Syncope-like episodes as a symptom of conversion syndrome in a 15-year-old girl

The authors present a case of a 15-years-old girl with syncope-like episodes occurring for 6 months. We found that disturbances of consciousness observed in our patient were due to conversion syndrome. Problems concerning differential diagnosis of syncope-like episodes are discussed with special emphasis on psychogenic syndromes, cardiogenic, neurogenic and metabolic causes, as well as the use of modern diagnostic techniques (e.g. video/EEG monitoring).     

Low levels of beta hexosaminidase A in healthy individuals with apparent deficiency of this enzyme

The common denominator of the different meanings of dizziness is a disturbance of spatio-postural orientation, which indicates an imminent danger of fall. H?henschwindel (fear of hights) with grasping and holding in the primate is instinctive behavior caused by a visual cliff or sudden dizziness. Because of the many possible meanings of dizziness, the case history is important for differential diagnosis. Vertiginous and non-vertiginous dizziness, black out and unsteady gait without vertigo should be distinguished. In addition, the duration and time course of the attack, releasing mechanisms and accompanying symptoms of dizziness should be explored. In recurrent dizziness without hearing loss, vestibular, vascular, cardial and epileptic disorders should be considered as well as intoxication, cerebral tumor, cerebellar hemangioblastoma, multiple sclerosis, neurosis and psychosis. Epileptic dizziness occurs not only in the prodromal stage of grand mal attacks and in temporal lobe epilepsy, but also in petit mal absences of short duration (less than 5 s) in which the blurring of consciousness is not apparent; absences of short duration are easily overlooked in childhood. Besides the objective history obtained from the patient's relatives, EEG-recording when falling asleep in the morning after one night of sleep deprivation are the best means for the diagnosis of epilepsia. Spontaneous nystagmus after complete exclusion of visual fixation is a physiological phenomenon. For differential diagnosis between physiological and pathological spontaneous nystagmus, Frenzel's spectacles in the dark room are indispensable. The distinction of spontaneous nystagmus in the narrower sense, gaze nystagmus and fixation nystagmus is discussed. The diagnostic importance of the direction of nystagmus is mentioned. Jerking nystagmus may be congenital. Pendular nystagmus may be acquired. Therefore, additional criteria for the differential diagnosis between congenital and acquired nystagmus are necessary.     

Fetal pulse oximetry. A methodogical study

Holter monitoring was obtained from 44 clinically normal dogs and 68 dogs with heart disease or being suspicious for a cardiopathy. Several employments of the holter monitoring are shown by means of some examples. This method proved to be effective in the diagnosis of syncopes and the review of the therapy of arrhythmias. Limits and difficulties are discussed.     

Investigations on the distribution of HBs antigen subtypes

The localisations of bone cysts known under the title of "intraosseous ganglion, synovial cyst of bone and solitary unicameral cyst" are summarised from the literature. Two of the authors' patients are added to the few cases of talar cysts recorded up to the present. In addition, a patient with a calcaneal cyst is described. The cysts can be traumatic or non-traumatic in origin. The various theories concerning their etiology are discussed. The clinical findings, differential diagnosis and therapy of subchondral bone cysts particularly in the region of the foot are considered.     

Repeated prenatal corticosteroids delay myelination in the ovine central nervous system

In the near future the number of patients suffering from cognitive impairment and senile dementia will increase because of the change in the structure of population. General practitioners and specialists will be confronted with this problem. The early and differential diagnosis of senile dementia is still a problem. Corresponding with the diagnostic algorithms of ICD 10 and DSM IV the diagnostic procedure is discussed with geriatric, neuro/psychiatric, psychological and psychosocial aspects. The diagnosis also relies on history obtained from family and friends. Although cognitive loss is considered a core symptom of senile dementia, loss of behavioral disinhibition, loss of functional autonomy and mood problems are considered as more important by clinicians and family and are of great diagnostic value. Psychometric tests are important but they are only one out of many different possibilities to find the right diagnosis. If it is possible different specialists should examine the patient. Out of the different methods and views of the specialists a comprehensive image of the patient takes shape and allows a better understanding of dementia.     

Syncope. A neurologist's viewpoint

Syncope is caused by a global reversible reduction of blood flow to the brain. Three hemodynamic abnormalities can cause syncope: (1) a fall in systemic blood pressure because of ineffective control of peripheral vascular resistance, (2) an acute decrease in cardiac output, and (3) an acute increase in cerebrovascular resistance. Complicating the differential diagnosis of syncope are other causes of loss of consciousness, such as seizures, metabolic disorders, and psychiatric disorders, which may simulate syncope.     

Hearing loss. The physician's responsibility

Hearing loss is a very important and common problem in the United States, affecting 13 to 14 million people. It is primarily a medical problem, requiring diagnosis and, when indicated, treatment by a physician, preferably in collaboration with an audiologist. History taking is the most important part of the diagnostic process, followed by a physical examination with special attention to the head, neck, and ears. The primary object of the workup is to exclude all possible extrinsic causes of hearing loss. Intrinsic or genetic deafness is a diagnosis of exclusion. After the hearing loss has been classified as congenital or delayed and as genetic or nongenetic, a differential or working diagnosis can be made in all cases and a specific diagnosis in most cases. The hearing loss must then be identified as stable, progressive, or fluctuant over time. Follow-up at least every two years is important to check for possible changes in status.     

Immunohistochemical localization of UDP-glucuronosyltransferases in rat brain during early development

OBJECTIVE: Benign tumors account for less than 1% of testicular tumors and the incidence is even lower in children. A rare case of epidermoid cyst of the testis in a child is described. The differential diagnosis and treatment options are discussed. METHODS/RESULTS: A case of unilateral epidermoid cyst of the testis in an 11-year-old boy is presented. The clinical and diagnostic aspects are discussed. Definitive diagnosis could be made only after surgical excision. CONCLUSIONS: Pathological analysis of the entire testis is warranted to make the definitive diagnosis of epidermoid cyst. However, preservation of the testis can be considered, particularly in those cases with bilateral involvement, if supported by solid, consistent diagnostic evidence, including intraoperative biopsy.     

Epidural hematoma with atypical clinical course

The prognosis of epidural haematomas (EDH) is generally favourable if an operation is carried out in good time. Suspected EDH is mostly diagnosed as a result of a "typical" neurological manifestation (initial unconsciousness/asymptomatic interval/loss of consciousness), which then leads to an in-depth diagnosis (X-ray of the skull, CT, MRI). However, atypical clinical manifestations are frequent and can result in dangerous delays in diagnosis and treatment. A decisive factor in the early detection of EDH is close clinical-neurological monitoring by specially trained staff and their prompt reaction when changes occur, no matter how minor. Qualitative changes in the patient's state of consciousness and behaviour are just as important in this respect as quantitative ones.     

Traumatic thenar ischemia

A case of posttraumatic digital ischemia involving the thenar portion of the hand is presented and the differential diagnosis of hand ischemia is discussed. The importance of obtaining an occupational history for assessment of possible hand trauma is emphasized. Angiography can confirm the diagnosis of posttraumatic arterial injury and will localize thrombosis or aneurysms for possible surgical repair.     

The head-up tilt test with nitroglycerin provocation in the diagnosis of vasovagal syncope

The study compares the diagnostical values of "head-up tilt" tests both with or without nitroglycerin the provocation. On the basis of the comparison of a group of 60 patients and 20 healthy people we can state that the "head-up tilt" test with the provocation by nitroglycerin is appropriate for the statement of diagnosis of the cardioinhibitory type of vasovagal syncopes. (Tab. 4, Ref. 14.)     

Reversible changes of motor cortical outputs following immobilization of the upper limb

Dopa-responsive dystonia (DRD) is no longer a rare oddity. For the clinician, DRD poses a diagnostic challenge as its clinical presentation can be quite diverse. Marked and sustained response to L-dopa is the most crucial and absolute hallmark in confirming a diagnosis. Absence of degenerative nigral cell loss underlies the remarkable L-dopa response. The broadening spectrum of the clinical presentations, progress in molecular genetics with evidence of incomplete penetrance and phenotypic variability, biochemistry, utility of nuclear imaging in differential diagnosis, and treatment are discussed. I propose the concept of DRD as a syndrome, defined as selective nigrostriatal dopamine deficiency caused by genetic defects in dopamine synthesis without degenerative cell loss. I further propose the term DRD-plus, defined as inherited metabolic disorders which have symptomatic features of DRD, and those features not seen in DRD as well.     

The diagnosis of IgD-Myelomatosis (author's transl)

Two patients with IgD-lambda myelomatosis are presented and the differential diagnosis is discussed. Typical features of this disease are the high incidence of Bence-Jones proteinuria, osteolytic lesions, amyloidosis and the predominance of male patients. Furthermore, an augmentation of serum IgD level to 165 mg% was observed in a 22-year-old female patient with presumed Coxsackie myocarditis. The theories in regard to IgD function are discussed.     

Tilt test in the etiological diagnosis of syncope unexplained by electrophysiological study

In order to determine the role of tilt testing in the aetiological diagnosis of syncope unexplained by electrophysiological investigation, the authors retrospectively studied the results of this test in 275 patients with a mean age of 64 +/- 16 years. These 275 patients were divided into two groups: group I: 43 patients with a mean age of 50 +/- 19 years presenting with vagal syncopes, group II: 232 patients with unexplained syncope, probably vagal: group IIa (120 patients, mean age: 67 +/- 15 years), sudden syncope: group IIb (112 patients, mean age: 67 +/- 13 years). The electrophysiological investigation was inconclusive in every case. In group II, 50% of tilt tests were positive (19% under basal conditions, 31% after isoproterenol), with 61% of positive tests in group IIa, including 31% on the basal test, and 38% of positive tests in group IIb, including 11% on the basal test. In group I, 84% of tests were positive (33% on the basal test, 51% after isoproterenol), indicating a sensitivity of the test of 84%. In 96 patients with a doubtful electrophysiological investigation, the tilt test was positive in 70% of cases, allowing specific treatment or a pacemaker to be avoided in the majority of cases. 84% of vasovagal syncopes were therefore confirmed by tilt testing; 50% of syncopes unexplained by electrophysiological investigation were demonstrated to be of vasovagal origin. The author emphasize the value of tilt testing in certain discordant situations in which the clinical context is disturbing and/or electrophysiological investigation is not completely reassuring.     

Clinical judgement and decision making in practice. A patient with hemoptysis

A 43-year-old man was admitted because of severe and recurring haemoptysis, which was eventually ascribed to Goodpasture's syndrome. In case of an aspecific sign such as haemoptysis experienced clinicians will try to restrict the differential diagnosis by concentrating on other signs that are relevant to the main problem. In haemoptysis these other signs are general illness, fever, shortness of breath, painful respiration, chronic productive cough, and signs or a history of cardiac or pulmonary disease. If the differential diagnosis consists mainly of rare disorders or rare manifestations of common disorders, all possibilities should be considered. If Goodpasture's syndrome is suspected, further specific diagnostic tests should be done without delay.     

Disorders of adult personality and behaviour (F6). Results from the ICD-10 field trial of the Diagnostic Criteria for Research in German-speaking countries

Immune-mediated inner ear disease, first described by McCabe in 1979, typically presents with an idiopathic, rapidly progressive bilateral sensorineural hearing loss. The course of the hearing loss occurs over weeks to months. It may occur in both sexes and at a variety of ages, but is most common in middle-aged females. It may be accompanied by tinnitus, Meniere's-like vertigo, or more commonly, ataxia or unsteadiness. Approximately 30% of patients will have associated systemic immune-mediated disease. Although refinements in laboratory tests for specific inner ear antigens are being made, and non-specific laboratory indicators of inflammatory or systemic immune disease may be useful in confirming the diagnosis, the most important diagnostic finding is the improvement in hearing seen with a trial of immunosuppressants. This report includes a typical evaluation of the patient with suspected immune-mediated inner ear disease and an illustrative case. Sensorineural hearing loss due to immune-mediated inner ear disease, although unusual as a cause of hearing loss, is important to recognize because early diagnosis and treatment can have a marked effect on the clinical outcome.     

Vitreous loss following infantile cataract surgery

An improved understanding of the role of the vitreous in ocular pathology has led to a more rational approach to the prevention and management of vitreous loss during infantile cataract extractions. Infantile cataract surgery, properly performed by modifications of the Scheie aspiration and Kelman phacoemulsification techniques, should be associated with an incidence of vitreous loss no greater than that for adult extractions by current intracapsular or extracapsular techniques. Preexisting ocular lesions, faulty technique, and an inexperienced operator all contribute to the occurrence of vitreous loss. Improved techniques, surgical expertise, and an understanding of the factors that predispose to vitreous loss can reduce its incidence. Proper management of vitreous loss will decrease or eliminate its untoward sequelae; eyes so managed can be visually rehabilitated with the same ease or difficulty as similar eyes in which vitreous was not lost. The authors do not, however, advocate either the accidental or intentional disturbance of the intact vitreous body.     

Subcutaneous suturing of the ruptured Achilles tendon under local anaesthesia

Debate concerning the appropriate treatment of ruptures of the Achilles tendon still continues. Conservative treatment can be associated with a high incidence of re-rupture and with relative weakness and lengthening of the triceps surae but with low costs. Surgical treatment contributes to a much lower incidence of re-rupture but can be associated with significant complications as well as with time loss and high costs of hospitalization. Subcutaneous reconstruction combines the advantages of surgical and non-surgical management. Operating with local anaesthesia reduces hospitalization time and operative costs; there are also almost no contraindications for the operation. The functional results in 36 patients operated on in this way are encouraging.     

Effect of compounds with antibacterial activities in human milk on respiratory syncytial virus and cytomegalovirus in vitro

In differential diagnosis of a delir also adverse effects of medicaments have to be taken into account beside other causes. We report a case of an agitated delir with nocturnal disturbance of consciousness, confusion, restlessness and sleeplessness. This delir existed exclusively during the therapy of a cutaneous herpes zoster with zovirax-pills which can only be explained by a causal connection--after exclusion of other causes. As a so far undescribed predisposition for neurotoxicity of oral therapy with acyclovir signs of vascular encephalopathy were found in the patient's cranial magnetic resonance imaging. The central nervous side effects of acyclovir were summarized shortly.     

The assessment of light intensity preference in psychiatric patients: a questionnaire

PROBLEM: Psoas abscesses are really rare so that the diagnostic onset is commonly very late. The differential diagnosis to other retroperitoneal processes is therefore important. METHOD: In a period of observation of 6 years 21 patient were treated with psoas abscesses. The evaluation of 16 records was done retrospectively under consideration of etiology, history, clinical examination, lab results and x-ray/CT/MRI etc. RESULTS: With the knowledge of the anatomy of the ilio-psoas muscle the clinical examination gives us important information about the diagnosis of psoas abscess. The history and the clinical examination precede the further diagnostics and are condition for high rates of sensitivity and specificity. Lab results indicate an absedation without being specific. The exclusive position of radiological diagnostics is undisputed. Ultrasound, x-ray and leucocyte marked bonescan are proven to be helpful in cases of unknown location of the abscesses. Method of choice seems to be the contrast enhanced CT-scan. The differential diagnosis includes gastrointestinal or renal disorders as well as pathology of bone or joints. In our cases differential diagnosis was complicated since the diagnostic onset was delayed and the initial therapy was not adequate. The diagnosis "abscess of the psoas" does not imply a general regime for therapy therefore an individual treatment in consideration of percutaneous and operative drainage has to be recommended. In selected cases a combination therapy is advised. CONCLUSION: In every case of retroperitoneal symptoms the differential diagnosis of an abscess of the psoas has to be regarded. The diagnosis is subtil and requires clinical and laboratory examinations as well as contrast enhanced computerscan. The therapy follows operative measures. The technique has to be individually decided.