Isquemia cerebral secundaria a una endocarditis trombótica no bacteriana como forma de presentación de un tumor ovárico / Cerebral ischaemia secondary to non-bacterial thrombotic endocarditis as the presenting symptom of an ovarian tumour

Introducción. En los pacientes con cáncer, los accidentes cerebrovasculares (ACV) son la complicación en sistema nervioso central más común después de las metástasis. Una de sus etiologías es la endocarditis trombótica no bacteriana (ETNB), que se presenta de forma excepcional como primera manifestación del tumor. Las manifestaciones clínicas de la ETNB son resultado del embolismo sistémico múltiple. Los émbolos se componen de plaquetas y hebras de fibrina que se depositan en las válvulas cardíacas, en el contexto de un estado de hipercoagulabilidad secundario al tumor. Los tumores más frecuentemente asociados a ETNB son los adenocarcinomas secretores de mucina. En las diferentes series publicadas, los casos de cáncer de ovario con ETNB son excepcionales. Caso clínico. Mujer de 58 años que, previamente asintomática, presentó de forma brusca disminución de nivel de conciencia, hemiplejía derecha y afasia motora. La tomografía axial computarizada a las 48 horas mostraba dos lesiones isquémicas agudas en el hemisferio izquierdo. La resonancia magnética cerebral con secuencia de difusión mostró múltiples lesiones isquémicas en diferentes territorios arteriales. El ecocardiograma transtorácico a las 24 horas mostraba una vegetación en el velo posterior de la válvula mitral. La paciente se trató con heparina sódica intravenosa y no volvió a presentar nuevos ACV. Las lesiones valvulares desaparecieron tras el tratamiento. En un estudio de búsqueda neoplasia oculta, se halló un tumor ovárico derecho. Conclusiones. La posibilidad de ETNB debe considerarse en casos de embolia cerebral de origen desconocido. La mayoría de pacientes muestran datos analíticos de coagulación intravascular diseminada crónica. Para el diagnóstico las pruebas más útiles son el ecocardiograma transesofágico y la resonancia magnética cerebral con secuencia de difusión. El tratamiento de elección es la heparina (AU)

Introduction. In cancer patients, cerebrovascular accidents (CVA) are the most common complication occurring in the central nervous system after metastasis. One of its causations is non-bacterial thrombotic endocarditis (NBTE), which appears on rare occasions as the first symptom of the tumour. The clinical manifestations of NBTE are the result of multiple systemic embolism. Emboli consist of platelets and strands of fibrin that are deposited in the valves of the heart, within a context of a state of hypercoagulability secondary to the tumour. The tumours that are most frequently associated to NBTE are mucin-secreting adenocarcinomas. Cases of ovarian cancer with NBTE are rare in the different series reported in the literature. Case report. We describe the case of a 58-year-old female, previously asymptomatic, who suddenly showed a lowered level of consciousness, hemiplegia on the right-hand side and motor aphasia. A computerised axial tomography scan taken at 48 hours showed two acute ischaemic lesions in the left hemisphere. Magnetic resonance imaging of the brain with diffusion sequences revealed multiple ischaemic lesions in different arterial territories. Transthoracic echocardiography at 24 hours showed a vegetation on the posterior leaflet of the mitral valve. The patient was treated with intravenous sodium heparin and no new CVA appeared. The valve injuries disappeared after treatment. In a study conducted to search for occult neoplasia, a tumour was found in the right ovary. Conclusions. NBTE must be taken into account in cases of cerebral embolism due to unknown causes. The results of the analyses of most patients reveal chronic disseminated intravascular coagulation. The most valuable diagnostic tests are the transesophageal echocardiogram and magnetic resonance imaging of the brain with diffusion sequences. Preferred treatment is with heparin (AU)

[Cerebral ischaemia secondary to non-bacterial thrombotic endocarditis as the presenting symptom of an ovarian tumour]. / Isquemia cerebral secundaria a una endocarditis trombótica no bacteriana como forma de presentación de un tumor ovárico.

INTRODUCTION: In cancer patients, cerebrovascular accidents (CVA) are the most common complication occurring in the central nervous system after metastasis. One of its causations is non-bacterial thrombotic endocarditis (NBTE), which appears on rare occasions as the first symptom of the tumour. The clinical manifestations of NBTE are the result of multiple systemic embolism. Emboli consist of platelets and strands of fibrin that are deposited in the valves of the heart, within a context of a state of hypercoagulability secondary to the tumour. The tumours that are most frequently associated to NBTE are mucin-secreting adenocarcinomas. Cases of ovarian cancer with NBTE are rare in the different series reported in the literature. CASE REPORT: We describe the case of a 58-year-old female, previously asymptomatic, who suddenly showed a lowered level of consciousness, hemiplegia on the right-hand side and motor aphasia. A computerised axial tomography scan taken at 48 hours showed two acute ischaemic lesions in the left hemisphere. Magnetic resonance imaging of the brain with diffusion sequences revealed multiple ischaemic lesions in different arterial territories. Transthoracic echocardiography at 24 hours showed a vegetation on the posterior leaflet of the mitral valve. The patient was treated with intravenous sodium heparin and no new CVA appeared. The valve injuries disappeared after treatment. In a study conducted to search for occult neoplasia, a tumour was found in the right ovary. CONCLUSIONS: NBTE must be taken into account in cases of cerebral embolism due to unknown causes. The results of the analyses of most patients reveal chronic disseminated intravascular coagulation. The most valuable diagnostic tests are the transesophageal echocardiogram and magnetic resonance imaging of the brain with diffusion sequences. Preferred treatment is with heparin.

[Leptomeningeal carcinomatosis as presenting symptom of a gallbladder carcinoma]. / Carcinomatosis leptomeníngea como forma de presentación de un adenocarcinoma de vesícula biliar.

INTRODUCTION: Meningeal carcinomatosis is rare accounting for 4-5% in autopsy of patients with solid tumors, and even less frequent, 1%, in its pure form without brain metastases. We report a case of psychosis symptomatic of a meningeal carcinomatosis as presenting manifestation of a gallbladder carcinoma. This clinicopathological combination has not been described previously. CASE REPORT: 74 years-old man. His past medical history included Parkinson's disease treated with L-dopa 50 mg/8 hour and selegiline; duodenal ulceration and hypertiroidism. He started with delirium and visual hallucinations that do not responded to a reduction of L-dopa and suppression of selegiline. The examination of CSF was diagnostic, malignant cells were identified in the initial examination. The patient dead and his autopsy diagnostic was gallbladder carcinoma with meningeal carcinomatosis. CONCLUSIONS: Leptomeningeal carcinomatosis in its pure form is the infiltration of the leptomeninges without brain metastases. It is less than 1% of meningeal metastases from solid tumors. The most frequent primary tumors are: lung, breast, stomach-esophagus, melanoma, colo-rectal, genital and urinary; and the most frequent histological type is adenocarcinoma. The commonest presenting symptoms are focal brain, medullar or radicular symptoms. Psychiatric as isolated symptom are exceptional. Diagnosis is confirmed by the examination of CSF. Malignant cells appear in the first examination in 45-50% of cases. Leptomeningeal carcinomatosis in gallbladder carcinoma is rare; only four cases has been described previously none of them presenting as isolated psychiatric clinical picture.

[A case report of mixed, parenchymatous and meningo-basal neurocysticercosis]. / Presentación de un caso de neurocisticercosis mixta, parenquimatosa y meningobasal.

Neurocysticercosis is the most common parasitic disease of the central nervous system. Its incidence diminished dramatically in the last decades in our country, but due to emigration from endemic areas is expected an increase in the next years. In spite of the new immunologic and neuroradiographic techniques, diagnostic of centeinty may be very difficult. In this way exists controversy about the appropriate treatment. We present a case of mixed neurocysticercosis with parenchymal and meningeal disease that shows the difficulty of this disease in its diagnostic and treatment.

Carcinomatosis leptomeníngea como forma de presentación de un adenocarcinoma de vesícula biliar / Leptomeningeal carcinomatosis as presentig symptom of a gallbladder carcinoma

Introducción. La meningitis carcinomatosa es una entidad poco frecuente, pues aparece solamente en un 45% de las autopsias de pacientes con tumores sólidos y en un 1% en su forma pura sin metástasis cerebrales. Presentamos un caso de psicosis sintomática de meningitis carcinomatosa pura como manifestación inicial de adenocarcinoma biliar. Esta combinación clinicopatológica no se ha descrito previamente. Caso clínico. Varón de 74 años, con antecedentes de ulcus duodenal e hipertiroidismo, diagnosticado de enfermedad de Parkinson grado 1 en tratamiento con levodopa 50 mg/8 horas y selegilina. El paciente consultó por presentar un cuadro de delirio con alucinaciones visuales que no respondió a la disminución de la dosis de L-dopa y la suspensión de la selegilina. El análisis del líquido cefalorraquídeo (LCR) fue diagnóstico, pues se identificaron células malignas en la primera punción. El paciente falleció y el diagnóstico de autopsia fue de adenocarcinoma de vesícula biliar con leptomeningitis carcinomatosa por dicho tumor. Conclusiones. Se denomina meningitis carcinomatosa pura a la infiltración de la leptomeninge en ausencia de metástasis cerebrales. Aparece en menos del 1% de pacientes con neoplasias sólidas. Los tumores que con más frecuencia producen dicha meningitis son los de pulmón, mama, esófago-estómago, melanoma, colo-rectal, génito-urinario; y la forma histológica más frecuente es el adenocarcinoma. Los síntomas de presentación más frecuentes son los focales cerebrales,medulares o de raíces lumbosacras. Los síntomas psiquiátricos aislados son muy poco habituales. El diagnóstico se confirma por el hallazgo de células malignas en el LCR. La positividad de la primera punción es del 45-50%. La meningitis carcinomatosa por adenocarcinoma biliar es una rareza, sólo descrita previamente en cuatro casos anteriores y en ninguno de ellos se manifestó con síntomas exclusivamente psiquiátricos (AU)

Introduction. Meningeal carcinomatosis is rare accounting for 4-5% in autopsy of patients with solid tumors, and even less frequent, 1%, in its pure form without brain metastases. We report a case of psychosis symptomatic of a meningeal carcinomatosis as presenting manifestation of a gallbladder carcinoma. This clinicopathological combination has not been described previously. Case report. 74 years-old man. His past medical history included Parkinson’s disease treated with L-dopa 50 mg/8 hour and selegiline; duodenal ulceration and hypertiroidism. He started with delirium and visual hallucinations that do not responded to a reduction of L-dopa and suppression of selegiline. The examination of CSF was diagnostic, malignant cells were identified in the initial examination. The patient dead and his autopsy diagnostic was gallbladder carcinoma with meningeal carcinomatosis. Conclusions. Leptomeningeal carcinomatosis in its pure form is the infiltration of the leptomeninges without brain metastases. It is less than 1% of meningeal metastases from solid tumors. The most frequent primary tumors are: lung, breast, stomach-esophagus, melanoma, colo-rectal, genital and urinary; and the most frequent histological type is adenocarcinoma. The commonest presenting symptoms are focal brain, medullar or radicular symptoms. Psychiatric as isolated symptom are exceptional. Diagnosis is confirmed by the examination of CSF. Malignant cells appear in the first examination in 4550% of cases. Leptomeningeal carcinomatosis in gallbladder carcinoma is rare; only four cases has been described previously none of them presenting as isolated psychiatric clinical picture (AU)

Presentación de un caso de neurocisticercosis mixta, parenquimatosa y meningobasal / A case report of mixed, parenchymatous and meningo-basal neurocysticercosis

La neurocisticercosis es la enfermedad parasitaria más frecuente del Sistema Nervioso Central. Su incidencia disminuyó en nuestro país drásticamente en las últimas décadas pero debido al flujo migratorio desde área endémicas es de esperar un aumento de la misma en los próximos años. A pesar de las técnicas modernas inmunológicas y de neuroimagen el diagnóstico de certeza puede ser muy difícil. Asimismo existe todavía controversia sobre el tratamiento más adecuado y su efectividad. Presentamos un caso de neurocisticercosis mixta, parenquimatosa y meningobasal que ilustra las dificultades diagnóstico-terapéuticas que puede plantear esta enfermedad (AU)

[Leptomeningeal carcinomatosis as a form of presentation of anorectal melanoma]. / Carcinomatosis leptomeníngea como forma de presentación de un melanoma anorrectal.

We report a case of anorectal melanoma, whose first manifestation was a carcinomatous meningitis. The anorectal melanoma is a rare tumor of great malignity which represents 1-3 per cent of melanomas and 0.5 per cent of anorectal tumors. The most frequent symptoms are non-specific: rectal bleeding, pain at defecation, changes in the intestinal rythm. Sixty per cent of cases presented metastasis at the moment of diagnosis limited to the regional lymph nodes. In none of the cases published did the metastasis present as the first symptom. The case presented here manifested itself only with neurologic symptomatology compatible with carcinomatous meningitis whose finding led to the search of the original tumor, and this is what makes this case exceptional since the infrequency of this tumor is united to an unusual clinical presentation, not previously described in the literature.