexplained persistent vomiting, even in the absence of other features to suggest a neurological problem. Autonomic function testing may provide additional information.     

Cholecystitis, cholelithiasis, and ganglioneuromatosis of the gall bladder: an unusual presentation of MEN type 2b

A 40 year old man with multiple endocrine neoplasia type 2b (MEN 2b) presented with cholecystitis caused by gall stones. Twenty four years earlier, he had had a partial thyroidectomy for a cold nodule. At his initial presentation MEN 2b with medullary carcinoma of the thyroid had not been made. This was diagnosed while investigating his gall bladder symptoms and he was found to have asymptomatic residual medullary thyroid carcinoma and bilateral adrenal phaeochromocytomas. The cholecystectomy specimen contained several mixed calculi and extensive ganglioneuromatosis with large, prominent nerves containing ganglion cells in the gall bladder wall.     

The "defense" of Sigmund Freud.

Argues that Freud abandoned his seduction theory, not (as J. Masson [1984] asserted) owing to his colleagues' hostility, but because he could not accept the strong possibility that he and his siblings had been seduced as children, possibly by their father. Freud developed the Oedipus complex as an acceptable defense against such a realization; however, the defense was not completely effective, and he persisted in many of his neurotic symptoms. Freud's belief that he suffered from hysteria was most pronounced during self-analysis, which corresponded to the period during which he abandoned the seduction thesis. Eventually Freud (1931) was able to state that seduction causes neurosis, and that sexual abuse of children is not uncommon, but the seduction theory never regained the status of primary causal agent for many of the neurotic disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-control techniques as an alternative to pain medication.

A 65-yr-old retired army officer with a productive work history was admitted to a psychiatric ward with symptoms of chronic abdominal pain and social withdrawal. For several years his pain had been managed with Talwin (pentazocine), which was self-administered intramuscularly 6 times/day. The patient was taught self-control of his pain through a program of relaxation, covert imagery, and cognitive relabeling. He was then withdrawn from medication by diluting the Talwin with increasing proportions of normal saline. Follow-up showed the patient to be socially active, without medication, and more successfully controlling his pain. Results are discussed in terms of punishment, self-attribution of change, the nature of pain, and the ethical issues involved in instituting a treatment procedure without the completely informed consent of the patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A case of primary hyperparathyroidism that had been treated under a diagnosis of depression for 10 years

A 66 year old man who had been treated under a diagnosis of depression for 10 years was referred to the Kyoto Prefectural University of Medicine, Kyoto because of general fatigue and appetite loss. The patient was diagnosed as having primary hyperparathyroidism (PHPT) based on the increased parathyroid hormone (PTH) and serum calcium levels. Computed tomography revealed solitary adenoma of parathyroid gland. The resection of this solitary adenoma improved the PTH and serum calcium concentrations to normal ranges, which resulted in an improvement in his depressive state. This case suggests that ionic calcium levels contribute to the mental symptoms associated with PHPT. As PHPT is curable, the possibility of PHPT should be taken into account when patients have depressive symptoms.     

Acute poisoning with clenbuterol--a case report

In the paper we have described a case of acute, unintentional intoxication with clenbuterol, a selective beta 2-agonist. A 21-year-old bodybuilder to improve his physical fitness and to increase his muscle bulk was using clenbuterol in a dose of two tablets (20 mg) daily for a week before poisoning. On a day of acute intoxication he drank orange juice containing 48 tablets (4.8 g) of clenbuterol, which had been placed there by his friends. The patient was admitted to our clinic with tachycardia at rate 160 bpm, headache, dizziness, tremor, sweats, muscle weakness, agitation. Serum potassium concentration was 2.6 mmol/L, blood glucose level 18.7 mmol/L. All the symptoms and biochemical abnormalities disappeared after intravenous treatment with propranolol (1.0 mg) and potassium chloride (60 mmol) within five hour period. This case indicates that more attention should be paid to clenbuterol widely used as a stimulant by athletes, especially by bodybuilders.     

Successfully operated case of posterior fossa tuberculoma in childhood (author's transl)

A case of intracerebellar tuberculoma is described in which a tuberculoma was removed successfully through the administration of antituberculous agents, and a full recovery was obtained. The patient was a 3-year-old boy who had been receiving antituberculous agents for about 4 months because of acute inflammation followed by osteomyelitis of his right big toe, which was suspected to be tuberculous, and because of pulmonary tuberculosis diagnosed in a chest roentgenogram taken about 1 month after osteomyelitis was cured. While his osteomyelitis was being treated, disturbance in his gait, due to progressive spastic paraparesis, was not iced, and thereafter left cerebellar symptoms with impairment of equilibrium appeared additionally. Then, he was reffered to our clinic for further neurosurgical examination, and was admitted on November 1, 1974 after right carotid and vertebral angiography was performed via the right axillar artery, in which findings suggesting left cerebellar tumor and internal hydrocephalus were obtained. After he was admitted to our clinic, a diagnosis of tumor of the left cerebellum and internal hydrocephalus was more precisely confirmed by pneumoventriculography. Suboccipital craniectomy was then carried out and the tumor, weighing 60 gm, was completely removed from the left cerbellar hemisphere. The tumor was confirmed as tuberculoma not only by histological findings but also by the vertification of tuberculous bacilli in it. Though, moderate fever lasted for about 2 weeks postoperatively, no obvious meningitic signs or new neurological deficits were noted. The patient showed marked improvement especially in his gait disturbance, and was discharged ambulatory 40 days after the operation, and has since been asymptomatic except for slight ataxic gait. The antituberculous agents have been continuously administered postoperatively.     

HMG-CoA reductase inhibitor and risk of stroke

A 75-year-old-man who had been occupationally exposed to asbestos over several decades was admitted complaining of dry cough and mild exertional dyspnea. Chest X-ray films revealed the presence of bilateral infiltrates. An open biopsy showed the lung pathology to be desquamative interstitial pneumonitis (DIP), and detected a calcified plaque of the left parietal pleura at cost-phrenic sulcus, which on microscopic inspection demonstrated thin needle-like structures suggestive of asbestos particles. A hormonal examination showed decreased levels of tri-iodothyronine and tetraiodothyronine and an increased level of thyroid stimulating hormone. Additionally, a positive microsome test indicated autoimmune hypothyroidism. A serological study was positive for anti-nuclear antibody and direct Coombs, and showed heightened levels of IgG. The patient was placed on oral prednisolone therapy; one month later, his symptoms had subsided, and his lung function and chest x-ray findings had improved significantly. In addition, the abnormal values for autoimmune and thyroid function eventually returned to normal ranges. These findings suggest that DIP and humoral immune dysfunction were caused by asbestos exposure, and responded well to steroid treatment.     

The Maryland State Board of Dental Examiners and the chemically dependent dentist

Non-convulsive status epilepticus may present as confusion, behavioural disturbances and psychiatric conditions. We present the case of a 17-year-old man who had episodes of non-convulsive status epilepticus as his only manifestation of epilepsy which was mis-diagnosed as a psychiatric condition for over 10 years. He has had almost complete resolution of his symptoms with the introduction of carbamazepine. Non-convulsive status epilepticus is probably commoner than previously thought, and should be considered as a possible diagnosis in all patients presenting with prolonged episodes of altered consciousness even without other manifestations of epilepsy.     

Radiological evidence of involvement of dust exposure in pathogenesis of pulmonary alveolar proteinosis

A 52-year-old man was admitted because of increasing dyspnea on exersion and presence of pulmonary infiltrates. The patient had pulmonary tuberculosis at the age of 31, which resulted in volume loss and calcified foci in the upper lobe of his left lung. As a construction worker for more than 20 years, he had been exposed to inorganic dusts. Chest radiographs showed a symmetrical consolidation of infiltrates in both lungs with the exception of the left upper lobe, where no apparent infiltrates were shown. A computed tomographic scan of the chest revealed widely panlobular consolidation with the exception of the left upper lobe. A diagnosis of pulmonary alveolar proteinosis (PAP) was established by analysis of bronchoalveolar lavage fluid. Although the patient underwent segmental bronchoalveolar lavage four times under general anesthesia, he suffered frequent pulmonary infection and died two years after the onset his symptoms. Interestingly, the patient had a markedly narrowed orifice in the left upper lobe, as demonstrated by fiberoptic bronchoscopy. Chest radiographs of this lung field revealed no infiltrative shadows. These results suggest that some inhalative agent was involved in the pathogenesis of PAP in this case. In addition, significantly increased levels of KL-6 detected in both serum and bronchoalveolar lavage fluid were attributable to overproduction of KL-6 by Type II pneumocytes that had been stimulated or damaged by PAP.     

Fulminant cerebello-brainstem encephalitis with polyradiculitis following probable Epstein-Barr virus infection]

Epstein-Barr virus (EBV) infection is occasionally accompanied by acute neurological impairment. The pathogenesis of neurological manifestations with EBV infection consists of primary inflammations of EBV infection, and secondary immunologic reactions. However, their clinical course and prognosis are usually favorable. Here we report a patient with fulminant neurological involvement in association with EBV infection. The patient was a 44-year-old man. One morning he developed ataxic gait and speech following flu-like symptoms. He noticed double vision in the afternoon. He had disturbance of consciousness, bilateral ptosis with mydriasis, opthalmoplegia, facial diplegia, bulbar palsy, and weakness of muscles in extremities and respiratory system on the next day. He required mechanical ventilatory support for a month. His symptoms began to improve gradually two weeks after the onset. Two month later, neurological examinations disclosed severe cerebellar ataxia of the four extremities and ocular movement, cerebellar speech, and moderate weakness in his limbs. Moderate cerebellar ataxia and diminished deep tendon reflexes remained for 8-months. Although he had no physical manifestations of infectious mononucleosis, DNA of EBV was identified in the cerebrospinal fluid (CSF) by the polymerase chain reaction method. From these results, we diagnosed his condition as a cerebello brainstem encephalitis with polyradiculitis associated with EBV infection. The cell counts and protein content of CSF gradually normalized in the early stage of his illness, but CSF protein increased again, and had the peak of 275 mg/dl in about one month. In spite of normalized CSF cell counts, his neurological symptoms persisted. CT scan and MRI studies of the brain and the spinal cord were repeated, but demonstrated no significant abnormalities. Clinical course and CSF findings revealed that his fulminant neurological symptoms were most likely produced by the secondary immunologic reactions following the primary inflammations by EBV infection.     

Massive and progressive hepatosplenomegaly caused by disseminated nontuberculous mycobacteriosis in a patient with acquired immunodeficiency syndrome

A 28-year-old hemophilia A patient was admitted to our hospital in July, 1991 because of high fever, chronic diarrhea and anemia. The patient had been recognized as a asymptomatic carrier of human immunodeficiency virus (HIV) in 1985 and had developed Pneumocystis carinii pneumonia and had been diagnosed as acquired immunodeficiency syndrome (AIDS) in 1990. Hematologic laboratory examinations on admission revealed pancytopenia and a CD4+ cell count of 3/mm3. X-ray findings of chest and abdomen were normal and bacterial cultures of sputum, urine, blood, stool, cerebrospinal fluid and bone marrow yielded no pathogenic microorganisms. Microscopical examination of the stained specimens showed no acid-fast bacilli. On his fifth hospital day, his liver and spleen enlarged markedly and an abdominal CT scan obtained on the 13th day revealed high-grade hepatosplenomegaly. Administration of several kinds of antibiotics, antifungal agents, antiviral agents, antituberculous agents and gamma-globulin medicines did not relieve the symptoms. On the 28th day the patient had developed a subarachnoid hemorrhage and died five days later. Retrospectively all cultures for acid-fast bacilli of the specimens on his admission yielded nontuberculous mycobacteria. The bacteria were identified as Mycobacterium avium by polymerase chain reaction and his disease was eventually diagnosed as disseminated Mycobacterium avium complex (MAC) infection. The liver and spleen weighed 2,660 g and 1,840 g respectively at autopsy. Although hepatosplenomegaly is commonly recognized in AIDS patients with disseminated MAC infection, such massive and rapid enlargement has been rarely observed. This case study emphasize the importance of diagnosis and rapid treatment at the early stage of MAC infection.     

Tinnitus and ECT

We report the case of a 69-year-old man with major depressive disorder and occupational tinnitus; both problems were refractory to several different treatment modalities, but were successfully treated with electroconvulsive therapy (ECT). The tinnitus was present for 15-20 years, but had worsened during the 3 years before treatment, causing him significant distress. Extensive organic workup did not identify a treatable etiology for his symptoms. To date, he has been hospitalized four times due to depressive symptoms associated with tinnitus. He has received ECT each time, and has responded well on each occasion.     

Depressive symptoms across older spouses and the moderating effect of marital closeness.

Independent interviews with husbands and wives from 317 community-dwelling older couples showed that depressive symptoms in 1 spouse had a significant impact on depressive symptoms in the other spouse, after controlling for potentially confounding respondent sociodemographic and health status variables. Relationship quality moderated the influence, with spouse depressive symptoms contributing more of the variance to a respondent's symptoms when a couple were close than when they were not and closeness to a spouse buffering the potentially depressive effects of a respondent's own frailty and financial distress. Husband's own variables explained more of the variance in his symptoms when the couple were not close than when they were, and closeness to his wife increased a husband's vulnerability to the impact of the wife's health status. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Corneal involvement in epidermolysis bullosa simplex

A 17-year-old boy and his mother represent the first reported cases of ocular (corneal) involvement of the simplex form of epidermolysis bullosa. Both had a ring-like configuration of fine bullous lesions in the midperiphery bilaterally at the level of deep corneal epithelium superficial to Bowman's membrane (basal cell layer), with the son manifesting symptoms when some of his bullae ruptured through to the corneal epithelial surface. Nonscarring blistering was present in three generations of this family, suggestive of dominantly inherited epidermolysis bullosa simplex, and was confirmed by electron microscopy of a skin specimen from the son. Thus, ocular involvement has now been observed in all of the major types of epidermolysis bullosa.     

Functional differentiation of human naive helper T cells

Here we report a case of a 56-year-old male with post-poliomyelitis muscular atrophy (PPMA), who presented with cranial nerve signs and widespread atrophy of the extremities. He had suffered from poliomyelitis at the age of 2 years. After recovery from the acute stage, the paralysis remained in his left arm. He noticed muscle weakness of the right upper and lower extremities at the age of 45 years and the muscle atrophy progressed to his arms, hip and thigh at the age of 55 years. Neurological examination revealed muscle atrophy of the neck and disturbance of left V, VIII, IX, X and bilateral XI cranial nerves. We diagnosed this case as PPMA from his history and electromyographic and muscle biopsy findings which suggested chronic denervation. Among the 21 PPMA cases in the past in which the acute poliomyelitis had resulted in paralysis of the only one limb, ours was the only case that had muscle atrophy of all the limbs. Cranial nerve involvement is known to occur in acute poliomyelitis; therefore, there is a possibility that the involvement of the cranial nerves in our case might be a delayed progressive symptoms.     

Cerebral infarction associated with nephrotic syndrome in a young adult: a case report

We report a 19-year-old man who developed a cerebral infarction in the territory of the anterior choroidal artery and showed a hypercoagulable state and nephrotic syndrome after diarrhea and appetite loss. He had suffered from nephrotic syndrome from the age of three and had been treated for five years. MR-angiography showed an occlusion originating in the right internal carotid artery. The right anterior and middle cerebral arteries were imaged from the left internal carotid artery via the anterior communication artery. He showed symptoms of left hemiparesis, agnosia, loss of activity, anasarca and left hypacusis following his clinical course, but had recovered from all but left hemiparesis following medical treatments including steroid therapy. The histologic finding by a renal biopsy revealed focal glomerulosclerosis. In this case, we considered that when he was in a hypercoagulable state and had a second attack of nephrotic syndrome because of inflammation and dehydration due to diarrhea and appetite loss, his hypercoagulable state grew worse, and he then developed a cerebral infarction. When one see a patient with nephrotic syndrome, one should be attentive to the possibility of a complication of cerebral infarction.