11/316. Status-like recurrent pilomotor seizures: case report and review of the literature. A diabetic 66 year old man who presented with pilomotor seizures in his right hemibody is described. The seizures recurred with an increasing frequency, leading to a status-like condition associated with Korsakoff's syndrome. An EEG was performed and several electroclinical seizures were recorded. brain MRI was negative. The patient, who was treated with carbamazepine, became seizure free after 1 week. memory and behaviour gradually returned to normal within 3 weeks. There was no further neurological episode during an 8 year follow up. Hyperosmolar, non-ketotic hyperglycaemia was considered to be the cause of the seizures. The pathophysiology of pilomotor seizures is discussed and the literature on the subject reviewed. ( info) |
12/316. Clinical efficacy of insulin-like growth factor-1 in a patient with autoantibodies to insulin receptors: a case report. The type B insulin-resistance syndrome is characterized by the presence of anti-insulin receptor antibodies that cause severe insulin resistance. Treatments including steroids, cyclophosphamide, plasmapheresis, or insulin-like growth factor-1 (IGF-1) are chosen according to severity of insulin resistance. We describe a patient with type B insulin resistance syndrome who was treated successfully with human recombinant (hr) IGF-1, although this treatment provoked a severe allergic reaction. An elderly man with impaired glucose tolerance and unpredictable hypoglycemic episodes which were gradually worsening increased in hemoglobin (Hb)A1c concentration from 6.5 to 13.4%. His fasting and postprandial hyperglycemia were associated with severe hyperinsulinemia. The patient was diagnosed with type B insulin-resistance syndrome by the presence of anti-insulin receptor antibodies. Double-filtration plasmapheresis, plasma exchange, and immunosuppressive therapy with cyclophosphamide and cyclosporin all failed to suppress anti-insulin receptor antibodies more than transiently. When we attempted the treatment by daily administration of hrIGF-1, fasting and postprandial plasma glucose concentrations became normal and HbA1c levels decreased to 7.1% over 2 months, until on one occasion administration resulted in anaphylaxis. After the patient became stable, desensitization therapy was performed successfully, and hrIGF-1 could be administered again with the plasma glucose returning. We concluded that IGF-1 therapy was an effective treatment choice for type B insulin-resistance syndrome in cases whose plasma exchange and immunosuppressive therapy have failed. ( info) |
13/316. Homonymous visual field defects in patients without corresponding structural lesions on neuroimaging. Homonymous visual field defects usually occur with structural processes affecting retrochiasmal visual pathways. The responsible lesion is usually evident on magnetic resonance imaging or on other neuroimaging studies. When results of neuroimaging are normal, functional illness is often suspected. The authors report four patients with homonymous visual field defects who presented with no evident corresponding lesion on magnetic resonance or computed tomography imaging. Etiologies for the visual field defects included the Heidenhain variant of Creutzfeldt-Jacob disease, degenerative dementia, subtle occipital ischemia demonstrated only on positron-emission tomography scanning, and nonketotic hyperglycemia. Clinicians should be aware of the alternative etiologies of organic homonymous visual field loss in patients with normal neuroimaging. ( info) |
14/316. Case 1. Cardiovascular dysfunction syndrome. A 56-year-old woman is referred with angina. A number of sequential management strategies have been attempted with varying results. Upon examination of her case, it is clear that she has cardiovascular dysmetabolic syndrome and is thus at high risk for adverse cardiovascular events. Two opinions for further management are presented. ( info) |
15/316. Refractive changes in diabetic patients during intensive glycaemic control. AIMS: To evaluate the clinical course and the characteristics of transient refractive error occurring during intensive glycaemic control of severe hyperglycaemia. methods: 28 eyes of patients with persistent diabetes were included in this prospective study. During the observation period, patients underwent general ophthalmological examination and A-mode scan ultrasonography was performed at each examination-at days 1, 3, and 7, and then once every week or every other week until recovery of hyperopia. RESULTS: A transient hyperopic change occurred in all patients receiving improved control after hyperglycaemia. Hyperopic change developed a mean of 3.4 (SD 2. 0) days after the onset of treatment, and reached a peak at 10.3 (6. 1) days, where the maximum hyperopic change in an eye was 1.47 (0. 87) D (range 0.50-3.75 D). Recovery of the previous refraction occurred between 14 and 84 days after the initial assessment. There was a positive correlation between the magnitude of the maximum hyperopic change and (1) the plasma glucose concentration on admission (p<0.01), (2) the HbA(1c) level on admission (p<0.005), (3) the daily rate of plasma glucose reduction over the first 7 days of treatment (p<0.001), (4) the number of days required for hyperopia to reach its peak (p<0.001), and (5) the number of days required for the development and resolution of hyperopic changes (p<0.0001). There was a negative correlation between the maximum hyperopic change of an eye and baseline value of refraction (p<0.01). During transient hyperopia, no significant changes were observed in the radius of the anterior corneal curvature, axial length, lens thickness, or depth of anterior chamber. CONCLUSIONS: The degree of transient hyperopia associated with rapid correction of hyperglycaemia is highly dependent on the rate of reduction of the plasma glucose level. A reduction of refractive index in intraocular tissues, especially in lens, appears to be responsible for this hyperopic change. ( info) |
16/316. Exploration of motor cortex excitability in a diabetic patient with hemiballism-hemichorea. Hemiballism-hemichorea in older patients with hyperglycemia, associated with high signal intensity in the contralateral striatum on T1-weighted magnetic resonance scans, is now an accepted clinical entity. We present an additional patient with this disorder. Using transcranial magnetic stimulation, we show that intracortical inhibition in the motor cortex contralateral to hemiballism-hemichorea is increased. This finding is discussed in the context of current models of basal ganglia-thalamo-cortical connectivity. ( info) |
17/316. Hyperglycemic pseudorejection in the diabetic transplant patient. serum creatinine elevation in a stable transplant recipient most often suggests rejection of the transplant and requires further evaluation and management. In our series of juvenile diabetic patients who have received kidney transplants, we frequently have observed creatinine elevations in association with hyperglycemia. Correction of the hyperglycemia resulted in return of serum creatinine to normal levels and no rejection therapy was required. To better define this syndrome, 2,734 paired measurements of blood glucose and serum creatinine were obtained in 52 stable post-transplant diabetic patients. A mean increase in blood glucose of 100 mg. per 100 ml. was found to increase serum creatinine by 0.5 mg. per 100 ml. in these patients (r=0.93; p less than or equal to 0.001). Evidence strongly suggests that the pathogenesis of this phenomenon is not a result of a laboratory artifact due to the technique used to determine serum creatinine. The pathogenesis may be due to the increased serum osmolarity and resulting intracellular dehydration associated with hyperglycemia. Recognition of this syndrome is important to all centers participating in the care and management of the diabetic transplant recipient. ( info) |
18/316. Ruptured ectopic pregnancy presenting with hyperglycaemia. A ruptured ectopic pregnancy is always an emergency. The key to successful treatment is early diagnosis, which is not always easy, mainly because typical presenting features may be absent. We report a case of a ruptured ectopic pregnancy that presented with a gastroenteritis illness together with hyperglycaemia, leading to an initial diagnosis of diabetes mellitus. The patient was treated successfully, however, once the correct diagnosis had been made. We conclude that a urine pregnancy test should be a routine procedure in all abdominal emergencies involving female patients of childbearing age, to avoid misdiagnosis or a delay in diagnosis. ( info) |
| Vacuolization of the renal tubular epithelial cells (the Armanni-Ebstein lesion) associated with diabetic hyperglycemia is usually regarded as an accumulation of glycogen. In a case of death of diabetic coma, the vacuoles were stained strongly for lipids. This observation may have both clinical and therapeutic consequences, and may increase our knowledge of the metabolism in diabetes. ( info) |
20/316. Hyperosmolar nonketotic syndrome with hypernatremia: how can we monitor treatment? We report the case of a 62 year-old symptomatic patient with severe hyperglycemic hyperosmolality associated with hypernatremia. During treatment, the progressive decrease in serum tonicity, which resulted in the amelioration of the neurological symptoms, followed the decrease in serum glucose and mainly the corrected serum sodium levels rather than the decrease in the uncorrected serum sodium levels. The case illustrates the usefulness of glucose - corrected serum sodium levels to monitor treatment in such conditions in order to avoid neurological consequences caused by the decrease in serum osmolality. ( info) |