Trimethoprim-sulfamethoxazole-induced aseptic meningitis: case report and literature review.

Aseptic meningitis is a rare adverse drug reaction, reported with non-steroidal anti-inflammatory agents (NSAIDs) and with miscellaneous drugs such as trimethoprim-sulfamethoxazole (TMP-SMX). The most common clinical findings reported are fever, headache, stiffness and altered level of consciousness. We report a case of aseptic meningitis related to TMP-SMX ingestion that caused severe derangements of the patient's vital signs, requiring Intensive Care Unit admittance. The prompt diagnosis and discontinuation of the drug resulted in complete recovery. We examine the case according to the literature on this topic. We conclude that, since the signs and symptoms of this unusual drug reaction may mimic those of central nervous system infection, the clinician should consider this etiology when he is faced with a patient with suspected meningoencephalitis, especially if the latter has already been treated at home with unknown drugs. Further studies should investigate the pathogenetic mechanism of TMP-SMX-induced aseptic meningitis.

Renegeración aberrante del tercer nervio craneal: comunicación y análisis de una serie de pacientes atendidos en un período de 17 años en la Unidad de Neuro-Oftalmología del Hospital Vargas de Caracas / Aberrant regeneration of third cranial nerve: analysis and communication of patients series attend in a period of 17 years in the Unidad de Neuro-Oftalmología of the Hospital Vargas of Caracas

El presente estudio tiene por finalidad dar a conocer las características clínicas de la regeneración aberrante del tercer nervio craneal (RA3ºNC), motivado a que una basta mayoría de pacientes con esta condición, el 96,7 por ciento de los enviados a nuestra unidad, carecían de diagnóstico preciso. Se halló un total de 101 enfermos con parálisis del tercer nervio craneal, de los cuales 38 casos (37,6 por ciento) presentó durante su evolución RA3ºNC. La edad promedio de nuestros pacientes fue de 34,9 años, con dos picos de frecuencia entre 21 y 40 años (36,8 por ciento) y otro entre 41 y 60 años (34,2 por ciento). Las causas principales de RA3ºNC secundaria fueron: Traumáticas en 20 pacientes (52,6 por ciento), aneurismas intracraneanos en 8 (21 por ciento) y meningitis en 3 (7,9 por ciento). Sólo se encontraron 2 pacientes con RA3ºNC primaria (5 por ciento). Los signos de RA3ºNC más comunes fueron: Discinesia del párpado superior en mirada horizontal (80 por ciento), pseudo signo de Von Graefe (77,5 por ciento), pseudo pupila de Argyll Robertson (52,5 por ciento) y pupila de Czarnecki (37,5 por ciento). La importancia clínica de los elementos mencionados, radica en la posibilidad de diagnosticar con certeza condiciones dolorosas o indolentes en el seno cavernoso

Prevalence of GB virus-C/hepatitis G virus infection in patients with cryptogenic chronic liver disease and in patients with primary biliary cirrhosis or Wilson's disease.

OBJECTIVE: To assess the role of hepatitis G virus (HGV) in cryptogenic chronic liver disease (CLD), we investigated the prevalence of HGV RNA among patients with cryptogenic CLD, patients with nonviral CLD (primary biliary cirrhosis [PBC] and Wilson's disease [WD]) and subjects without clinically evident liver disease (controls). METHODS: Ninety patients with cryptogenic CLD (43 with chronic hepatitis, 20 with cirrhosis, and 27 with hepatocellular carcinoma [HCC]), 143 patients with PBC, 22 patients with WD, and 134 controls were recruited. HGV RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR) and antibodies against HGV E2 protein (anti-E2) by an immunoassay test. RESULTS: HGV RNA was detected in 7.8% of patients with cryptogenic CLD (chronic hepatitis, 9.3%; cirrhosis, 5.0%; HCC, 7.4%), in 2.4% of patients with PBC or WD, and in 2.2% of controls. As a consequence, a positive association of HGV infection with cryptogenic CLD was found (odds ratio, 3.1; 95% confidence interval [CI], 1.0-9.7; p = 0.05). No difference was observed between HGV RNA-positive and -negative patients by age, sex, histology, or liver function tests. Anti-E2 prevalence did not differ between patients with cryptogenic CLD (26.5%), patients with PBC (28.1%), and controls (22.1%). Transfusion history was associated with HGV RNA but not with anti-E2 seropositivity. CONCLUSIONS: Although an association was found between cryptogenic CLD and HGV infection, the role of the virus seems far from important, the proportion of cryptogenic CLD attributable to it being only 5.2%.

Prolonged treatment of chronic C hepatitis by means of medium-high doses of recombinant alpha-2b interferon: an open study to evaluate response and long-term relapse.

Thirty-six patients with hepatitis C virus-RNA positive chronic hepatitis were studied to evaluate whether recombinant alpha-2b interferon, in medium-high doses, (6-9 MU 3 times/week) over a long period (12-18 months), was more effective in reducing or normalizing alanine aminotransferase values, and in reducing the relapsing percentage than the historical trials. At the end of the 12th and 18th month of treatment, mean alanine aminotransferase values were significantly reduced; the level of complete responses was 36.1%, at the end of the 12th month, and 19.4% at the end of the 18th month (intention to treat). These results were no better than comparable findings in the literature. At the end of the first follow-up (12th month), percent complete responses fell to 15.5%, with a relapse rate of 14.3%. At the end of the second follow-up (24th month), percent complete responses fell further to 11.1% (all 4 patients with a 24 months sustained response showed absence of viraemia), with a relapse rate of 42.9%; even these percentages were judged unsatisfactory. In conclusion, no significant advantage was obtained by prolonging interferon treatment and/or using higher dosages. However, the possible virus clearance in all the long-term responders seems to justify further investigation in terms of cost-benefit analysis.

Liver cell dysplasia is a major risk factor for hepatocellular carcinoma in cirrhosis: a prospective study.

BACKGROUND/AIMS: In humans, the role of liver cell dysplasia as a preneoplastic lesion is still debated. A prospective, long-term, multicenter study was performed to establish whether liver cell dysplasia in cirrhosis is associated with an increased risk for hepatocellular carcinoma (HCC). METHODS: A cohort of 307 consecutive patients in whom liver cirrhosis was diagnosed by histology was investigated for development of HCC at 6-month intervals by ultrasonography and determination of alpha-fetoprotein levels. RESULTS: At enrollment, liver cell dysplasia was found in 75 patients (24%) and in 53% (P < 0.01) of those positive for hepatitis B surface antigen (HBsAg). After a mean follow-up of 46 months, HCC was detected in 45 cases, and it was significantly more frequent in patients with liver cell dysplasia (P < 0.01) and HBsAg-serum positivity (P < 0.01). Multivariate analysis showed that liver cell dysplasia was the most important risk factor correlated with HCC development. HBsAg positivity and age over 60 years were also independent risk factors for HCC. CONCLUSIONS: These results indicate that liver cell dysplasia is a major risk factor for HCC, and it should be looked for carefully by pathologists in liver biopsy specimens to identify patients requiring more intensive observation.

Cerebrospinal fluid and plasma concentrations of SRIH, beta-endorphin, CRH, NPY and GHRH in obese and normal weight subjects.

Numerous hypothalamic peptides are involved in the control of eating behaviour. We assessed plasma and cerebrospinal fluid (CSF) levels of SRIH, beta-endorphin (beta-EP), CRH, NPY and GHRH in a group of massively obese patients and in normal weight subjects. In the obese patients, CSF SRIH and beta-EP levels were significantly reduced and increased, respectively, compared with controls (20.6 +/- 2.62, mean +/- s.e.m., vs 34.5 +/- 2.14 pg/ml, P < 0.05, for SRIH and 111.2 +/- 5.00 vs 80.4 +/- 5.32 pg/ml, P < 0.001, for beta-EP). Considering the data of obese and control subjects altogether, SRIH and beta-EP concentrations correlated negatively and positively, respectively, with BMI values (r = -0.641, P < 0.005 and r = 0.518, P < 0.05). No significant differences were observed in CSF levels of CRH, NPY and GHRH between obese and normal weight subjects, though GHRH levels were close to the assay sensitivity. CSF concentrations of CRH were positively correlated with those of SRIH in obese patients (r = 0.60, P < 0.05) and with those of NPY both in obese (r = 0.69, P < 0.02) and in control subjects (r = 0.83, P < 0.005). Plasma levels of SRIH, beta-EP, NPY and GHRH did not differ significantly in the two groups of subjects; plasma CRH was undetectable. Our results argue against the hypothesis of an enhanced SRIH tone as the cause of impaired GH secretion in obese patients, a primary defect in GHRH or GH release seems more likely. Moreover, they emphasise the importance of an increased tone of endogenous opioids in the pathophysiology of human obesity.

[Preanesthesia in elderly patients undergoing subarachnoid anesthesia: chlordesmethyldiazepam versus diazepam]. / La preanestesia nei soggetti anziani sottoposti ad anestesia sub-aracnoidea: clordemetildiazepam vs diazepam.

Forty patients over 65 undergoing subarachnoid anesthesia with bupivacaine 0.50% (5 mg) and fentanyl (0.1 mg) were subdivided into two equal groups: one was premedicated with atropine and chlordesmethyldiazepam (0.03 mg/kg-1) and the other with atropine and diazepam (0.015 mg/Kg-1). A statistically significant difference was found in the group treated with diazepam which required an increase for anesthetic drugs during surgery. The authors suggest a probable synergic or an enhanced effect between intramuscular chlordesmethyldiazepam and opiates in spinal anesthesia.

Comparison of nimesulide and diclofenac in the prevention and treatment of painful inflammatory postoperative complications of general surgery.

In a double-blind study, 40 patients scheduled for saphenectomy or inguinal hernioplasty were randomly assigned to treatment with nimesulide (200mg 3 times daily) or diclofenac (100mg 3 times daily) administered rectally. Therapy with either drug resulted in significantly less pain, oedema and hyperaemia, and resolution of mild fever. No adverse reactions attributable to treatment were observed.

Trazodone for deafferentation pain. Comparison with amitriptyline.

We report a clinical multicentre experience with antidepressant agents (trazodone and amitriptyline) in the treatment of chronic pain due to deafferentation. Forty five patients were admitted to the study; most of them with oncological peripheral nerve lesions. Almost all of them were already being treated with NSAID in association with weak or strong opioids. A random double blind study was performed: 23 patients were treated with trazodone, 22 with amitriptyline. In the assessment of results, pain intensity, hours of sleep, hours standing and lying, side effects, mood, anxiety and weakness were all taken into consideration. The therapeutic analgesic efficacy of the two drugs proved to be similar.

Antidepressants for cancer pain and other painful syndromes with deafferentation component: comparison of amitriptyline and trazodone.

The Authors report a clinical multicentre experience with antidepressant agents (trazodone and amitriptyline) in the treatment of chronic cancer pain with deafferentation component. Forty-five patients were admitted to the study: 27 with oncological peripheral nerve lesions, 6 with post herpetic neuralgias, 10 with not oncological nerve lesions, 2 with central nervous lesions. Almost all of them were already being treated with NSAID associated with weak or strong opioids. A random double blind study was performed: 23 patients were treated with trazodone, 22 with amitriptyline. In the assessment of results, pain intensity, hours of sleep, hours standing and lying, side effects, mood, anxiety, weakness were all taken into consideration. The therapeutic analgesic efficacy of the two drugs proved to be similar.

[Preoperative parathyroid ultrasonography. 45 recent verified cases]. / Ultrasonographie parathyroïdienne préopératoire. Quarante-cinq cas vérifiés récents.

In a series of 45 patients operated upon for primary hyperparathyroidism, a total of 167 parathyroid glands were confirmed. Thirty out of the 43 parathyroid masses potentially accessible to ultrasounds were correctly identified by preoperative cervical ultrasonography. There were 124 true negative results, including one retro-oesophageal mass and one mediastinal mass, 1 false-positive result and 11 false-negative results, giving the method a sensitivity of 73% and a specificity of 99%. Sensitivity increases with the experience of the operator. The main factors that reduce sensitivity are change of apparatus, old age of the patient, small masses (less than 500 mg) and coexistence of a thyroid disease (22% of the cases). The ease with which parathyroid masses can be correctly identified is independent from plasma calcium and parathyroid hormone values.

Intrathoracic intercostal nerve block with phenol in open chest surgery. A randomized study with statistical evaluation of respiratory parameters.

Seventy-three patients who underwent thoracic surgery were randomly selected for intraoperative intercostal nerve block using phenol (32 block and 41 control subjects). The patients were divided into three groups: pneumonectomies, lobectomies and explorative thoracotomies and evaluated by pain level, respiratory function parameters (VT, IRV, ERV, VC) and blood-gas analysis, both six and 24 hrs after surgery. The patients who had intraoperative nerve block using phenol enjoyed a more comfortable postoperative period. In particular, respiratory parameters were statistically better.

Inhibition by phospholipid liposomes of the prolactin and cortisol response to insulin hypoglycemia in man.

This study was designed to further investigate the purported dopaminergic activity of phospholipid liposomes (PL) prepared from bovine cerebral extracts, and to obtain further indications about their pituitary or suprapituitary site of action. In eight normal subjects, we have studied the effects of PL administration (250 mg as IV bolus plus additional 250 mg infused IV over a 60-min period), compared to placebo, on the prolactin (PRL), cortisol and growth hormone (GH) response to an insulin tolerance test (ITT). In eight additional subjects, the effects of PL on the PRL and TSH response to TRH were evaluated. PL medication blunted the PRL and cortisol response in the ITT: significant differences, with respect to placebo administration, were observed between mean peak PRL values (51.9 +/- 13.63 SEM vs 83.4 +/- 26.35 ng/ml, P less than 0.05) and mean cortisol values at 120 min time (20.9 +/- 0.67 vs 26.7 +/- 2.46 micrograms/dl, P less than 0.05). In contrast, PL administration did not modify the ITT-related GH rise or the PRL and TSH release in response to TRH. These findings favour the view that PL are endowed with intrinsic biological activity which is dopamine-mediated, and point to the hypothalamus as their primary site of action.