ABSTRACT
BACKGROUND: Medical toxicologists are frequently consulted when young patients present with delirium attributed to suspected poisoning. Medical toxicologists should be aware of non-toxicological mimics of delirium. We describe two patients ultimately diagnosed with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis for which a toxicological consultation was requested to evaluate for neuroleptic malignant syndrome (NMS). CASE 1: A 21 year old male was sent from a psychiatric facility for new, worsening psychotic symptoms. He had autonomic instability, confusion, and hyper-reflexia. He was treated for NMS without improvement, and after an extensive workup was unrevealing, he was discharged home with significant cognitive dysfunction. Stored CSF later tested positive for anti-NMDAR antibodies. CASE 2: A 27 year old female was sent from a psychiatric facility for a seizure and new psychiatric symptoms. She was agitated and had violent, alternating extremity flexion and extension along with autonomic instability. She was treated for NMS, rhabdomyolysis, and rabies before analysis of CSF demonstrated anti-NMDAR antibodies. Treatment included surgical resection of a suspicious ovarian cyst, steroids and IVIG, with moderate improvement. DISCUSSION: Autoimmune syndromes of the central nervous system result from receptor dysfunction after an antibody response to extracellular or intracellular antigens, such as subunits of the NMDA receptor. The NMDA subunits NR2b and NR2a, in addition to the N-terminal region of the glycine binding NR1 subunit, have been implicated. Typical features such as memory loss, movement disorders, and hallucinations reflect the density and distribution of neuronal NDMA receptors. As young people, particularly young women, are predominantly affected, initial symptoms may be attributed to encephalopathy from drug abuse or schizophrenia. Toxicologists may be consulted as many features mimic NMS. Serum and cerebrospinal fluid can be checked for anti-NMDAR antibodies as part of a paraneoplastic or meningioencephalitis panel. Effective treatments have been described and include surgical resection and immunosuppressive medications.
Subject(s)
Anti-N-Methyl-D-Aspartate Receptor Encephalitis/diagnosis , Autoantibodies/cerebrospinal fluid , Delirium/diagnosis , Neuroleptic Malignant Syndrome/diagnosis , Adult , Anti-N-Methyl-D-Aspartate Receptor Encephalitis/physiopathology , Delirium/physiopathology , Diagnosis, Differential , Female , Humans , Male , Neuroleptic Malignant Syndrome/physiopathology , Referral and Consultation , Young AdultABSTRACT
Gastroesophageal reflux (GER) is common among patients with asthma, and it has been speculated that high GER may exacerbate asthma in some. This study was designed to determine if suppression of acid reflux in patients with asthma would improve pulmonary function. A double-blind, placebo-controlled crossover study design was used to determine the effect of GER suppression with omeprazole (20 mg twice daily) on pulmonary function among asthmatic patients with esophagitis. Four of 15 (27%) asthma patients with GER were shown to have a > or = 20% net improvement in pulmonary function (FEV1) after treatment for six weeks with omeprazole. These results indicate that some patients with asthma and GER will have improved pulmonary function when acid GER is treated with omeprazole.
Subject(s)
Asthma/drug therapy , Gastroesophageal Reflux/drug therapy , Omeprazole/therapeutic use , Respiration/drug effects , Adult , Asthma/epidemiology , Asthma/physiopathology , Cross-Over Studies , Double-Blind Method , Esophagus/drug effects , Esophagus/physiopathology , Female , Gastroesophageal Reflux/epidemiology , Gastroesophageal Reflux/physiopathology , Humans , Hydrogen-Ion Concentration , Male , Manometry , Middle Aged , Omeprazole/pharmacology , Placebos , Statistics, NonparametricABSTRACT
Anticholinergic side effects of commonly used antihistamines are known to aggravate voiding difficulties in older men with benign prostatic hypertrophy. Newer antihistamines, such as terfenadine (Seldane), with less anticholinergic side effects may not have such an effect on voiding. We performed a randomized, double-blind, placebo-controlled, crossover study in eight normal male volunteers (phase I) and in 11 patients with documented benign prostatic hypertrophy (phase II) to study the effect of terfenadine on voiding. Subjects received either 60 mg of terfenadine or an identical placebo twice daily for 1 week each. After a 1-week washout period, they were crossed over to receive the other drug. Evaluation took place on days 0, 7, 14, and 21. Prick skin testing was performed with serial threefold dilutions of histamine to assess efficacy and degree of compliance. Uroflowmetry and urinary symptom assessment were also done. In phase I, after 1 week of terfenadine, mean skin test suppression was 83.8% compared with -0.5% with placebo (P < .01). Urinary peak flow increased 10.4% on terfenadine and 9.7% on placebo (P = NS). In phase II, the mean prick skin test suppression was 87.8% compared with 12.0% for placebo (P < .002). Urinary peak flow was decreased 0.1% from baseline on terfenadine and increased by 18.7% for placebo (P = NS). None of the subjects noted alterations in voiding symptom scores. We conclude that the commonly recommended dose of terfenadine does not significantly alter voiding characteristics in normal men or in patients with documented benign prostatic hypertrophy.
