Clinical diagnosis in Karwinskia humboldtiana polyneuropathy.

Intoxication by Karwinskia humboldtiana presents a neurological picture similar to that for Guillain-Barré syndrome or other polyradiculoneuropathies. Clinical diagnosis in poisoned humans may be difficult if no evidence of previous fruit ingestion is available. We present our experience in the clinical diagnosis of Karwinskia humboldtiana polyneuropathy, as confirmed by toxin detection in blood. We designed an open trial at the Pediatric Neurology service and included all cases with acute ascending paralysis that were admitted to our hospital in the last two years. In all cases, we performed hematological, immunological and biochemical profiles, CSF analysis including immunological studies, oligoclonal bands and myelin basic protein determinations. Electrodiagnostic studies were performed, including motor conduction velocities, distal latencies, F-wave latency and compound muscle action potential (CAMP) amplitude. The presence of Karwinskia humboldtiana toxins in blood were determined by thin layer chromatography. In six cases, T-514 Karwinskia humboldtiana toxin was detected. These cases had a symmetric motor polyneuropathy with the absence of tendon reflexes and no sensory signs or cranial nerve involvement. Only one patient required assisted ventilation due to bulbar paralysis. In two of these cases, a sural nerve biopsy revealed a segmental demyelination with swelling and phagocytic chambers in Schwann cells and without lymphocytic infiltration. All six cases survived, with complete recovery in five. We conclude that this intoxication is common in Mexico. The availability of toxin detection in blood samples allows the clinician to establish an accurate diagnosis and should be included in the study of children with polyradiculoneuropathy, especially in countries where this poisonous plant grows.

Rhinocerebral and systemic mucormycosis. Clinical experience with 36 cases.

We analysed retrospectively our clinical experience with 36 cases of mucormycosis. They were seen during the last 15 years. The diagnosis suspected on clinical grounds, was confirmed in 31 cases by finding the hyphae in hematoxylin-eosin stained material obtained from aspirated or tissue biopsy or by isolation of the fungus in culture. Rhinocerebral mucormycosis was diagnosed in 22 patients. Diabetes was the underlying disorder in 20 cases, kidney failure in one and myelodysplastic syndrome in one. Nine had stable and 11 unstable diabetes (ketoacidosis in 10 and hyperosmolar coma in 1). The earliest sign was facial edema, followed by proptosis, chemosis and extraocular muscle paresis. They were treated by extensive surgical debridement, insulin and antifungal drugs with 69% of survival rate. The disseminated mucormycosis was diagnosed at the autopsy in 5 cases, acute leukemia was the underlying disease in 2 of them. Pulmonary mucormycosis was diagnosed in 2 cases, cutaneous form in 2, sinuorbital form in 4 and brain abscess in one patient. Eight of these 9 cases survived after therapy. We emphasize the importance of an early diagnosis. This can only be made in the presence of a typical clinical setting confirmed by finding the hyphae in tissue or culture. Antifungal drugs along with treatment of the underlying disorder and aggressive surgical debridement must follow.

Cost of stroke in Mexico.

We report the estimated costs of stroke management in Mexico. The cost of stroke in our country has not been formerly described previously. The costs were estimated from population-based studies: the national survey on stroke and those performed by the Health Mexican Foundation. Other sources were the administration of private hospitals and official statistics obtained from the National Institute of Informatic, Statistic and Geography. Of 89 million Mexicans, 6.1% are older than 60 years. Based on the national stroke survey, it was calculated that 32,000 people suffer from stroke each year. Their mean age is 63 years. The estimated cost of acute stroke care in 1994 was $7,700 (U.S. dollars) per patient in private hospitals and $6,600 in institutions of the health sector. The major portion of the costs were spent in diagnostic procedures (40%). Physician costs ranged from 12% to 19%. The average in-hospital stay was 9 days with 18% in hospital mortality rate. About 20% of the total population are not covered by health care institutions. The cost of stroke care in Mexico is lower than in industrialized countries because of a shorter hospital stay and lower personnel wages. Indirect costs for chronic care are unknown in our country. The number of people older than 60 years will increase in the next century; hence, the number of persons with stroke will rise.

[Reye's syndrome in an adult. Review of pathogenic mechanisms]. / Síndrome de Reye en un adulto. Revisión de los mecanismos patogénicos.

Reye's syndrome is considered a disease of the pediatric age. It is characterized by a prodrome of viral illness followed by vomiting and encephalopathy with associated hepatic dysfunction. This syndrome is potentially life-threatening with high morbidity and mortality rates. There are 27 other cases of adult onset Reye's syndrome reported in the literature. We describe a 18-year-old woman who developed varicella and four days later started with vomiting, delirium and in the following day she became comatose. Laboratory tests of liver function and pathology of a liver biopsy proved the diagnosis. The patient survived. A review of the proposed pathogenic mechanisms are presented. Our patient represents case the number 28 in world literature and the first in the mexican literature.

Ischemic stroke due to deficiency of coagulation inhibitors. Report of 10 young adults.

BACKGROUND AND PURPOSE: Deficiencies in coagulant inhibitors protein C, protein S, and antithrombin III increase the risk of venous thrombosis. We describe 10 young adults with cerebral arterial thrombosis due to deficiencies in these factors. METHODS: Sixty patients younger than 45 years were hospitalized because of acute ischemic stroke diagnosed through computed tomography or magnetic resonance imaging. Cerebral angiography was performed in 54 cases. Hematologic and coagulation profiles, autoantibody screen, syphilis serology, and lupus anticoagulant were analyzed in all patients. Among the total cases, Holter monitoring was performed in 13 patients, echocardiography in 20, and cerebrospinal fluid studies for cysticercosis and tuberculosis in two. The quantitative analysis of protein C, protein S (by Laurell rocket immunoelectrophoresis), and antithrombin III (by radial immunodiffusion) was performed on admission and 3 months after stroke in all patients and in relatives of six patients. RESULTS: In 10 cases (17%) the stroke was attributed to deficiency of coagulation inhibitors: three men had protein C deficiency, two women had protein S deficiency, and five had antithrombin III deficiency (three men and two women). The cerebral infarction involved the carotid territory in these 10 patients. None had previous thromboembolic disease. Eight patients showed a complete recovery. An acquired disorder was presumed in one protein S-deficient and in two antithrombin III-deficient patients; the remainder were considered heterozygous. CONCLUSIONS: The cerebral vasculature may be primarily involved in the deficiency of these natural anticoagulants. Young adults seem to be the most often affected. A knowledge of these new clotting defects will enable the clinician to improve the prevention and treatment of this devastating neurological disease.

[Diagnosis of thrombosis of cavernous sinus in magnetic resonance imaging]. / Diagnóstico de trombosis del seno cavernoso en imagen por resonancia magnética.

The diagnosis of the cavernous sinus thrombosis requires a careful clinical evaluation and appropriate radiological methods. In this report we describe the magnetic resonance imaging findings in a patient with the clinical diagnosis of cavernous sinus disorder and its correlation with orbital phlebography and histopathologic studies.

Nuclear magnetic resonance in bipolar affective disorders.

Nuclear magnetic resonance produced by a FONAR QED 80 whole-body scanner with measurement in vivo of T1 proton relaxation time was used in 20 patients with the clinical diagnosis of bipolar affective disorder. Diagnoses were based on Research Diagnostic Criteria, Diagnostic Statistical Manual III code 296.66, and on Schedule for Affective Disorders and Schizophrenia. Proton T1 relaxation times were measured in all patients and in 18 normal controls before and after lithium carbonate treatment. Normal values of T1 in frontal and temporal lobes were 210 +/- 10 msec. All but three patients had prelithium T1 values higher than the controls (264 +/- 8.8 msec). After lithium therapy of 900 mg/day for 10 days, serum lithium levels were in the therapeutic range of 0.5-1.5 mEq/L, and patient T1 values were near normal levels (208 +/- 8.0 msec). One patient with a prelithium level within normal range proved to have cyclothymic disorder and not bipolar affective disorder; two patients did not complete the study. This study shows a statistically significant difference (p less than 0.01) in the behavior of hydrogen protons in bipolar affective disorder, which has not previously been reported in medical literature.