1/15. An unusual manifestation of diabetes mellitus.MEDICAL history: Type 2 diabetes mellitus for five years; unexplained 35-lb weight loss three years ago; Bell's palsy on right side many years ago. MEDICATIONS: glipizide, 10 mg/day. family history: Father died of leukemia at age 65; mother has kidney stones; no diabetes or neuromuscular disease. SOCIAL history: insurance salesman; heterosexual, promiscuous, uses condoms; smokes (25 pack years); does not drink. physical examination: Well-nourished, well developed, not in acute distress; had difficulty rising from a sitting position because of right lower extremity weakness. blood pressure, 154/74; pulse, 88; temperature, 36.6 degrees C; respiratory rate, 16. Head, eyes, ears, nose, and throat: normal. neck: normal. Heart: S4. Lungs: clear. abdomen: mildly obese. extremities: no cyanosis, clubbing, or edema; atrophy and weakness of right thigh and both calves; wide-based gait; able to walk on toes but not heels. Neurologic responses: cranial nerves intact; deep tendon reflexes, 1 symmetrically; plantar reflexes, flexor bilaterally. skin: macular rash in sun-exposed areas. LABORATORY FINDINGS: Hemoglobin, 13.2 gm/dL; mean corpuscular volume, 80 micron 3; white blood cell count, 7,200/mm3 (normal differential); platelet count, 137,000/mm3. serum: electrolytes, normal; blood urea nitrogen, 18 mg/dL; creatinine, 0.8 mg/dL; glucose, 308 mg/dL; total protein, albumin, liver enzymes, and creatine kinase, normal. urine: 1 glucose. Venereal disease test: nonreactive; hiv test: negative. DIFFERENTIAL diagnosis: dermatomyositis; heavy-metal poisoning; diabetic amyotrophy. HOSPITAL COURSE: The patient was given 50 mg/day of oral amitriptyline to alleviate the painful paresthesias and was switched to 20 U/day of subcutaneously injected neutral protamine Hagedorn (NPH) insulin to normalize the blood glucose level. Histologic studies of skin and muscle showed sun damage and neuropathic changes, respectively. There was no evidence of vasculitis. Screening for heavy-metal toxins produced negative results.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/15. Respiratory failure due to muscle weakness in inflammatory myopathies: maintenance therapy with home mechanical ventilation.polymyositis and dermatomyositis are idiopathic inflammatory myopathies. Respiratory complications are a common feature, but ventilatory insufficiency is rare in these patients. We describe here three patients diagnosed with inflammatory myopathy (polymyositis) with respiratory failure due to muscle weakness who did not respond to immunosuppressive therapy. Mechanical ventilation at home with nasal or tracheal intermittent positive pressure resulted in improved chronic hypoventilation. This treatment improves the quality of life of patients with inflammatory myopathies and can be lifesaving in some cases.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/15. An unusual schwannoma of the median nerve: effects on the motor branch.An unusual case of a schwannoma of the median nerve is presented where pressure due to the tumour on the motor branch to the thenar muscles caused weakness and wasting of the abductor pollicis brevis muscle, a previously unreported phenomenon. The patient achieved a full functional recovery after enucleation, which is also unusual considering the patient's age. Aspects of schwannoma biology, differential diagnosis, investigation and treatment are discussed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/15. Unilateral spatial neglect associated with chronic subdural haematoma: a case report.A 69-year-old right-handed man who exhibited unilateral spatial neglect in association with a chronic subdural haematoma, presented with mild left arm and leg weakness first noted 4 weeks prior to admission. neurologic examination on admission revealed a mild left hemiparesis, including the face. Neuropsychologic examination revealed left unilateral spatial neglect, but no language disturbance. Minimal support was necessary to maintain activities of daily living. Computed tomography revealed a large right temporoparietal, extraaxial hypodense fluid collection containing scattered hypodense foci. The haematoma was evacuated via a right parietal burr hole. Following surgery, the patient dramatically improved neurologically and neuropsychologically, as well as in independent performance of daily activities. It is suggested that the improvement in ADL provides a behavioural correlate of improvement in the latter, represented a behavioural correlate of improved cerebral function, and that either direct compression by the chronic subdural haematoma or an interhemispheric pressure difference had caused unilateral spatial neglect. Such neglect is an unusual consequence of chronic subdural haematoma.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/15. Visual loss with papilledema in guillain-barre syndrome.papilledema and raised intracranial pressure have been reported in association with guillain-barre syndrome. papilledema is usually asympotomatic or associated with mild visual field defects, without any visual loss. The cerebrospinal fluid protein is usually reported to be high. A case of a 35 year old lady is reported, who presented with headache, diplopia and progressive visual loss in both eyes and limb weakness with hyporeflexia. Optic fundus examination showed bilateral papilledema. She had features of pseudotumor cerebri. Nerve conduction studies were suggestive of polyradiculopathy. The unusual things in this case, were the profound visual loss normal cerebrospinal fluid profiles and the presentation of papilledema before the limb weakness.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/15. Cardioactive steroid poisoning from an herbal cleansing preparation.We describe a case of unintentional poisoning from a cardioactive steroid and the subsequent analytic investigation. A 36-year-old woman with no past medical history and taking no conventional medications ingested an herbal preparation marketed for "internal cleansing." Its ingredients were neither known to the patient nor listed on the accompanying literature. The next morning, nausea, vomiting, and weakness developed. In the emergency department, her blood pressure was 110/60 mm Hg, and her pulse rate was 30 beats/min. Her ECG revealed a junctional rhythm at a rate of 30 beats/min and a digitalis effect on the ST segments. After empiric therapy with 10 vials of digoxin-specific Fab (Digibind), her symptoms resolved, and she reverted to a sinus rhythm at a rate of 68 beats/min. Her serum digoxin concentration measured by means of the fluorescence polarization immunoassay (Abbott TDx) was 1.7 ng/mL. Further serum analysis with the Tina Quant digoxin assay, a more digoxin-specific immunoassay, found a concentration of 0.34 ng/mL, and an enzyme immunoassay for digitoxin revealed a concentration of 20 ng/mL (therapeutic range 10 to 30 ng/mL). serum analysis by means of high-performance liquid chromatography revealed the presence of active digitoxin metabolites; the parent compound was not present. When the diagnosis of cardioactive steroid poisoning is suspected clinically, laboratory analysis can confirm the presence of cardioactive steroids by using immunoassays of varying specificity. An empiric dose of 10 vials of digoxin-specific Fab might be beneficial in patients poisoned with an unknown cardioactive steroid.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/15. Supratentorial and infratentorial intraparenchymal hemorrhage secondary to intracranial CSF hypotension following spinal surgery.STUDY DESIGN: A single case study was conducted. OBJECTIVES: To detail the occurrence of multiple intracranial, intraparenchymal hemorrhages following an iatrogenic acute reduction in cerebral spinal fluid pressure following excision of an intradural extramedullary spinal tumor. SUMMARY OF BACKGROUND DATA: Multiple supratentorial, intraparenchymal, intracranial hemorrhages following an acute reduction in cerebral spinal fluid pressure have not been previously reported in the literature. methods: A case report and literature review are presented. RESULTS: The patient made an uneventful full recovery. CONCLUSION: Intracranial hemorrhage must be considered in the differential diagnosis of patients presenting with persistent headache following spinal surgery when the dura has been breached and is associated with significant cerebrospinal fluid loss.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
8/15. Idiopathic spinal cord herniation associated with a large erosive bone defect: a case report and review of the literature.We report a case of idiopathic spinal cord herniation associated with a large bone defect. MRI and computed tomographic myelography revealed ventral deviation of the spinal cord and erosion of the vertebral body at T6-T7. Microscopic surgery revealed a dural defect. The etiology of this condition has not been clarified. In most previously reported cases, the peak portion of the herniation was around the intervertebral disc space. In addition, in our patient, it was hard to think that the intervertebral disc has become depressed due to the pressure exerted by the spinal cord. We considered that a certain condition of the intervertebral disc, such as herniation, was one of the causes of the dural defect, and cerebrospinal fluid pulsation pushed the spinal cord toward that portion, causing herniation.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/15. Recurrent spinal fistula as result of a rare combination of a perimedullary and peridural spinal fistula: case report.OBJECTIVES: We report on a patient with the combination of a peridural and a perimedullary spinal fistula, which manifested consecutively. The clinical course and diagnostic steps reveal important observations helpful in the management of this pathology. CASE PRESENTATION: A 61-year-old male patient presented with a six-month history of progressive weakness of the lower limbs. Magnetic resonance imaging revealed edema and dilated spinal veins of the lower thoracic spinal cord. Spinal angiography confirmed the diagnosis of spinal dural fistula at level T9 on the left. The patient underwent surgery and the fistula was surgically excised. Two months after initial improvement, the clinical symptoms of lower limb weakness recurred. On re-angiography a spinal perimedullary fistula was found at level T7 that was not apparent on the previous angiogram and on the postoperative control angiogram. The patient underwent surgery again, and the second fistula was also excised. The clinical symptoms subsequently improved. CONCLUSION: The interesting point in this case was the rare combination of a peridural and a perimedullary spinal fistula. They presented consecutively and could not be identified simultaneously on the first angiogram. Only after closure of the first fistula did the second become apparent. We believe that this may be a result of a postoperative pressure change in the venous system of the cord. After closure of the first fistula, the arterio-venous (AV) shunt of the second fistula developed gradually. The possibility of a second fistula should be considered in the presence of persistent edema of the cord on magnetic resonance imaging (MRI) and subsequent clinical deterioration.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/15. McArdle's disease presenting as unexplained dyspnea in a young woman.McArdle's disease is a rare, inherited deficiency of myophosphorylase, an enzyme required for the utilization of glycogen. patients with myophosphorylase deficiency classically present with exercise intolerance, leg pain and muscle fatigue. The case of a young woman with exertional dyspnea and leg cramps is described. exercise testing confirmed the presence of exercise intolerance and demonstrated an accelerated heart rate response, despite the absence of an anaerobic threshold and a respiratory exchange ratio of less than 1.0. Subsequent ischemic forearm testing and muscle biopsy confirmed the diagnosis of myophosphorylase deficiency. Evaluation of lung mechanics with esophageal pressure measurements demonstrated the presence of respiratory muscle weakness and early fatiguability, suggesting that the patient's dyspnea might have been attributable to an increased respiratory effort. dyspnea is not a classic symptom associated with myophosphorylase deficiency, although subclinical respiratory muscle impairment may be present. No previous studies have evaluated respiratory muscle function during exercise in patients with myophosphorylase deficiency.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
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