Rhabdomyolysis in transplant patients

In a retrospective analysis of all our patients with seizure onset prior to age 16 years, 25 patients with primary generalized tonic (n = 10) or tonic-clonic (n = 15) seizures were identified. These patients constituted 5.7% of the total seizure patient population in our institute between the ages of 1 month and 16 years. The natural history of generalized tonic-clonic seizures is known to be benign; however, that of isolated primary generalized tonic seizures is not clear. Therefore, an attempt was made to characterize the patients suffering from primary generalized tonic seizures and determine their outcome. Analysis of our patient population shows that both seizure types are characterized by early onset of generalized seizures that appear in normally developed children with a normal electroencephalographic background. The children usually respond quickly to antiepileptic drugs. A long-term follow-up (mean period of 7.6 years) was possible in 84% of the patients, and showed that 95% of them were seizure free at the end of the follow-up period. There was no significant difference between the two groups in regard to age of onset, family history, and seizures at follow-up. In conclusion, the natural history of patients with generalized tonic seizures is similar to the benign course of those with generalized tonic-clonic seizures.     

Clinical trial of intramuscular anti-snake venom administration as a first aid measure in the field in the management of Russell's viper bite patients

Efficacy of intramuscular anti-snake venom administration immediately after bite as a first aid measure in the field followed by standard hospital management versus standard hospital management alone in the therapy of Russell's viper bite patients was studied. There was a definite reduction in the number of patients with systemic envenomation, complications following disseminated intravascular coagulation and in fatality rate of Russell's viper bite victims who had received first aid intramuscular anti-snake venom prior to hospitalization when compared with those who had not.     

Severe coagulopathy after a bite of a green bush viper (Atheris squamiger): case report and biochemical analysis of the venom

A 34 year old male bitten by an adult Atheris squamiger snake developed symptoms of nausea, vomiting, diarrhea which were followed by drowsiness and impaired breathing. Local hemorrhage, edema and pain at the bite-site occurred, but no systemic bleeding or hemorrhagic diathesis developed. All clinical and laboratory parameters were in the normal range except for afibrinogenemia, thrombocytopenia and slight proteinuria. Replacement therapy (fibrinogen and platelet concentrates) and treatment of shock stabilized the patient within 2d and coagulation returned to normal. Atheris squamiger venom was subjected to biochemical and biological analysis. The LD50 of the venom was 5 mg/kg (mice, s.c.). It produced local hemorrhage corresponding to about 25% of the activity of puff adder venom (Bitis arietans). In vitro the venom had a fibrinogen-converting activity, it did not activate purified prothrombin but very likely contained a F V and Ca2+-dependent prothrombin activator. The venom exhibited strong platelet-aggregating activity, which was not inhibited by protease inhibitors and by EDTA or EGTA. The venom also aggregated acetylsalicylic acid treated platelets indicating, that the arachidonic acid pathway was not essential for activation. Rat serum rapidly inhibited the platelet-aggregating activity of the venom; human serum, however, had only a partial inhibitory effect. Preliminary experiments showed that platelet-aggregating activity may be separated from fibrinogen-converting activity by anion-exchange chromatography.     

Rhabdomyolysis in antiretroviral therapy with Lamivudin

HISTORY AND CLINICAL FINDINGS: Six weeks after antiretroviral treatment with lamivudin (a nucleoside analogue) had been started (300 mg daily) in a 31-year-old man with AIDS developed pain and weakness in his muscles. On admission he had myalgia on pressure and movement as well as weakness of the entire body musculature, especially of the arms. The history and findings suggested bacterial or HIV-associated myositis. INVESTIGATIONS: Creatinekinase activity (4442 U/l) and myoglobin concentration (3250 micrograms/l) were greatly increased, while creatine (96 mumol/l) and C-reactive protein (22 mg/l) levels were only slightly raised. Serology was negative for acute and bacterial infections and autoimmune myositis. Magnetic resonance imaging and biopsy indicated marked rhabdomyolysis without myositis. DIAGNOSIS, TREATMENT AND COURSE: After excluding other causes, lamivudin and other drugs were discontinued, drug-induced rhabdomyolysis being suspected. This and the administration of prednisolone (100 mg daily) improved the symptoms. Creatinekinase activity and myoglobin level became normal within 14 days. On renewed administration of lamivudin creatinekinase and myoglobin concentrations in serum doubled to 180 U/l and 110 micrograms/l, respectively. Cessation of medication once again restored them to normal. CONCLUSION: Rhabdomyolysis is a serious but rare side effect of lamivudin treatment. Appropriate biochemical monitoring should therefore be undertaken when it is used in the treatment of HIV-positive patients.     

Rhabdomyolysis associated with simvastatin-gemfibrozil therapy

Simvastatin is a potent inhibitor of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase intended for use as a hypocholesterolemic agent. The long-term clinical experience with simvastatin indicates that it is a safe, effective, and well-tolerated hypolipidemic agent. Laboratory adverse events involving elevations of serum transaminase levels and serum creatine kinase (CK) levels to more than three times the upper limit of normal range have been seen in 1.5% and 3.4% of cases, respectively. We describe a case of severe myopathy and rhabdomyolysis associated with concomitant use of simvastatin and gemfibrozil. Seven days after discontinuing administration of gemfibrozil and simvastatin, the patient's condition improved and she was discharged home. Although this is the first report to indicate an association between myopathy and concomitant use of simvastatin and gemfibrozil, we strongly recommend caution and careful monitoring if simvastatin is given to patients receiving gemfibrozil.     

Rhabdomyolysis in autosomal dominant progressive external ophthalmoplegia

Multiple mtDNA deletions have been reported to be a cause of inherited recurrent myoglobinuria. We report a 57-year-old man with autosomal dominant progressive external ophthalmoplegia and multiple mtDNA deletions who developed acute rhabdomyolysis provoked by alcohol. A repeated alcohol intake resulted in a 57-fold increase in serum myoglobin. Patients with mitochondrial myopathy and multiple mtDNA deletions, regardless of associated phenotype and mode of inheritance, may develop rhabdomyolysis.     

Russell's viper venom fractions and nephrotoxicity

Apparently healthy Wistar rats of body weight 250-300 g were chosen for the experiments. A group of 6 rats were assigned for each fraction. The dose of Russell's viper venom (RVV) fraction used for in vivo experiments was 0.75 microgram/g body weight. Of each batch of 6 rats 3 were sacrificed on the third day and the remaining 3 on the fifth day after the administration of test venom fractions. Daily urine output with proteinuria and serum creatinine were determined on the day they were sacrificed. Kidneys from the rats were also examined under light microscopy after hematoxylin and eosin staining. In the in vitro experiment, kidney slices (1 mm thickness) from normal rat was incubated with RVV fractions of 5 mg/ml concentration. The predominant renal lesions observed in both sets of animal experiments were tubular degeneration and necrosis. The changes were mostly confined to proximal tubules. Glomerular changes were mild. Similar tubulotoxic effects were produced by whole RVV as well as single fractions. Therefore, it is possible that RVV contains a common nephrotoxic (protein) component which is present in all fractions of the venom. The renal damage caused by RVV seemed to be due to both systemic effects (mainly DIC and renal ischemia) and direct tubulotoxic effects of the venom.     

Horse bite injury

Bite wounds are relatively frequent, the order of frequency being, dogs, cats and humans. The clinical importance of other types of bites depends on the severity of the injury or any subsequent infection. We report on the case of a woman bitten on her thigh by a horse, producing severe haematoma, fat necrosis and muscle rupture, without an external wound. We emphasize the importance of the ultrasound examination in the evaluation of the extent of the crush injury.     

Mosquito bite hypersensitivity

Incidence of gastrointestinal tuberculosis increases in the western world. Exact epidemiological data about this rare extrapulmonological disease are not available in Hungary. Three advanced cases with intestinal tuberculosis have been reported, all of them recognised during surgery due to complications. The clinicopathological correlations are briefly reviewed, and the importance of early diagnosis is emphasized.     

Snakes and snake bite in Nepal

In this paper the author shows the basic concepts of set theory, which ones are necessary to understand biometric methods. The sets, the most important operations, the power of sets and the types of the used variables are presented.     

Rat bite fever after a bite from a tame pet rat]

A 43-year-old woman presented with a generalized febrile illness, an exanthema with mixed maculopapulous and pustulous eruptions on the lower halves of the extremities, elbows, knees, palms and soles. There was also severe arthralgia and asymmetric arthritis. The diagnosis was rat bite fever. The disease became manifest eight days after she was bitten by a pet rat. Rat bite fever can easily be missed, even after adequate anamnesis and physical examination, while the differential diagnostic considerations are numerous. Our patient was cured completely after intravenous administration of penicillin G. Antimicrobial therapy was completed by an oral course of doxycycline.     

Rhabdomyolysis and hypoxia associated with prolonged propofol infusion in children

Propofol, a new anesthetic, is now used more commonly to sedate patients in the intensive care unit. Propofol's rapid elimination has popularized its use to induce and maintain hypnosis in patients with refractory status epilepticus. It is also associated with occasional severe metabolic acidosis and hypoxia of indeterminate cause in children. We report a child and an adolescent who developed severe metabolic acidosis, progressive hypoxia, and rhabdomyolysis during maintenance infusion of propofol for the treatment of refractory status epilepticus. We suggest that propofol should not be used for prolonged sedation in children until its safety can be ensured.