A resistant case of spontaneous intracranial hypotension.

The case of a 39-year-old with intractable spontaneous intracranial hypotension (SIH) is presented. He developed bilateral and symptomatic subdural hygromas that were drained in response to clinical deterioration, but proved ineffective. An initial MRI of the lumbar region suggested a lumbosacral CSF leak, but he failed to respond to local blood patching. Subsequent CT myelography revealed a thoracic dural leak and a second directed blood patch proved effective. The aetiology, pitfalls and management of SIH are summarized.

Walking performance and its recovery in chronic stroke in relation to extent of lesion overlap with the descending motor tract.

We investigated the association between the degree of lesion overlap with the corticospinal tract and walking performance before and after 4-weeks of partial body weight support (PBWS) treadmill training in 18 individuals (ten male, eight female) with a mean age 59 +/- 13 years (mean +/- SD), range 32-74 years, who were ambulant and 6 months from a subcortical ischaemic stroke. Lesion volumes were manually defined on high resolution T1-weighted 3T-MRI scans and a probabilistic map of the corticospinal tract created using diffusion tensor imaging data collected previously in healthy subjects. The percentage overlap between the lesion and the corticospinal tract was calculated for each patient. Walking performance was determined by measures of 10 m speed, spatiotemporal parameters, percentage recovery of centre of mass (CoM), walking symmetry and 2-min endurance walk prior to and following 4 weeks of treadmill training with PBWS that emphasised normal fast walking. Lesion overlap measures weakly correlated with walking performance measures. Spatiotemporal and performance measures changed in response to training, but spatial symmetry and mechanical energy recovery did not. Walking speed at entry to the study predicted change in response to training of 10 m walk time and swing time asymmetry. Age and lesion overlap did not add to prediction of outcome models. The extent of lesion overlap with the corticospinal tract was not strongly associated with either walking performance or response to gait retraining, despite the correlation of these parameters with upper limb recovery.

Ising model of polarity formation in molecular crystals: from the growth model to the asymptotic equilibrium state.

We analyze a layer-by-layer growth model of crystals consisting of dipolar molecules with two directional states. The model is characterized by the assumption of thermal equilibrium formation of new adlayers, whereas previous layers are treated as being "frozen" in the state in which they were formed. Longitudinal and transverse Ising-type nearest neighbor interactions are taken into account. Under such assumptions, bulk polarization is known to arise. We mainly consider asymptotic one- and two-layer statistics after many steps of growth; we have obtained a theorem relating this statistics to thermal equilibrium of an appropriate two-layer system. Local polarization patterns resembling those of ferromagnetism and antiferromagnetism emerge, depending on signs and magnitudes of the coupling constants. We have explored such effects by means of simulations, by a mean field approximation, and by a Bethe-Peierls analysis.

Late onset heterozygous ornithine transcarbamylase deficiency mimicking complex partial status epilepticus.

A 57 year old woman with post-traumatic complex partial seizures was admitted because of recurrent episodes of altered mental state over the preceding 4 years, each lasting up to 5 days. There was a history of dietary protein intolerance since childhood and two of her daughters had died in the neonatal period from unexplained encephalopathies. In hospital she developed fluctuating confusion, amnesia, and sudden episodes of unresponsiveness. An EEG was consistent with complex partial status epilepticus but there was no response to benzodiazepines. Nasogastric feeding and sodium valproate were given and shortly afterwards she lapsed into a deep coma. Blood ammonia and urinary orotate were raised, and genetic testing confirmed that she was a carrier of a mutation in exon 3 of the ornithine transcarbamylase gene (C to T at position 92). Treatment with protein restriction, carnitine, and sodium phenylbutyrate led to a full recovery over a period of 3 months. To our knowledge this is the oldest age of onset yet described in a manifesting carrier. She is the fifth patient with heterozygous ornithine transcarbamylase deficiency reported to have had a severe reaction to sodium valproate. Hyperammonaemic encephalopathy should be considered in patients of any age who experience fluctuating confusion.

Gabaculine does not inhibit cytokinin-stimulated biosynthesis of chlorophyll in Pinus nigra seedlings in the dark.

Chlorophyll (Chl) accumulation was monitored during black pine (Pinus nigra L.) seed germination for 14 days in the light and in the dark in the presence of gabaculine (GAB) and cytokinin in order to elucidate the regulation of gymnosperm seedling greening in the dark, primarily at the level of aminolevulinic acid formation. In the light, GAB inhibited chlorophyll accumulation in a manner dependent on concentration and developmental stage, and in the dark it showed no effect. Cytokinin, 10(-5) M benzyl adenine (BA) partly overcame GAB-induced inhibition in the light, mainly during earlier developmental stages. In the seedlings grown in the dark, an equal quantity of Chl accumulated in the presence of cytokinin with and without GAB and it was approximately 20-40% higher than in the control seedlings or in the seedlings grown only in the presence of GAB. 5-Amino-levulinic acid (ALA) synthesis was equal in the light and in the dark in seedlings of the same age and seedlings treated with GAB grown in the dark. In the light, GAB inhibited ALA synthetic activity. The results indicate that ALA synthesis is not a rate-limiting step within Chl biosynthesis in pine seedlings grown in the dark.

Aggressive behaviour at a residential epilepsy centre.

There is an extensive literature on epilepsy and violence, but no study has addressed aggression (i.e. apparently intentional violence) in a residential-care population. We performed a retrospective study at the Chalfont Centre for Epilepsy (a residential-care facility in rural Buckinghamshire) in order to determine the frequency and character of episodes of aggression. This allowed us to identify a group of aggressive subjects who were compared with age- and sex-matched control subjects drawn from the remaining residents. We found the prevalence of aggression to be 27.2% in 1 year amongst long-term residents. The overall frequency was estimated at between 121 and 207 incidents per 100 persons per year. A few incidents (0.7%) were related to an acute psychosis but they were more likely to result in significant injury. Offenders were younger than non-aggressive residents. Gender, age of onset of epilepsy, history of psychosis, mobility, abnormality on MRI scan, learning disability and seizure frequency were not associated with aggressive conduct.

[Reactivation of herpes zoster infection by varicella-zoster virus]. / Reaktivacija herpes zoster infekcije varicela-zoster virusom.

HISTORY: There has been considerable interest in varicella-zoster virus in the middle of the twentieth century. Virus isolation in 1958 had made it possible to find out the complete DNA sequence of the varicella-zoster virus. Molecular identify of the causative agents of varicella and shingles had been proved. ETIOPATHOGENESIS AND HISTOPATHOLOGY: Varicella-zoster virus is a member of the Herpesviridae family. After primary infection which results in varicella, the virus becomes latent in the cerebral or posterior root ganglia. Some of these individuals develop shingles after several decades because of virus reactivation. It is caused by decline of cellular immune response. Circumstances such as old age, hard work, using of steroids or malignancies contribute to the appearance of shingles. Histopathological findings include degenerative changes of epithelial cells such as ballooning, multinucleated giant cells and eosinophilic intranuclear inclusions. EPIDEMIOLOGY: Shingles occur sporadically, mainly among the elderly who have had varicella. There is no seasonal appearance of shingles. Individuals suffering from shingles may be sometimes contagious for susceptible children because of enormous amount of virus particles in vesicle fluid. CLINICAL FEATURES: Clinically, shingles is characterized at first by pain or discomfort in involved dermatome, usually without constitutional symptoms. Local edema and erythema appear before developing of rash. Maculopapular and vesicular rash evolves into crusts. The most commonly involved ganglia are: lumbar, thoracic, sacral posterior root ganglia, then geniculate ganglion of the VIIth cranial nerve and the trigeminal ganglion. The most common complication, postherpetic neuralgia, may last for as long as two or three weeks, sometimes even one year or more. Other complications that may be seen in shingles, but more rarely, are ocular (keratitis, iridocyclitis, secondary glaucoma, loss of sight), neurological (various motor neuropathies, encephalitis, Guillain-Barre syndrome), secondary bacterial infection of vesicles. Immunocompromised patients often develop more severe disease lasting up to two weeks, skin lesions are more numerous and often with hemorrhagic base and there is a high possibility for cutaneous dissemination and visceral involvement including viral pneumonia, encephalitis and hepatitis. Chronic shingles may also be found in immunocompromised hosts, particularly in those with a diagnosis of HIV infection. In patients with HIV infection, shingles is often characterised by radicular pain and itching several days before appearance of skin lesions. Those patients may have two or more dermatomes involved and recurrences of shingles cannot be quite infrequent in those patients. But visceral involvement is rarer than in other immunocompromised patients. Shingles may occur in the second half of pregnancy and usually have a mild course. However, congenital abnormalities has been described in few cases. DIAGNOSIS: The diagnosis of shingles is usually made by history and physical examination. Exceptionally, for example in zoster sine herpete and atypical forms of shingles, virus isolation and serological tests must be used. DIFFERENTIAL DIAGNOSIS: Some other diseases may cause similar skin lesions and rash (varicella, erysipelas, impetigo, enteroviral infections, herpes simplex infections). These diseases are excluded by using detailed history taking and physical examination, laboratory findings, virus isolation and commercially available serological tests. THERAPY: The vast majority of immunocompetent persons with shingles should be treated only by symptomatic therapy. Predominantly it is directed toward reduction of fever and avoiding secondary bacterial skin infection in immunocompetent hosts. Acute neuritis and post-herpetic neuralgia require administration of various analgesics, even like amitriptyline hydrochloride and fluphenazine hydrochloride. Acyclovir therapy is limited to ophthal

[Agranulocytosis as a complication of acute infectious mononucleosis]. / Agranulocitoza kao komplikacija akutne infektivne mononukleoze.

INTRODUCTION: Acute infections mononucleosis is the most common clinical manifestation of primary Epstein-Barr virus (EBV) infection occurring during adolescence. It is a benign lymphoproliferative, usually self-limiting disease. Complications are relatively rare, but they may occur, especially hematological. Most common are autoimmune hematolytic anemia and thrombocytopenia, and they respond to corticoid therapy. Deuteration of white blood cells is rather rare, whereas mild neutropenia is a normal finding during the course of acute disease. On the other hand, agranulocytosis is extremely rate, and almost every case has been reported in the literature. Filgrastim--the recombinant human granulocyte colony-stimulating factor (G-CSF) stimulates the activation, proliferation and maturation of progenitor granulocyte cells. This drug is usually applied in treatment of iatrogenic neutropenia, during chemotherapy of malignancies and in some idiopathic and cyclic neutopenias. CASE REPORT: A female patient, 18 years of age, has been hospitalized at the Clinic of Infectious Diseases in Novi Sad on two occasions. First because of severe acute infectious mononucleosis with acute hepatitis and jaundice 10 days after onset of symptoms. Physical examination revealed severe intoxication, dehydration, icteric skin, mucosis and massive hepatosplenomegaly. The diagnosis was confirmed by ELISA IgM, EBV VCA positive and ELISA IgG EBV VCA and IgG EBVNA negative results. The patient was discharged from hospital after 24 days without complaints and with normal physical and laboratory findings. For several days she felt well, but gradually severe fatigue and malaise occurred and she became febrile again. That was the reason why she was hospitalized again, two weeks later. This time she was febrile, extremely intoxicated with general lymphadenopathy, catarrhal gingivostomatitis and massive splenomegaly. The first laboratory findings showed severe neutropenia (absolute count of granulocytes was 0.156 x 10/l, with only 12% segmented neutrophils). Mild anemia--3.05 x 10/l was also registered, while the platelet count was normal. Other biochemical analyses were normal, the Coombs' test negative, while the serological response was also normal. Bone marrow puncture was performed and normocellular bone marrow was registered, somewhere hypercellular due to hyperplasia of granulocyte progenitor cells from promyelocytes to normal maturated cells. Anemia showed megaloblastoid proliferation, while megakaryocytes were normal. High doses of corticosteroids were applied (dexamethasone 160 mg daily) and filgrastim 5 micrograms every other day. From the very beginning of therapy the patient felt better, whereas granulocytes responded with elevation as soon as 48 hours after initiation of therapy. On the sixth day the treatment was stopped because the level of granulocytes was normal and the patient has completely recovered. She was discharged from hospital 4 weeks later with mild meteorism, but normal physical and laboratory findings and mild splenomegaly registered only by ultrasonography. DISCUSSION: During the last 10 years only several cases of severe leukopenia with acute infectious mononucleosis had been reported in literature. In all cases it was associated with some other hematological complications and it occurred in young adults without previously registered immunodeficiency. We have no knowledge about application of filgrastim in treatment of EBV-induced agranulocytosis, but the International Association for Studying Agranulocytosis and Aplastic Anemia reported that in 4% of patients Epstein-Barr virus can cause agranulocytosis even a year after the occurrence of acute disease.

[Chlorophyll synthesis in cotyledons after gamma ray irradiation of black pine seeds]. / Sinteza hlorofila u kotiledonima crnog bora posle gama zracenja semena.

The radiosensitivity of the greening system of Pinus nigra Arn. cotyledons has been studied in this paper. An exponential relation exists between the effect and dose for chlorophyll synthesis in the dark. Chlorophyll synthesis in the light roughly parallels that of chlorophyll synthesis in the dark. The restoration of chlorophyll was observed both in the light and in the dark. A stimulative effect of low doses of gamma radiation on chlorophyll synthesis was noticed. The radiosensitivity of chlorophyll a and chlorophyll b synthesis varied with the experimental conditions, suggesting that chlorophyll b synthesis might occur independently of chlorophyll a synthesis.

[The role of Epstein-Barr viruses as etiologic agents in the mononucleosis syndrome]. / Uloga Epstein-Barrovog virusa kao etioloskog cinioca u mononukleoznom sindromu.

Mononucleosis syndrome represents a number of symptoms with different etiology and pathogenicity with similar clinical features. The aim of the study was to investigate etiologic structure of mononucleosis syndrome, effects of etiologic factors and age on the severity of clinical features, clinical forms of the disease, complications and the outcome. The investigation was conducted in 46 patients treated at the Clinic who had been diagnosed as having mononucleosis syndrome. EBV-IM was confirmed in 43%, adenoviral IM in 13%, while in 44% of the patients etiology of the disease was not established. In both groups more severe forms were present in patients over 16 years of age, but more frequently in EBV-IM than in other patients with mononucleosis syndrome (40% vs 19.23%). Complications in the form of acute hepatitis were found only in patients with EBV-IM in 20% of the cases, mean age 17 years. We are of the opinion that EBV is a significant etiologic agent in mononucleosis syndrome, that the disease is more severe in older patients who also develop complications. The outcome for all the patients was favorable.

[Abdominal typhus today]. / Trbusni tifus danas.

Abdominal typhus is all the rearer disease among acute infectious diseases in Vojvodina. In the last ten years (1981-1990) 16 patients with abdominal typhus were treated at the Department of Infectious Diseases in Novi Sad, mostly young individuals from 6 to 30 years of age (13 patients). Positive epidemiologic features were found in 13 patients. In 80% of the cases the source of infection was outside Vojvodina. They usually were admitted at the Department on the first and second week of the disease (11 patients), and 3 patients were admitted on the third week. None of the patients was suspected of having abdominal typhus at the time of admittance. Delayed hospitalization and unrecognized abdominal typhus were most likely due to the atypical onset and course of the disease. Atypical features in the clinical picture occurred in all the patients with a sudden onset of the disease. The abrupt temperature elevation in 50% of the patients was followed by shivering, fever and shaking. Hepatosplenomegaly was found in 12 patients, abdominal meteorism in 10, typical typhus tongue in none. Typhus state was not found in any of the patients. Normal leucocyte count was found in 7 patients, positive Widal's agglutination reaction in 13, coproculture in 8 and hemoculture in 15 patients. The atypical clinical picture was the result of early administration of broad-spectrum antibiotics before the established etiology of the febrile state.

[Pneumococcal meningitis from 1974 to 1984]. / Meningitis pneumococcica u periodu 1974-1984. godine.

We examined a group of 22 patients presented with the acute infective meningeal syndrome. Lumbar punction confirmed diagnosed purulent meningitis--meningoencephalitis, and bacteriologic liquor culture identified Streptococcus pneumoniae as a cause of the disease. Patients were mostly aged over 30. Clinical picture revealed signs of general infection and the meningeal syndrome. The severity of the disease was assessed on the basis of apparent signs of general infection, state of consciousness and endotoxic shock symptoms. Severe consciousness disorders were present in 16 (72.72%) patients. In our patients possible pneumococcus infection foci were: sinusitis, otitis media, pneumonia, mastoiditis and adnexitis. Lethal outcome occurred in 5 (22.72%) patients. In the therapy we used penicillin, chloramphenicol and ampicillin along with corticosteroid administration.

[Typhoid fever--case report]. / Tifusna groznica--prikaz slucaja.

The paper describes a case treated at the Department of Infective Diseases in Novi Sad admitted during the remittance of typhoid fever. The course of the disease was atypical. Epidemiological and clinical features resembled those found in malaria but laboratory findings gave the true diagnosis. We found the case interesting because the diseased patient moved around a lot, making contacts with many people. Fortunately, contact diseases never happened to occur.

The life-saving effect of physostigmine in haemorrhagic shock.

The intravenous injection of physostigmine (70 micrograms kg-1) produces a life-saving effect in acute haemorrhagic shock in non-anaesthetized rabbits. This effect is most probably due to a transfer of tissue fluids into circulation. The crucial beneficial effect of physostigmine might be a decrease of the capillary hydrostatic pressure due to changes in pre- to postcapillary resistance ratio. Both lines of defence comprise a normalization of blood pressure and normalization of blood volume, thus saving the life of the animal.

Erythropoietin level and macrocytosis in patients with chronic pulmonary insufficiency.

In 30 patients with respiratory insufficiency due to chronic obstructive pulmonary disease and with normal red blood cell counts, the effect of hypoxia on erythropoiesis was studied. Pronounced hypoxaemia was ascertained in all the patients by measuring PaO2. The calculated HbO2 saturation was less than 85% in group I and greater than 85% in group II, each consisting of 15 patients. Although the RBC counts and Hb concentration were within the limits of normal values, the packed RBC volume was higher than 45% in all the patients tested. The calculated MCV was increased and the erythropoietin level in plasma, indirectly measured in polycythaemic mouse bioassay, was higher than normal. Macrocytosis was shown to be PaO2-dependent and should be, according to Stohlman's data, the result of erythropoietin excess and the subsequent cessation of nucleic acid synthesis with skipped terminal division of erythroblasts in the bone marrow. The absence of erythrocytosis in these patients could be explained by a shortened survival time of macrocytes and/or other causes.