[Pitfalls in the diagnosis of benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is a common but often unrecognized cause of treatable vertigo. Possible causes of misdiagnosis of BPPV were studied by review of the records of 191 patients referred to our neurology clinic; 36 were identified as having BPPV not previously diagnosed. On referral the patients carried the following diagnoses: unspecified dizziness/vertigo (33%), transient ischemic attacks (28%), cervicogenic vertigo (19%), psychogenic dizziness/vertigo (11%), and others (8%). The paroxysmal nature of the vertigo and position-precipitating factors were not spontaneously reported by 31%. Atypical, even bizarre, symptoms including dizzy sensations were reported by 19%, and neck pain and headache were cardinal symptoms that accompanied vertigo. The Dix-Hallpike maneuver, which is essential for the diagnosis of BPPV, was not performed in any of the patients prior to referral. 30 (83%) experienced complete resolution of signs and symptoms after the first physical treatment session. We conclude that non-paroxysmal, non-positional vertigo does not rule out BPPV. Atypical and even bizarre complaints of dizziness, as well as neck pain and headache could be cardinal symptoms of BPPV. The Dix-Hallpike maneuver is mandatory in those complaining of dizziness and vertigo.

Value of prothrombin fragment 1.2 (F 1.2) in the diagnosis of stroke in young patients with antiphospholipid antibodies

The presence in the serum of antiphospholipid antibodies (aPL) is associated with venous and arterial thrombosis. This observation has led to the search for these antibodies in young patients with ischemic neurologic syndromes. However, 1% to 5% of healthy people may be found to have circulating aPL without necessarily being at increased risk of thromboembolism. Thus, the finding of APLA in a patient with cerebral ischemia does not necessarily provide an explanation for the etiology of the clinical syndrome. The aim of this study was to determine whether the presence of aPL in young patients with stroke or transient ischemic attacks represents a possible cause of hypercoagulability as defined by ongoing thrombin formation with resultant elevation of prothrombin fragment 1.2 (F1.2) levels. This was a retrospective, case-control study involving 57 subjects. Twenty-seven patients had a recent cerebrovascular ischemic event--either TIA or a stroke. Fifteen were positive for aPL, and 12 were aPL-negative. Thirty subjects, matched for age and sex with no history of cerebrovascular disease, served as controls. Of this group, 20 were aPL-positive and 10 were aPL-negative. Causes of hypercoagulability other than aPL were excluded by laboratory testing. A positive test for aPL was repeated after a 6-week interval and two positive tests were required for a patient to be regarded as being aPL-positive. Levels of F1.2 were measured by an ELISA technique. There was a significant difference (p < 0.05) in the mean F1.2 levels between the aPL-positive group with a history of cerebrovascular disease (mean F1.2 = 2.3733) and each of the other study groups. There was no statistically significant difference between any of the other study groups. Our findings suggest that F1.2 levels are elevated in young patients with cerebrovascular syndromes who have aPL and in whom other causes of hypercoagulability and atherosclerotic vascular disease are absent. Elevated F1.2 in these patients may be a potential marker of the hypercoagulable state associated with aPL.

Idiopathic intracranial hypertension and anticardiolipin antibodies

The association of idiopathic intracranial hypertension (IIH) or pseudotumour cerebri (PTC) with anticardiolipin antibodies (aCL-Abs) has been only acknowledged recently. However, its true incidence is as yet unknown. In this retrospective study, the co-occurrence of IIH and aCL-Abs was looked for among a relatively large group of patients diagnosed with IIH or PTC in the neuro-ophthalmology clinic during the years of 1992-8. All patients underwent routine blood tests and the presence of activated protein C resistance and protein S and protein C deficiency were recorded. ACL-Abs were determined in all patients. The co-occurrence of IIH and aCL-Abs was found in three out of 37 patients (8.1%), which is higher than the incidence of aCL-Abs in the general population but considerably lower than that reported in two previously published studies. The aCL-Ab positive patients in our series were significantly older and thinner than those in whom antibodies were undetected. In conclusion, it seems that patients with this association should be considered as a unique subgroup of IIH.

Transmission of HTLV-I to rats via peripheral blood mononuclear cells and serum from a patient with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) with amyotrophic lateral sclerosis (ALS)-like features

We tested the possibility that lymphocytes and serum obtained directly from a patient with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) induce infection in rats. Inbred Fischer F344 immunosuppressed rats were inoculated intravenously with 10x10(6) peripheral blood mononuclear cells (PBMC; 3 rats) and serum (3 rats) obtained from a HAM/TSP patient, who was seropositive and polymerase chain reaction (PCR)-positive for the HTLV-I proviral genome. Antibodies to HTLV-I appeared in the rat sera 2 months later; rat peripheral blood lymphocytes, spleen, salivary gland, and spinal cord were found to contain the proviral genome. Control rats inoculated with normal donor PBMC and serum tested negative for the HTLV-I antibodies and for the HTLV-I proviral genome by PCR. The positive control F344 rats inoculated with 5x10(6) cells of a SLB-1 HTLV-I cell line were found to be infected after 2 months. This study demonstrates for the first time that HTLV-I can be transmitted not only by human cellular components but also by human cell-free sera in a rat model.

In vivo 23Na NMR studies of myotonic dystrophy

Myotonic dystrophy is an inherited multi-system disease. Its pathophysiology leading to muscle malfunction and damage is not well understood. 23Na NMR spectroscopy was applied here for an in vivo comparative study of the calf muscles of 7 myotonic dystrophy patients at various stages of the disease and 11 healthy volunteers. Both the total sodium content, expressed as the ratio of the 23Na and 1H water signals, and the fast transverse relaxation time, T2f, determined from the triple quantum-filtered spectra, increased in correlation with the severity of the disease. The results demonstrate that 23Na NMR enables the quantitation of myotonic dystrophy progression.

Cerebral venous thrombosis and chronic active hepatitis as part of the antiphospholipid syndrome

A case of antiphospholipid syndrome, presenting as sinus vein thrombosis together with chronic active hepatitis, is reported in a 35-year-old woman.

[Post-shock optic neuropathy]

A case of rare, post-shock optic neuropathy is presented. In most cases, it occurs after blood loss or decrease in blood pressure. We present a woman, aged 47, with this condition in whom 3 possible causes, hypoxia, hypercoagulability and vasodilatation, coexisted. Neurologists and ophthalmologists should be aware of this rare condition, because prompt treatment with steroids and hemodynamic stabilization may significantly improve outcome.

[Optic nerve sheath enlargement and reversal of optic nerve head in pseudotumor cerebri]

Using standard cerebral computerized tomography (CT), we diagnosed pseudotumor cerebri (PTC) and correlated the CT findings with CSF pressure and severity of visual impairment. 13 patients with a clinical diagnosis of PTC were compared with 20 age-matched controls with headache, but without papilledema or other neurologic signs. Cerebral CT consisted of axial sections of the posterior fossa, including the orbits. In all subjects the diameter of the optic nerve sheath, reversal of the optic nerve head, presence of empty sella, and size of the ventricles, cisterns and sulci were evaluated. There were no differences in basal cisterns and ventricles between those with PTC and control subjects. Empty sella was found in 6 of 13 PTC patients, compared with 1 of the 20 controls. Optic nerve sheath diameter in controls ranged from 3.5-5.0 mm (average 4.2 +/- 0.54 mm) but from 4.5-9.0 mm (average 6.8 +/- 1.54 mm) in those with PTC. Reversal of the optic nerve head was seen in 4 cases of PTC but in none of the controls. In PTC patients with opening CSF pressure greater than 270 mm water, the diameter of the optic nerve was wider than 7.5 mm. Thus, in most cases of PTC, bilateral enlarged optic nerves can be measured by standard cerebral CT and intracranial space-occupying lesions can be excluded as well. Moreover, reversal of optic nerve head, and empty sella can frequently be seen on CT in those with PTC.

Slowly progressive aphasia, a left temporal variant of probable Pick's disease: 15 years of follow-up

It is known that word-finding difficulties or anomia are the first signs observed in Pick's disease. We report a 15 year follow-up of a woman who at the age of 52 suddenly developed a speech impairment and only 6 years later showed other cognitive disturbances compatible with Pick's disease. This case demonstrates that nonfluent aphasia and agrammatic aphasia may constitute the first signs of this disease, stressing the importance of prolonged follow-up in such cases.

IL-2 and IL-6 secretion in dementia: correlation with type and severity of disease

The production of interleukin-2 (IL-2) and interleukin-6 (IL-6) by peripheral blood mononuclear cells (MNC) was assessed in patients with Alzheimer's disease (AD) who were subdivided into two groups--mild and moderately-severe--according to the severity of the disease, probable vascular dementia (VaD) patients and elderly control subjects. No differences in IL-2 secretion were found between mild AD patients and controls. However, there was a significant increase in IL-2 production both in the moderately-severe AD group and in the VaD group. IL-6 levels in AD patients of both groups were similar and significantly higher than those of VaD and controls. Our results suggest that increased levels of IL-2-production correlate with severity of the dementia, whereas increased levels of IL-6 production seem to be related to AD and thus may play a role in AD pathogenesis.

T lymphocyte subpopulations and activation markers correlate with severity of Alzheimer's disease

In this study we investigated immune-associated antigens of peripheral lymphocytes from patients with Alzheimer's disease (AD). The patients were divided into two groups--mild and moderately severe--according to severity of disease stage, and their lymphocytes were compared to those of elderly controls. In the mild stage of the disease we observed a slight increase in the HLA-DR marker (9.5 +/- 2.4% vs 6.5 +/- 1.1%; P = 0.06), but no changes in the CD4, CD8, and interleukin-2 receptor (IL-2R) markers. In the moderately severe stage, we observed a significant increase in the HLA-DR (18.5 +/- 2.7%) and CD4 markers (55.2 +/- 3.5% vs 43.5 +/- 2.1%, P < 0.01), and a slight decrease in the CD8 subset (19.5 +/- 1.4% vs 22.3 +/- 1.3%, P = 0.05). In the same group, following stimulation with the mitogen PHA, we observed a marked reduction in IL-2R expression (30.9 +/- 4.7% vs 41.1 +/- 2.7%, P = 0.05) and in the proliferative ability of lymphocytes (21131 +/- 4676 cpm vs 47909 +/- 1107 cpm, P < 0.04). However, mitogen-induced IL-2 secretion levels from the same lymphocytes were significantly elevated (17.4 +/- 4.8 U/ml vs 8.6 +/- 4.3 U/ml, P < 0.01). Marked changes in immunological parameters in the moderately severe group support the hypothesis of a peripheral immune reaction in AD which may be correlated with the clinical stage of the disease.

Fibrosing alveolitis associated with primary antiphospholipid syndrome

The spectrum of the primary antiphospholipid syndrome has expanded in recent years. It has been associated with a number of non-thrombotic syndromes such as pulmonary hypertension, adrenal insufficiency, chorea and avascular necrosis of bone. Yet, it has not been described in association with inflammatory pulmonary disease. We describe a young male with definite primary antiphospholipid syndrome who developed insidious diffuse pulmonary infiltrates. The histopathologic examination of the involved lung demonstrated alveolitis and fibrosis. We suggest that this pulmonary involvement may represent another manifestation of the primary antiphospholipid syndrome.

Correlation of cytokine secretion by mononuclear cells of Alzheimer patients and their disease stage

Cytokine secretion by human mononuclear cells (MNC) was investigated in age-matched controls and in patients with Alzheimer's disease (AD). AD patients were divided into two study groups: 'mild' and 'moderately severe'. A significant increase in interleukin-2 (IL-2) and gamma interferon (IFN-gamma) secretion was found in AD patients in the moderately severe stage of the disease, whereas in the mild stage of the disease there was a significant decrease in interleukin-3 activity (IL-3) and tumor necrosis factor (TNF) levels. No significant differences were found in the level of production of interleukin-1 (IL-1 beta). Our results demonstrate the existence of defective immune functions in AD patients which are correlated with the clinical condition of these patients.

Elevated interleukin-6 secretion levels by mononuclear cells of Alzheimer's patients

It has been suggested in recent research that interleukin-1 (IL-1) and interleukin-6 (IL-6) play a role in the pathogenesis of Alzheimer's disease (AD). Production of IL-1, by lipopolysaccharide (LPS)-stimulated monocytes, and IL-6, by phytohaemagglutinin (PHA)-stimulated mononuclear cells, was assessed in patients with AD divided into two groups--mild and moderately severe--according to severity of disease, and elderly controls. No differences in IL-1 production were found among AD patients and controls. However, significant elevation in IL-6 secretion levels was observed in both the mild and moderately severe AD patients. Our results suggest that peripheral IL-6 secretion levels may be responsible for acute-phase proteins observed in the serum of AD patients.

Myasthenia gravis: rarity of gallstone formation

There is an increase in the production of gallbladder stones (cholelithiasis) following gastrectomy associated with vagotomy; we hypothesized that in the presence of constant stimulation of the vagal system, there should be decreased production of gallstones. Forty-two myasthenia gravis patients taking continuous anticholinesterase medications underwent ultrasound study of the gallbladder; only one patient, aged 62, had gallstones. In the control group of 112 nonmyasthenics matched for age and ethnic origin, 45 had stones. This study suggests that cholinergic medications protect against gallstones.

Decreased IL-3 production by peripheral blood mononuclear cells in patients with multiple sclerosis

The production of interleukin-3 by peripheral blood mononuclear cells (MNC) was assessed in patients with relapsing multiple sclerosis (MS) in both the active and the stable state, and in healthy controls. IL-3 levels were compared to levels of production of interleukin-2 (IL-2), tumor necrosis factor (TNF) and gamma-interferon (gamma-IFN). No significant differences in IL-3 levels were observed between stable-state patients and controls. When levels of cytokine production of patients in the inactive phase were compared to those of the same patients during relapse a significant decrease in IL-3 levels was observed, as opposed to significant increases in gamma-IFN and TNF levels, and an increase, though a non-significant, in IL-2 levels. The functional significance of lowered IL-3 production is unknown. However, the findings support the hypothesis of a highly complex interaction of overlapping regulatory influences within the cytokine network which parallels MS disease activity.

[Septic cavernous sinus thrombosis]

Septic cavernous sinus thrombosis is a rare complication of facial infections, particularly of the dangerous triangle (nose and upper lip) and less often of the orbit, middle ear, pharynx or teeth. Staphylococcus aureus is the most frequent causative agent. Prompt diagnosis and early aggressive antibiotic therapy, with or without anticoagulants, is required. A 49-year-old woman developed this complication following multiple nasal abscesses. Despite intensive antibiotic and anticoagulant therapy she became permanently blind. We present this case to stress the fact that this disease is still fraught with high morbidity, and even mortality.

Interferon system and natural killer cell activity in myasthenia gravis

The autoimmune response in myasthenia gravis is well characterized, but little is known about the mechanisms initiating it. We have studied the interferon system and natural killer cell activity in 25 patients with myasthenia gravis and compared them to 68 healthy subjects and 96 patients with acute viral infections. Forty-four per cent of patients had circulating interferon (greater than 16 mu/ml), and in a similar proportion their peripheral blood mononuclear cells were in an antiviral state, i.e., showed low levels of viral replication when infected by vesicular stomatitis virus. Spontaneous in vitro interferon production by patients' peripheral blood mononuclear cells was also common (greater than 10 mu/ml, 32 per cent), while the response to the alpha-interferon inducer poly I:C was lower than expected, possibly reflecting the already high state of activation of the interferon system. These results were essentially similar to those obtained in patients with viral illnesses and differed significantly from healthy controls. In many myasthenia gravis patients (16 of 22, 73 per cent), a markedly deficient natural killer cell activity was found, with a median cytotoxicity of 6.5 per cent compared to 29 per cent in healthy subjects (p less than 0.005). Thus, many patients with myasthenia gravis have evidence of an activated interferon system and defective natural killer cell activity, suggesting an occult viral infection or reflecting nonspecific stimulation which may nevertheless contribute to the pathogenesis of the autoimmune response.

The interferon system in subacute sclerosing panencephalitis and its response to isoprinosine

Plasma interferon activity (IFN) and its spontaneous and stimulated production by peripheral blood mononuclear cells (PBMC) was studied in 11 patients with subacute sclerosing panencephalitis (SSPE) and age-matched healthy controls. The patients, similar to the healthy controls, had no detectable plasma IFN activity. However, their PBMC failed to produce IFN in response to stimulation with poly I:C and PHA. After isoprinosine administration to 7 patients for several days a significant increase in plasma IFN activity was observed and their PBMC responded to stimulation by producing IFN. The long-term effect of isoprinosine on the IFN response was evaluated in 3 patients who had been treated for 57-88 days. Induction of the abolished IFN production was observed with initiation of therapy. However, discontinuation of isoprinosine for 10 days resulted in recurrence of the inactivation state of the IFN system.

MRI parameters in multiple sclerosis patients

Magnetic resonance imaging (MRI) findings of 20 patients with clinically definite multiple sclerosis (MS) are presented. The studies were performed on a 0.5 Tesla magnet using spin-echo technique. Analysis of the MRI findings included detailed linear measurements of the ventricular and the subarachnoid spaces and reading of the intensity of the grey and white matter and intensity of the MS plaques. The plaques were sorted according to their number and size. The younger patients (20-40 years) had overall more plaques than the older ones (over 40 years). The small plaques were the most numerous and the large ones were the least common. Statistically significant association was found between the number of plaques and the cella media width. The intensity ratios between the non-plaque white matter/grey matter showed a significant correlation with the ventricular score. A significant negative correlation was found between the antero-posterior diameter of the spinal cord and the number of MS plaques in the brain. The plaque/white matter ratio had a significantly negative correlation with the cervical cord's width.

Acute brain edema due to water loading in a young woman

Increased intracranial pressure developed in a mentally and physically normal patient following ingestion of 30 glasses of water as a voluntary preparation for ultrasonic gynecological examination. Hyponatremia resulted and induced brain edema which provoked increased intracranial pressure. Hyponatremia was treated by intravenous infusion of hypertonic NaCl and mannitol solutions. Corticosteroids were added and continued for a week. The patient totally recovered 4 days after admission.

Gonadotropin, prolactin and TSH secretion in patients with myasthenia gravis

Hypothalamic pituitary function was studied in 13 patients with myasthenia gravis. Gonadotropin, TSH, and prolactin dynamics were investigated using conventional provocative stimuli. No consistent abnormality was found in either gonadotropin or prolactin release. Abnormal TSH responses to TRH administration was present in six of the 13 patients in association with normal free thyroxine indices and the absence of antithyroid antibodies. This latter observation is relevant when the association of myasthenia gravis with hyperthyroidism, thyroiditis and hypothyroidism is considered.

Unusual association of insulin-dependent diabetes mellitus with congenital myasthenia gravis and autoimmune thyroid disease

A 26-year-old woman with congenital myasthenia gravis and antibodies to the acetylcholine receptor developed overt insulin-dependent diabetes with positive islet cell antibodies and thyroid microsomal and gastric parietal cell antibodies. Her younger sister has been an insulin-dependent diabetic since the age of 7 years, and the mother has nongoitrous hypothyroidism. In the same period the woman in question developed a transient chemical hyperthyroidism. HLA typing of the family members showed that the diabetes was probably associated with an HLA AW30, BW38, DR4 haplotype, found in both sisters and in their father, and that the thyroid disease was associated with the A29, B7, DR6 haplotype found in the patient and in her mother. This familial HLA pattern may indicate that each autoimmune manifestation in the patient is due to a different susceptible gene associated with the HLA system.

Recurrent neuroleptic malignant syndrome due to tiapride and haloperidol: the possible role of D-2 dopamine receptors

Two typical recurrent episodes of neuroleptic malignant syndrome (NMS) in the same patient are described. The first episode was caused by a sulpiride derivative, tiapride. This is the first case in which a drug of the benzamide group has been reported to have caused such adverse drug reaction. In the second episode, NMS occurred due to haloperidol in the lowest dose ever reported and was accompanied by highly excessive levels of various muscle enzymes. Involvement of hypothalamic and striatal dopamine system, and particularly of D-2 subtype receptors, is suggested by this case.

Lead encephalopathy treated by versenate (CA-EDTA)

A patient with generalised epileptic seizures, mental and psychotic signs was diagnosed as suffering from lead encephalopathy. He was a big consumer of home-made arrack, illicit alcohol prepared at home in secrecy, in tools containing copper and lead. Basophilic stippling increased the possibility of lead encephalopathy, which was soon proved. He was successfully treated with low doses of Versenate, a chelating factor, and totally recovered.

Oncocytoma of kidney

Oncocytoma is a rare, benign tumor of the kidney of which only 20 cases have been reported previously in the literature. We document 2 additional cases of renal oncocytoma and review the salient gross and microscopic features which characterize this tumor.

Cell-mediated immunity to polio and HLA antigens in amyotrophic lateral sclerosis

Cell-mediated immunity to poliovirus was demonstrated in 21 of 33 patients suffering from amyotrophic lateral sclerosis (ALS), whereas no response to poliovirus was found in patients suffering from other neurologic disorders or in healthy controls. Three of the severe bulbar cases produced a migration inhibition factor (MIF) in the presence of poliovirus, although skin tests to common antigens were negative. An increased incidence (46 percent) of HLA-A3 was found in patients with amytrophic lateral sclerosis. Nine of the 13 patients with HLA-A3 antigen also had a positive index of MIF to poliovirus. These findings suggest a strong linkage between HLA-A3 and poliovirus in the pathogenesis of amyotrophic lateral sclerosis.

Extrarenal Wilms' tumor: report of a case and review of the literature

A case of an extrarenal Wilms tumor arising in the inguinal region of a 2-month-old boy is described. A review of the literature indicates that nine well-documented cases of extrarenal Wilms tumor have previously been described. Four of these tumors arose within teratomas. The remaining five cases, in which no teratomatous components were encountered, probably arose in embryologic rests of renal tissue.

Abetalipoproteinemia (Bassen-Kornzweig syndrome). Muscle involvement

A 26-year old male suffered from Abeta-lipoproteinemia (Bassen-Kornzweig disease). In addition to C.N.S. lesions, he had myopathy. A muscle biopsy revealed accumulation of ceroid pigment in the striated muscle. A few muscle fibers showed severe degeneration of the myofibrils. Fibroblasts and macrophages in the interstitial tissue contained abundant ceroid. The relation between ceroid accumulation, abetalipoproteinemia and vitamin E-deficiency is discussed.