Paroxysmal Autonomic Dysregulation with Fever that was Controlled by Propranolol in a Brain Neoplasm Patient

Intractable fever in cancer patients is problematic and the causes of this fever can be diverse. Paroxysmal persistent hyperthermia after sudden mental change or neurologic deficit can develop via autonomic dysregulation without infection or any other causes of fever. Paroxysmal hyperthermic autonomic dysregulation is a rare disease entity. It manifests as a form of paroxysmal hypertension, fever, tachycardia, tachypnea, pupillary dilation, agitation and extensor posturing after traumatic brain injury, hydrocephalus, brain hemorrhage or brain neoplasm. We recently experienced a case of paroxysmal hyperthermia following intracerebral hemorrhage along with brain neoplasm. Extensive fever workups failed to show an infectious or inflammatory source and/or hormonal abnormality. Empirical treatments with antibiotics, antipyretics, morphine, steroid and antiepileptic agents were also ineffective. However, Propranolol, a lipophilic beta-blocker, successfully controlled the fever and stabilized the patient. Fever in cancer patients is a common phenomenon, but a central origin should be considered when the fever is intractable. Propranolol is one of the most effective drugs for treating paroxysmal hyperthermia that is due to autonomic dysregulation.

Disautonomía: un problema médico poco conocido / Dysautonomia: a not well known medical problem

La disautonomía es una condición médica frecuente, que por lo general cursa sin ser diagnosticada y es causada de problemas crónicos y mala calidad de vida. Estos enfermos muchas veces peregrinan de mÚdico en médico, se les hacen múltiples exámenes, se plantean múltiples hipótesis, pero el diagnóstico preciso no se hace, ya que no se tiene en cuenta la disautonomía. Una vez confirmado el diagnóstico con un Tilt test, se puede tratar sintomßticamente con bastante éxito. Hemos visto que la disautonomía frecuentemente se asocia al síndrome de hiperlaxitud articular, que es una forma frustra de las alteraciones hereditarias de la fibra colágena, que es muy prevalente en Chile.

Effect of losartan on albuminuria, peripheral and autonomic neuropathy in normotensive microalbuminuric type 2 diabetics.

BACKGROUND: Angiotensin converting enzyme (ACE) inhibitors are emerging as effective agents for preventing microvascular complications of diabetes. Losartan (angiotensin II antagonist) has an antihypertensive efficacy equivalent to ACE inhibitors, however its role in microvascular complications is not yet known. MATERIAL AND METHODS: We studied the efficacy of losartan (50 mg once daily for 12 weeks) on albuminuria, peripheral and autonomic neuropathy in 25 normotensive microalbuminuric type 2 diabetics who were asymptomatic for neuropathy. RESULTS: Mean age was 46.6 +/- 4.34 years with the average duration of diabetes being 8.1 +/- 1.54 years. Albuminuria improved significantly from 54 +/- 9.35 mg/L to 32.8 +/- 25 mg/L (Paired student's t-test, P=0.0005) after therapy. Autonomic neuropathy was observed in 64% while 76% had peripheral neuropathy; but there was no improvement with losartan. The duration of diabetes had a negative correlation with autonomic neuropathy. It also had a similar negative correlation with median and common peroneal nerve motor conduction velocities (Pearson's correlation coefficient, r = -0.53, P<0.01 and r = -0.56, P<0.01 respectively) implying that autonomic and peripheral neuropathy worsen as a diabetic ages. However, no correlation existed between albuminuria and autonomic or peripheral nerve function. CONCLUSION: Autonomic and peripheral neuropathy are highly prevalent in normotensive microalbuminuric diabetic patients. Losartan remarkably improves albuminuria but a similar benefit in autonomic or peripheral neuropathy is not seen over 12 weeks. The future may see a defining role for losartan in microvascular complications in normotensive diabetics.

Síndrome neuroléptico maligno: informe de un caso / Neuroleptic malignant syndrome: a report of a case

Reportamos el caso de un hombre de 48 años de edad, con historia de parálisis cerebral infantil y epilepsia neonatal, al que se le dieron neurolépticos 48 horas antes del inicio de su padecimiento, el síndrome neuroléptico maligno, el cual se caracterizó por hipertermia, aumento del tono muscular, deshidratación, incremento progresivo de la creatinina fosfoquinasa (CPR) y azoados. El tratamiento elegido fue la fluidoterapia y la administración de fármacos dopaminérgicos, a los que reaccionó favorablemente. Esta afección ocurre como complicación del tratamiento con neurolépticos y su incidencia es del 0.2 al 0.5 por ciento, con una mortalidad aproximada del 20 por ciento, la cual depende directamente de la complicación desarrollada; la más grave es la insuficiencia renal aguda producida por mioglobinuria secundaria a rabdomiolisis.

Difunçäo autonômica primária: investigaçäo diagnóstica e tratamento de uma paciente / Primary autonomic dysfunction: diagnostic investigation and treatment of one patient

Os autores apresentam o caso e discutem passo-a-passo, a investigaçäo diagnóstica de uma paciente idosa com a queixa principal de síncope recorrente. A análise dos resultados do exame clínico, exames complementares e avaliaçäo funcional e bioquímica do sistema nervoso autônomo concluiu ser a paciente portadora de insuficiência autonômica pura, uma doença degenerativa rara dos neurônios autonômicos pós-ganglionares. A apresentaçäo do caso termina com a discussäo da conduta terapêutica e do acompanhamento durante 18 meses após o diagnóstico