Presurgical functional transcranial Doppler sonography (fTCD) with intravenous echo enhancing agent SonoVue enables determination of language lateralization in epilepsy patients with poor temporal bone windows.

Presurgical determination of language lateralization is important for planning and outcome estimation of neurosurgical interventions in patients with drug-refractory epilepsy. Functional transcranial Doppler sonography (fTCD) provides an established measure for language lateralization using the temporal bone windows for continuous recording of the cerebral blood flow velocity (CBFV) in both middle cerebral arteries (MCAs). However, because of insufficient temporal bone windows, fTCD cannot be applied properly in every patient. Here, we established stable and sufficient CBFV signals in both MCAs using continuous intravenous application of echo-enhancing agent SonoVue in 7 of 10 patients with poor temporal bone windows and were thus able to determine language lateralization. We conclude that the application of SonoVue can solve one principal disadvantage of fTCD and improves the applicability of the technique as a presurgical functional language lateralization procedure.

Hemidiaphragmatic paresis can be avoided in ultrasound-guided supraclavicular brachial plexus block.

BACKGROUND AND OBJECTIVES: Supraclavicular brachial plexus block is associated with 50% to 67% incidence of hemidiaphragmatic paresis as a result of phrenic nerve block. We examined whether ultrasound-guided compared with nerve stimulation supraclavicular brachial plexus block using 0.75% ropivacaine results in a lower incidence of hemidiaphragmatic paresis. METHODS: In a prospective randomized observer-blinded controlled trial, 60 patients scheduled for elective elbow, forearm, wrist, or hand surgery under supraclavicular brachial plexus block without sedation were included. Supraclavicular brachial plexus block was performed with 20 mL of 0.75% ropivacaine using either ultrasound or nerve stimulation guidance. Ventilatory function was assessed by ultrasound examination of hemidiaphragmatic movement and spirometry. RESULTS: None of the 30 patients in the ultrasound group showed complete or partial paresis of the hemidiaphragm (95% confidence interval, 0.00-0.14), whereas in the nerve stimulation group, 15 patients showed complete paresis of the hemidiaphragm and 1 patient showed partial paresis of the hemidiaphragm (0% versus 53%, respectively; P < 0.0001). Ventilatory function (forced expiratory volume 1, forced vital capacity, peak expiratory flow) was significantly reduced in the nerve stimulation group compared with the ultrasound-guided group (P < 0.05). Two block failures occurred in the nerve stimulation group compared with none in the ultrasound group (P = 0.49). No adverse effects occurred in either group. CONCLUSIONS: Ultrasound-guided supraclavicular brachial plexus block, using 20 mL of 0.75% ropivacaine with the described technique, is not associated with hemidiaphragmatic paresis.

[Fever, pancytopenia, and splenomegaly 8 months after a trip to Majorca Island (Spain)]. / Hohes Fieber, Panzytopenie und Splenomegalie 8 Monate nach einem Mallorca-Urlaub.

BACKGROUND: Visceral leishmaniasis is a rare imported infectious disease in Germany. Approximately ten to 30 cases are recorded annually. The classic symptoms are often misinterpreted as lymphoma of the spleen. CASE REPORT: A 46-year-old patient presented with fever, malaise, night sweats, pancytopenia, and splenomegaly 8 months after a 2-week trip to Majorca Island (Spain). Bone marrow biopsy showed no evidence of malignant lymphoma. Serology confirmed the suspected clinical diagnosis of visceral leishmaniasis. Cytology and polymerase chain reaction from bone marrow aspirate were positive for Leishmania infantum. Treatment with liposomal amphotericin B was initiated and led to complete recovery. CONCLUSION: Visceral leishmaniasis is an important differential diagnosis for the clinical triad of fever, pancytopenia, and splenomegaly. An accurate travel history is therefore of paramount importance. Without treatment, the case fatality rate is high. A complete recovery is usually achieved with adequate therapy (liposomal amphotericin B, miltefosine).

[Severe side-effects of treatment with D-penicillamine (author's transl)]. / Schwere Nebenwirkungen bei der Therapie mit D-Penicillamin

In a 53-year-old woman an acute allergic thrombocytopenia (acute Werlhf's disease) occurred after treatment with D-penicillamine for one month which led to death. In two further patients transitory platelet deficiencies were observed after six and two months which regressed completely in six months and four weeks, respectively. One of the patients had nephrotic syndrome and a retrobulbar neuritis at the same time. Both symptoms were equally transitory and could not be demonstrated five weeks after cessation of therapy. In a further case a lethal Lyell syndrome developed three weeks after therapy was started. These observations show that during D-penicillamine treatment weekly, and later fornightly, blood counts should be performed. In the occurence of thrombocytopenia, leucopenia or anaemia treatments should be stopped; Signs of drug intolerance together with exanthemata should also led to a critical review of the indications and the dosage. D-Penicillamine should not be used when hypersensitivity to penicillin exists or when cell deficiencies have occurred after anti-reheumatic medication. The development of proteinuria should also result in withdrawal of the drug. Therapy with D-penicillamine requires conscientious follow-up urinalyses and blood counts as well as attention to allergic rashes.