[Dysphagia as first symptom of myasthenia gravis]. / Dysfagi som debutsymptom ved myasthenia gravis.

We present a case story of a 70-year-old female, who went through several examinations, multiple paraclinical investigations and lost 15 kg in bodyweight over a six month period, before the diagnosis myasthenia gravis (MG) was made. Dysphagia was from the early phase her most prominent and persistent complaint. However, other symptoms, thought to be allergic reactions, made the diagnosis difficult. The patient's symptoms are discussed. Most of these are consistent with MG, but on the other hand rare at the beginning of the disease. This report is a reminder that MG may present as dysphagia, addressed in particular to otolaryngologists and gastrosurgeons.

[Paraneoplastic opsoclonus]. / Paraneoplastisk opsoklonus.

Opsoclonus occurs in a number of clinical settings, but its association with carcinomas in adult patients is rare. We present a case of paraneoplastic opsoclonus in a 63 year-old male who had a small-cell lung cancer. Even though paraneoplastic opsoclonus may be associated with an immunological response, there was no elevation of blood parameters associated with inflammation. The patient was treated with prednisolon without any clinical effect, and died only a few months after opsoclonus was diagnosed.

[Treatment of patients with lumbar disc prolapse with ibuprofen. A controlled clinical trial]. / Behandling af patienter med lumbal discusprolaps med ibuprofen. En klinisk kontrolleret undersøgelse.

The justification of employing the anti-inflammatory agent, ibuprofen, in the conservative treatment of lumbar disc prolapse was investigated. Forty-two patients admitted with clinical symptoms compatible with lumbar disc prolapse participated in the investigation. They were allotted double blindly at random to treatment with a placebo or ibuprofen as a supplement to the conservative treatment consisting of rest in bed, traction and mild analgesics. The analgesic effect of treatment in the two groups was assessed with the aid of a visual analogue scale and also the amounts of supplementary analgesics necessary. No significant difference in the pain experienced or employment of supplementary analgesics in the two groups could be registered. This investigation has thus not demonstrated further analgesic effect of ibuprofen administered as a supplement to the conservative treatment otherwise employed for lumbar disc prolapse.

[Chronic subdural hematoma. A frequently suspected diagnosis]. / Kronisk subduralt haematom. En hyppigt mistaenkt diagnose.

A retrospective investigation was undertaken in which the clinical picture in 43 patients in whom chronic subdural haematoma (CSH) was diagnosed during a period of 11 years in a large central hospital were compared with the clinical picture in 97 patients referred for neurological assessment on account of suspected CSH during a period of three years. Thirteen out of the 97 patients referred with suspected CSH had the disease. All of the patients with CSH had focal neurological symptoms or complained of headache. None presented only mental symptoms and/or impaired consciousness. On this basis, the diagnosis could have been repudiated in 30% of the patients referred who presented neither focal neurological symptoms nor complained of headache. Information about previous head-injury was not found to be of any significant value for the diagnosis. Probably, no or only few cases of CHS are overlooked.

Epilepsy in the elderly: life expectancy and causes of death.

All patients over the age of 60 who experienced seizures between 1979-83, were registered. The number of deaths was registered until July 2, 1985. Included were 162 patients who received no anti-epileptic drugs prior to the study period; 87 patients had established epilepsy at the time of admission. The number of deaths among previously untreated patients significantly exceeded expectation. Mortality was not significantly correlated to severity of epilepsy. In patients with brain tumor all but one died within the first year. Mortality among patients with postapoplectic seizures was significantly higher than expected being especially during the first year. Numbers of deaths among patients with seizures of unknown cause did not differ from the expected, neither did causes of death. Numbers of deaths in patients with established epilepsy at the time of admission was significantly higher than expected although none had malignant tumours and only 4 had postapoplectic seizures thus illustrating the influence of selecting patients with chronic active epilepsy. Eleven patients died suddenly and unexpectedly of unknown cause, which was more than expected. These patients were found dead under circumstances compatible with death occurring during seizure. Epilepsy was mentioned on the death certificate in only one case, indicating that the frequency of sudden, unexpected death among epileptics could easily be underestimated.

Epileptic aphasia and dysphoria interpreted as endogenous depression.

A case is reported of a 29-yr-old female with attacks of aphasia/dysphasia over a period of several months which lasted days to weeks accompanied by a dysphoric state. The patients was for long regarded as endogenous depressive with a hysterical speech disorder. However, the diagnosis of epilepsy was finally made based on generalized attacks, appropriate EEG changes, and the response to anti-epileptic therapy.

Epilepsy in the elderly: prognosis.

251 patients were admitted with seizures after the age of 60 years to the county hospital of Frederiksberg during the period 1979-1983, 163 had not received anti-epileptic treatment prior to admission, of these 151 had been admitted with their first seizure, 88 had established epilepsy at the time of admission. Of patients not previously treated and observed for at least 12 months, 62% remained seizure-free throughout the study, while 47% with established epilepsy were seizure-free. Of those not previously treated, 72% entered remission within the first year with a slight increase during the subsequent years. The first year was crucial in determining the long-term prognosis. Compared to previous studies on the prognosis of epilepsy it seems that prognosis in the elderly is as good or even better. Measurement of S-drug-levels at the time of seizure recurrence suggests that suboptimal treatment and poor compliance are important factors, thus indicating the need for regular control and monitoring of S-drug-levels. The presence of paroxysmal activity in the EEG was significantly correlated to seizure recurrence. Thirty-three patients entered nursing homes during the study period. Deterioration in residence status was correlated to degree of dementia and to the presence of focal neurological signs but not to age or to the severity of epilepsy.

The value of EEG in the investigation of postapoplectic epilepsy.

During the 5 years 1979-1983 61 patients within the county of Frederiksberg developed postapoplectic seizures after the age of 60. Of these patients EEG was performed on 48. These EEG's were compared to the EEG's from 25 patients of the same age with epilepsy due to cerebral tumors 33 patients with acute stroke and 24 patients with stroke sequelae who had not experienced seizures. Slow wave activity and foci were seen more often among patients with acute stroke than among patients with postapoplectic seizures whereas paroxysmal activity occurred less often in patients with acute stroke than among patients with postapoplectic seizures patients with stroke sequelae and patients with seizures due to cerebral tumours. Patients with stroke sequelae with proven hemispheric localization had focal abnormalities more often than patients with postapoplectic seizures but apart from this EEG difference between patients with postapoplectic seizures and patients with stroke sequelae or seizures due to brain tumours were not found. In 12 of the patients with postapoplectic seizures and in 20 of the patients with stroke sequelae without seizures EEG at the time of the acute stroke was available. Differences between patients with and patients without seizures were not found neither at the time of the acute stroke nor at the time of readmission due to stroke sequelae or due to onset of seizures. It is concluded that a routine EEG is without value in the diagnosis of postapoplectic seizures in the elderly.

Etiology of seizures in the elderly.

Our study covered a 5-year period, and included all patients within a well-defined area who developed seizures after age 60 years. The dominant cause of seizures was a previous stroke, accounting for 32% of all cases. Tumors accounted for 14%, and the cause of seizures remained unknown in 25%. Seizures were recurrent in greater than 80% of patients with first seizure greater than 6 months after stroke. Fifteen of 21 patients with tumors had metastatic tumors. Of the six patients with primary brain tumors, five had malignant gliomas and one had a meningioma. We conclude that epilepsy with onset after age 60 years is more often symptomatic than is epilepsy in younger patients; since seizures were the first sign of a central nervous system (CNS) disease in half of the patients with brain tumors, careful investigation is necessary to reach a correct diagnosis.

Epilepsy in the elderly: incidence, social function, and disability.

The incidence of epilepsy in persons greater than or equal to 60 years was studied during a 5-year period in an urban area. The incidence of patients with definite epilepsy was 77 new cases per year per 100,000 citizens greater than 60 years of age, with a significant excess of male patients. Generalized and partial seizures each accounted for about half of the seizures, but the majority of patients experienced generalization at least once. Of 163 patients with onset of epilepsy during the study period, 152 could manage in their own home, but 97 of these required permanent home help. Marital status, dementia, and focal neurological signs, but not age, influenced patients' social function. A group of patients of the same age with established epilepsy before the study period managed as well or even better, indicating that epilepsy did not significantly influence social function. For both groups, too many patients as compared with the population at risk were economically inactive at the time of admission. Judging from patients' previous occupation, it seems as if patients predominantly came from the lower social classes, indicating that occupational risks may be of ethiological importance.

Increased frequency of goitre in epileptic patients on long-term phenytoin or carbamazepine treatment.

Thyroid function, the clinical occurrence of goitre and ultrasonically determined thyroid gland volume were investigated in 23 patients with phenytoin- and 28 patients with carbamazepine-treated convulsive disorders and compared with matched healthy controls. In the phenytoin treated group median thyroid volume was 26 ml (range 14-57 ml) compared to 17 ml (range 8-41 ml) in the controls (P less than 0.01). Ten patients and four controls had a goitre (NS). Median serum T4 and FT4I levels were reduced, serum TSH level increased and serum T3, T3RU, FT3I and thyroglobulin levels unaltered compared with the controls. In the carbamazepine treated group median thyroid volume was 25 ml (range 13-66 ml) compared to 16 ml (range 9-44 ml) in the controls (P less than 0.01). Thirteen patients and three controls had a goitre (P less than 0.02). Median serum T4, FT4I and FT3I levels were reduced, serum thyroglobulin increased and serum T3, T3RU and TSH levels unaltered compared with the controls. The increase in thyroid size is probably a compensatory mechanism due to the low free thyroid hormones in serum caused by an increased hepatic degradation of thyroid hormones by phenytoin and carbamazepine.

Lack of interaction between cimetidine and carbamazepine.

In order to investigate a possible interaction between cimetidine and carbamazepine (CBZ) 7 otherwise healthy epileptic patients on a long-term monotherapy with CBZ were given cimetidine (1 g daily) for 7 days. No significant alterations in steady-state plasma concentration of CBZ and the 10,11-epoxide metabolite (CBZ-E) were demonstrated.

Endocrine function and antiepileptic treatment.

A short survey on the influence of antiepileptic drugs on endocrine function is given. Although most antiepileptic drugs interfere with endocrine function, patients on antiepileptic drugs seldom experience any endocrine symptoms. In spite of this some knowledge on changed endocrine function in the epileptic patient is important for the clinician especially to avoid misinterpretation of endocrine parameters. Also the interaction between antiepileptic drugs and hormonal drugs especially oral contraceptives has practical importance.

Grand mal-provoked hyperuricemia.

A significant increase in S-urate was found postictally in 17 patients with two or more grand mal seizures within 24 h. In six patients S-urate was above the level at which hyperuricemic renal failure may develop. Impaired renal function was observed in two patients who had extremely high S-urates. It is proposed that prophylactic procedures against hyperuricemic renal failure should be carried out in all patients with repetitive convulsions.