Combination treatment of interferon ß-1b and warfarin for a patient with Baló's concentric sclerosis and antiphospholipid syndrome.

BACKGROUND: Baló's concentric sclerosis (BCS), a rare variant of multiple sclerosis (MS), as the initial presentation of antiphospholipid syndrome (APS) is unusual. The pathogenic role of antiphospholipid antibodies in the development of MS remains unknown. Anticoagulant therapy might be used in patients with MS and APS for prevention against the relapse of MS. CASE REPORT: We present a 27-year-old man diagnosed as BCS with APS. Initially, after corticosteroid therapy, he exhibited a complete recovery. During follow-up, his Baló-like lesion dissolved over time but transformed into other asymptomatic MS-like lesions. He also had persistently elevated anticardiolipin IgG levels. The patient was, therefore, on a combined therapy of interferon ß-1b and an anticoagulant agent. No new brain lesions were found on 2 occasional head magnetic resonance imaging studies at 1 year follow-up. CONCLUSIONS: To prevent further MS relapse and thrombotic complications of APS, a combined therapy of interferon ß-1b and an anticoagulant agent can be an important strategy in treating patients with both BCS and APS.

Adult-onset of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome presenting as acute meningoencephalitis: a case report.

BACKGROUND: Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is a rare mitochondrial disorder with a wide range of multisystemic symptoms. Epileptic seizures are common features of both MELAS and meningoencephalitis and are typically treated with anticonvulsants. OBJECTIVES: To provide the reader with a better understanding of MELAS and the adverse effects of valproic acid. CASE REPORT: A 47-year-old man with a history of diabetes, hearing loss, sinusitis, and otitis media was brought to our emergency department due to acute onset of fever, headache, generalized seizure, and agitation. Because acute meningoencephalitis was suspected, the patient was treated with antibiotics on an empirical basis. The seizure activity was aggravated by valproic acid and abated after its discontinuation. MELAS was suspected and the diagnosis was confirmed by the presence of a nucleotide 3243 A→G mutation in the mitochondrial DNA. CONCLUSION: Detailed history-taking and systematic review help emergency physicians differentiate MELAS from meningoencephalitis in patients with the common presentation of epileptic seizures. Use of valproic acid to treat epilepsy in patients suspected of having mitochondrial disease should be avoided. Underlying mitochondrial disease should be suspected if seizure activity worsens with valproic acid therapy.

Cerebral venous thrombosis initially presenting with left occipital hemorrhage and headache.

Cerebral venous thrombosis (CVT) can be difficult to diagnose because of its wide spectrum of clinical manifestations. In the present article, we report a 58-year-old man coming to our emergency department presenting with left temporal throbbing headache and right hemianopia. Computed tomography of the brain revealed acute hemorrhages over the left occipital area. Due to the unusual location of hemorrhage, magnetic resonance venography was performed, revealing absence of venous flow over the superior sagittal and transverse sinuses suggestive of CVT. He received anticoagulant therapy for 6 months and the headache subsided. We feel that a high index of clinical suspicion is needed to diagnose an intracerebral hemorrhage in an uncommon site caused by CVT, even if risk factors of CVT are not present, so that appropriate treatment can be initiated as promptly as possible. Failure to recognize the signs of CVT could result in inappropriate management and suboptimal secondary prophylaxis strategies, which could affect the patient's clinical outcome.