An Uncommon Presentation of Cryptococcal Meningoencephalitis.

Cryptococcal meningoencephalitis (CM) remains a common cause of central nervous system infections. Patients usually present with headache, fever, malaise, and altered mental status over several weeks. Signs are often absent, but they may include meningism, papilledema, cranial nerve palsies, and depressed level of consciousness. Individuals with CM can occasionally present with small vessel vasculitis causing cerebral lesions. The literature regarding patterns of cerebrovascular injury in CM is scarce. We describe a case of CM in which an unusual presentation was observed: transient focal neurological symptoms initially with absence of fever that led to a misleading primary diagnosis of transient ischemic attack. Since neurological symptoms may be a manifestation of a cryptococcal infection, it is necessary to have a high degree of suspicion for this pathology in the presence of focal neurological deficits, even in patients with vascular risk factors, requiring a thorough etiological investigation.

When Alice Took Sertraline: A Case of Sertraline-Induced Alice in Wonderland Syndrome.

Alice in Wonderland syndrome (AIWS) is a rare disorder that refers to episodic body image distortions, sometimes associated with altered perception of external space and time. AIWS is mainly associated with viral disease in children as well as migraines and epileptic seizures in adults. Its pathogenesis is still very much unknown and there are not many reported drug-associated cases in medical literature. We describe a case of a 67-year-old woman, with a relevant history of depressive disorder, nontoxic goiter, and dyslipidemia that presented short episodes of altered body perception associated with altered external space perception for a period of one week. Her physical examination was unremarkable and her cerebral computerized axial tomography (cerebral CAT) and blood tests showed no alterations. She had been medicated with sertraline till the previous year and had restarted it in the previous month. She reported similar episodes of body image distortions in the first weeks of initiating sertraline for the first time. The current episode lasted for two weeks and in one year follow-up she reported no recurrence. The patient was diagnosed with AIWS probably induced by sertraline, being the first reported case of the kind.

Flying From Hospital to Hospital: A Case of Caffeine Intoxication.

A 54-year-old woman with a history of excess weight and active smoking presented to the emergency department (ED) due to syncope after a long flight. She reported a similar episode in the previous month, which had also occurred after a long air voyage. She presented with hypotension, dehydration, and hyperlactacidemia. The clinical team ruled out acute coronary syndrome, pulmonary embolism, and cerebrovascular accident. After clinician insistence, she reported having ingested anhydrous caffeine, an over-the-counter diuretic usually used by individuals seeking to lose weight, and a diagnosis of caffeine intoxication was made. The over-the-counter sale of this apparently innocuous substances is a rising phenomenon, and physicians should be aware of the signs of its ingestion.

Hulk-Like Urine: A Case of Green Urine Caused by Flupirtine Intoxication.

Acute intoxications are common causes of admission to the Emergency Department (ED). Flupirtine is a non-opioid analgesic, originally used for acute and chronic pain. Because of several reports of severe liver toxicity, its use was limited to acute pain in 2013 by the European Medicines Agency. Although withdrawn from the European market in March 2018, there are still flupirtine tablets in many households, and most people are unaware of the hazards they might be facing. A 58-year-old man was admitted to the ED after a suicide attempt with 1 g of flupirtine. He was lethargic and confused but presented no focal neurological deficits or other symptoms, and the rest of his clinical examination was unremarkable. His cerebral CAT and blood chemistry showed no alterations. The only remarkable feature was that he had green urine. After a careful literature search, a similar case was found caused by flupirtine intoxication. After 24 hours of vigilance in the ED, he improved his neurological status and his urine lost part of its greenish color. He was then transferred to the Psychiatric Department, where he presented a complete remission of the clinical alterations. A follow-up check-up showed no permanent deficits.

Precisão da retinoscopia sem lentes neutralizadoras na hipermetropia experimental de olho artificial / Accuracy limits of retinoscopy without neutralising lenses for evaluation of experimental hypermetropia in a model eye

OBJETIVO: Avaliar a acurácia e a precisão da retinoscopia sem lentes neutralizadoras na hipermetropia experimental de olho artificial. MÉTODOS: Observação da projeção da faixa do retinoscópio em olho artificial preparado para apresentar hipermetropias de +1,00 D a +8,00 D. A movimentação da faixa é feita simultaneamente com a variação da sua largura, deslocando a luva do retinoscópio até a obtenção da neutralização do movimento. O retinoscópio foi preparado para dois modos de medida: com escala milimétrica sob a luva e com acoplamento a potenciômetro ligado a multímetro de leitura digital em ohms (Ù). Oito médicos oftalmologistas realizaram 1200 retinoscopias em cada modo de medida, num total de 2400. Calculou-se a média e o desvio padrão das observações. Para comparar os resultados em mm e em ohms (Ù) calculou-se o coeficiente de variação (CV) a partir dos desvios padrão das observações em cada modo. RESULTADOS: Pelos modos descritos foi possível estimar hipermetropias até +4,00 dioptrias. CONCLUSÃO: A acurácia e a reprodutibilidade experimentais foram boas na identificação de hipermetropias até +4 ,00 D.

OBJECTIVE: Evaluate accuracy and reproducibility of streak retinoscopy without neutralising lenses in experimental hyperopia of an artificial eye. METHODS: Observe a Welsh Allynretinoscope streak through the pupil of an artificial eye prepared do show hyperopia from +1,00 D to +8,00 D. The streak was moved while varying its width by sliding the sleeve upwards until neutralisation point. The retinoscope was fitted either with a millimetre scale under the sleeve or with a multimetre connected to a rheostat driven by a spool snugly fastened around the sleeve. Multimetre readings were taken in ohms (Ù). Eight ophthalmologists performed 1200 in each mode totalysing 2400 readings. Average and standard deviation of the readings in each mode were determined, as well as the variation coefficient in order to allow comparison of results in millimetre and Ù. RESULTS: Based on the proposed method it was possible to estimate hyperopia up to +4,00 D. CONCLUSION: Accuracy and reproducibility in experimental hyperopia of an artificial eye was feasible up to +4,00 D.

Acuidade visual e óculos. Novas propostas em saúde pública ocular / Visual sharpness and glasses. New proposals in public health

Em escrito precursor ao corpo da tese menciona-se a mudança do objeto da saúde pública ocular brasileira que privilegiando outrora a questão do tracoma passa a considerar prioritariamente os problemas da catarata no idoso, glaucoma na maturidade e defeitos de refração (ametropias) no escolar. Nos artigos da tese estudam-se os conceitos fundamentais da acuidade visual (AV), os antecedentes históricos de sua investigação, métodos de triagem, pontos de corte de AV para encaminhamento do escolar ao exame oftalmológico e critérios para prescrição de óculos em ações de saúde pública. Examinam-se os resultados do acompanhamento, durante 2 a 32 meses, do destino dos óculos prescritos a 125 escolares amétropes, estudando possíveis relações entre tipo de ametropia, potências dióptricas receitadas e uso permanente (49 por cento dos casos), uso em situações específicas (23 por cento) e abandono dos óculos (28 por cento). Considera-se a importância do ensaio de uso das lentes na armação de prova no consultório como indicador de ulterior uso ou rejeição dos óculos. Investiga-se clinicamente a proposta de FOSTER – triagem da visão com ambos os olhos abertos e ponto de corte em 0,5 de SNELLEN – pela leitura do abecedário em escrita cursiva em quadros negros por 133 escolares e 9 adultos. Nas condições de FOSTER o reconhecimento do mínimo de 19 letras a 5m ficou acima de 80 por cento em 87,5 por cento dos casos; a 6m ficou acima de 70 por cento em 81,3 por cento dos casos. Discute-se a proposta e sugere-se sua adoção em programas de saúde pública ocular com salvaguardas adequadas para proporcionar ao escolar assistência oftalmológica eficaz e a baixo custo

Refraçäo: cilindro cruzado; consequências da ciclopegia e miopizaçäo. Bifocais e multifocais / Refraction: crossed cylinder; consequence of cycloplegia and myopia. Bifocals and multifocals

Os autores discutem os aspectos opticos e práticos da prescriçäo de óculos e a adiçäo para a presbiopia. Os bifocais, trifocais e multifocais säo discutidos e seus aspectos opticos analisados. Todos os multifocais necessitam compensar a aberraçäo lateral com reduçäo da área de leitura

Causas comuns de cegueira: um estudo piloto em Pelotas, RS / Common causes of blindness: a pilot study in Pelotas, RS., Brazil

Cegueira é um importante problema de saúde que tende a agravar-se, cada vez mais, nos países em desenvolvimento. Neste estudo 132 pacientes cegos foram avaliados. As principais etiologias encontradas foram catarata (31,4%), miopia (25,4%), opacidades corneanas (6,8%), glaucoma (6,4%), atrofia óptica (6,4%), retinopatia diabética (5,3%) e uveítes (4,9%). Dois picos de prevalência de cegueira foram detectados: entre 0-19 anos, principalmente por miopia (59,9%) e catarata (10,1%), e acima de 45 anos, decorrente de catarata (54,3%) e glaucoma (11,6%). Existe uma prevalência relativa 1.8 vezes maior de cegueira entre 0-19 anos, e de 4,8 vezes maior naqueles com idade superior a 45 anos, se comparados com a populaçäo adulta entre 20-44 anos. A necessidade de um maior acesso da populaçäo a serviços de assistência oftalmológica é enfatizada, pois poderia ser drasticamente reduzida a prevalência das enfermidades tratáveis ou preveníveis que evoluem para cegueira