A case of cerebral infarction in association with free protein S deficiency and oral contraceptive use.

The purpose of this article is to describe protein S deficiency as a cause of cerebral infarction in the young adult. We report a 27-year-old previously healthy woman with a primary free protein S deficiency, who developed a left temporoparietal infarction. Protein S is a naturally occurring vitamin K-dependent protein which, in conjunction with active protein C, inhibits the clotting cascade. Protein S deficiency is known to be of clinical significance in patients with deep venous thrombosis or pulmonary emboli and in these patients, treatment is long-term anticoagulation. Protein S deficiency has been found to be associated with cerebrovascular occlusion and may possibly warrant long-term anticoagulation in these patients as well. Measurement of total and free protein S levels should be part of the evaluation for any young adult who has had a stroke.

PIP: A 27-year-old woman suffered from a sudden onset of slight paralysis of the right side of her body and the inability to express herself by speech, writing, or signs. She was admitted to the National Rehabilitation Hospital in Washington, D.C., in the US. 6 months prior to these events, she had been in a motor vehicle accident and had since experienced headaches and generalized musculoskeletal pain. The only drug she took was an oral contraceptive (OC), which she took irregularly. Health workers could not arouse her upon admission. Clinical examination revealed symptoms consistent with a left hemispheric stroke. Cerebral computed tomography and magnetic resonance imaging revealed a left temporoparietal infarct. Her free protein S was only 27% on admission and 14% 11 days after admission (normal range, 55-125%). Over the next 72 hours, her physical condition deteriorated, entailing focal motor seizures, right Babinski's sign, loss of pain reflex response on her right side, and complete paralysis of the right side of her body. The left middle cerebral artery appeared to be constricted, which physicians first believed was caused by vasculitis but later found was the result of emboli. The patient developed right femoral vein deep thrombosis. The physicians treated her initially with heparin and followed with warfarin therapy. Nevertheless, embolus. Health workers placed a filter in her inferior vena cava and continued warfarin therapy. She did not experience any more thrombotic or embolic episodes during the rest of her hospital stay. OCs reduce circulating levels of free protein S which, along with activated protein C, inhibits clotting. OCs likely reduced her already existing low levels of free protein S. Deficiency of free protein S was likely responsible for the cerebral infarction and her thrombotic and embolic episodes.

Methylphenidate in stroke patients with depression.

The treatment of depression after stroke is a difficult clinical problem. Many of the medications used to treat patients with depression in the general population have significant potential side effects that are of particular concern in elderly patients. We reviewed the records of ten patients with stroke treated with methylphenidate for depression during an inpatient rehabilitation program. Improvement was noted in seven patients. This suggests that methylphenidate in the treatment of post-stroke depression merits further study.

Thoracic disk herniation and recurrent dislocation of total hip prosthesis.

We have described a patient who had thoracic disk herniation, recurrent dislocation of a total hip prosthesis, and heterotopic ossification. The recurrent dislocation resulted from spasticity from a spinal lesion, but the treatment focused on technical solutions related to the hip. Evaluation for total hip arthroplasty should include careful neurologic examination. If recurrent dislocation occurs, spasticity from an occult lesion should be considered. Resection of calcified thoracic disks should be approached with caution.

Popliteal artery entrapment syndrome.

The purpose of this article was to describe popliteal artery entrapment syndrome, which is a cause of intermittent claudication in a young person, and to illustrate the importance of early diagnosis for successful treatment of this entity. A case report of a 28-year-old man with popliteal artery entrapment syndrome is presented. This patient had a classic history of calf pain that worsened with walking and was relieved by rest, running, or bicycle riding. Physical examination revealed evidence of ischemia in the distal extremity, and arteriography demonstrated signs of chronic occlusive disease. Early treatment might have included surgical release of the popliteal artery and arterial grafting. Due to extensive vascular disease, grafting was not possible and a below-knee amputation was performed. It is therefore essential to diagnose popliteal artery syndrome early for appropriate management.

Pulmonary toxicity of nitrofurantoin.

Nitrofurantoin is frequently used by the physiatrist for treatment of urinary tract infections or for urinary antimicrobial prophylaxis. There is a substantial risk of acute and chronic pulmonary side effects with this medication. The acute pulmonary toxicity presents with fever, leukocytosis, dyspnea, and nonproductive cough. Chronic nitrofurantoin use can lead to interstitial pulmonary fibrosis. A case is reported of a 47-year-old spinal cord injured woman with an acute pulmonary reaction to nitrofurantoin. The literature pertaining to pulmonary toxicity of nitrofurantoin is reviewed.