Unexpected worsening of progressive multifocal leucoencephalopathy following COVID-19 pneumonia.

Progressive multifocal leucoencephalopathy is a serious side effect of natalizumab, a humanized monoclonal antibody approved for the treatment of multiple sclerosis. Here, we report a case of unexpected worsening of natalizumab-related progressive multifocal leucoencephalopathy following COVID-19. After natalizumab discontinuation, a slight neurological improvement was observed, but, two months later the patient was admitted to the hospital because of neurological deterioration and COVID-19 mild pneumonia. Except for SARS-CoV-2 infection, no other potential factors of neurological worsening were identified. Thus, we pose the hypothesis that SARS-CoV-2 was instrumental in the progressive multifocal leucoencephalopathy deterioration.

[Stroke: from primary care to rehabilitation]. / Accident vasculaire cérébral: de la prise en charge précoce à la rééducation.

Stroke is a major health problem. The incidence of stroke in Belgium is estimated at 18,875 cases per year. Primary care needs to be fast in order to reduce mortality and disability. The European recommendations for the management of stroke are the following: 1) stroke patients should be treated in specialized stroke units. Therefore, suspected stroke victims should be transported without delay to the nearest medical centre with an available stroke unit, or to a hospital providing organized acute stroke care if a stroke unit is not available; 2) stroke should be considered as a medical emergency requiring fast management. Once stroke symptoms are suspected, patients or their proxies should call emergency transportation or a similar system; 3) Stroke Unit should provide co-ordinated multidisciplinary care by medical, nursing and therapy staff who specialize in stroke care. Treating patient in a specialized stroke unit allows reducing the mortality by 20% and improving the functional outcome of patients, regardless of age and/or stroke severity. Once the diagnosis of stroke is confirmed, causes and mechanisms should be clarified in order to prevent the recurrence of stroke. In case of ischemic stroke, less than 3 hours after the first symptoms, thrombolysis (which is the only curative treatment at present) may be proposed to the patient. The aims of neurological rehabilitation after stroke are: a) to enable the patient to recover a satisfactory quality of life considering the patient's status and environmental factors; b) to coordinate all means to prevent (or minimize) the inevitable functional, physical, psychological, social consequences and economic impairment caused by disability (activity limitation). These objectives are pursued by stimulating maximally the residual abilities of the patient.

Recurrent status epilepticus associated with Hashimoto's encephalopathy.

Hashimoto's encephalopathy (HE) is an infrequent disease with no well-known physiopathology. Status epilepticus is rarely reported in association with HE. We describe the 7-year evolution of a young woman who presented with recurrent status epilepticus as the main complication of HE. This evolution was especially marked by the occurrence of steroid-refractory symptoms and a poor outcome with persistent cognitive and behavioral consequences. We point out that the frontal lobes are especially implicated in these symptoms. This patient highlights the risk of multiple relapses and the need for a long follow-up period. We describe her clinical and paraclinical features, compare this patient to similar case reports, and comment on her outcome.

Are ACE-inhibitors or ARB's still needed for cardiovascular prevention in high risk patients? Insights from profess and transcend.

The HOPE and EUROPA clinical studies have shown that treatment with the angiotensin-converting enzyme (ACE) inhibitors, ramipril and perindopril, may reduce the occurrence of major cardiovascular events in patients with proven atherosclerotic disease. The recently published results of the PRoFESS and TRANSCEND trials completed the much needed information concerning the use of an angiotensin receptor blocker for patients at high risk of cardiovascular events. PROFESS compared a therapy of telmisartan 80 mg daily with placebo in patients with a recent ischemic stroke. The difference in the primary outcome of first recurrent stroke was not statistically significant between telmisartan and placebo. The secondary outcome of major cardiovascular events showed a relative risk reduction (RRR) of 7% in favour of telmisartan. This tended to be significant (p = 0.06) despite a rather short follow-up period of only 28 months. In TRANSCEND 5926 patients at high risk for cardiovascular events were randomized to a treatment with telmisartan 80 mg daily or placebo for a mean duration of follow-up of 56 months. The primary composite outcome of cardiovascular death, myocardial infarction, stroke or hospitalization for heart failure showed a non-significant 8% RRR in favour of the telmisartan treated patients. The main secondary outcome of cardiovascular death and myocardial infarction or stroke as used in the HOPE trial showed a non-significant RRR of 13% in favour of telmisartan treated patients (p = 0.068 adjusted for multiplicity of comparisons). In comparing the Kaplan-Meier curves for the endpoint of major cardiovascular events used in HOPE, EUROPA, TRANSCEND and PRoFESS, the trends are similar. Results of most of the recently published trials have been neutral.This could partly be explained by major improvements in the optimal background therapy of the patients included. Nevertheless, the results of PRoFESS and TRANSCEND do not contradict the results from previous studies with theACE inhibitors ramipril and perindopril and the ARB telmisartan.

Lessons from ONTARGET.

The recently published results of the ONTARGET trial shed a new light on the cardiovascular protection of patients at high risk of a cardiovascular event. Despite a number of trials looking at the efficacy of Angiotensin Converting Enzyme inhibitors (ACEis) or Angiotensin Receptor Blockers (ARBs) in the prevention of cardiovascular events in patients with specific high risk profiles, the question of the equivalence of ACEis and ARBs remained unanswered. The ONTARGET trial has shown that telmisartan 80 mg administered for a median duration of 4.5 years to patients at high risk of developing a major cardiovascular event, is equally effective to ramipril 10 mg. In addition, telmisartan was slightly better tolerated. The comparator ramipril has been chosen as it is currently the gold standard ACEi since the results of the HOPE study, in terms of the composite outcome of cardiovascular death, myocardial infarction and stroke. Moreover, ONTARGET is the first trial to test the hypothesis of superiority of adding an ARB (telmisartan 80 mg) to an ACEi (ramipril 10 mg) over the ACEi ramipril monotherapy in cardiovascular protection of the same broad range of high-risk patients. Surprisingly, despite a more pronounced blood pressure lowering, the combination of the two agents did not lead to an additional decrease in the number of events, but had significantly more side-effects compared to ramipril monotherapy. ONTARGET is a landmark study, performed according to the highest statistical and clinical standards, providing compelling evidence and clear answers to two important clinical questions.

Painful arm and moving fingers: clinical features of four new cases.

The syndrome of painful arm and moving fingers associates pain in one arm or hand with involuntary movement of one or several fingers. In the four cases described, an association between a central and a peripheral nervous system lesion is demonstrated or suspected. Treatment of the condition is disappointing.