Tardive dyskinesia: When one should suspect of another diagnosis?

Introduction

Tardive dyskinesia is a collection of symptoms related to the side effects of neuroleptic medications that can mimic other types of disorders. Accurate diagnosis can be challenging, as there is no single test for tardive dyskinesia.

Case report

Female patient, 64 years old, with personal history of Chronic Myeloid Leukaemia and psychosis since forth decade, currently medicated with quetiapine 350 mg/day, risperidone IM 50 mg 15/15 days and trazodone 150 mg/day (previously medicated with haloperidol, amisulpride and olanzapine). She started with involuntary movements interpreted as tardive dyskinesia after 2 years on neuroleptic treatment. The difficult control of involuntary movements motivated the reference to ambulatory Neurology department. The review of personal history suggested a family history of involuntary movements and psychiatric illness. Physical examination showed generalized choreic movements. The analytical and imagiologic study was unremarkable. The presence of family history and involuntary movements atypical to be classified as tardive dyskinesia supported a genetic test for Huntington's disease who detected a CAG expansion with 43 repetitions in HTT gene. Despite treatment with amantadine and riluzole she maintains disease progression and evident cognitive deterioration.

Conclusion

The diagnostic process of involuntary movements may involve more than one physician and requires the review of a detailed medical history, a physical examination and a neuropsychological evaluation in order to determine whether one is indeed suffering from tardive dyskinesia or a different neurological disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Water quality concerns due to forest fires: polycyclic aromatic hydrocarbons (PAH) contamination of groundwater from mountain areas

Water quality alterations due to forest fires may considerably affect aquatic organisms and water resources. These impacts are cumulative as a result of pollutants mobilized from fires, chemicals used to fight fire, and postfire responses. Few studies have examined postfire transport into water resources of trace elements, including the polycyclic aromatic hydrocarbons (PAH), which are organic pollutants produced during combustion and are considered carcinogenic and harmful to humans. PAH are also known to adversely affect survival, growth, and reproduction of many aquatic species. This study assessed the effects of forest wildfires on groundwater from two mountain regions located in protected areas from north and central Portugal. Two campaigns to collect water samples were performed in order to measure PAH levels. Fifteen of 16 studied PAH were found in groundwater samples collected at burned areas, most of them at concentrations significantly higher than those found in control regions, indicating aquifer contamination. The total sum of PAH in burned areas ranged from 23.1to 95.1 ng/L with a median of 62.9 ng/L, which is one- to sixfold higher than the average level measured in controls (16.2 ng/L). In addition, in control samples, the levels of light PAH with two to four rings were at higher levels than heavy PAH with five or six rings, thus showing a different profile between control and burned sites. The contribution of wildfires to groundwater contamination by PAH was demonstrated, enabling a reliable assessment of the impacts on water quality and preparation of scientifically based decision criteria for postfire forest management practices.

Kinetics of lactose fermentation using a recombinantSaccharomyces cerevisiae strain

This work presents a multi-route, non-structural kinetic model for interpretation of ethanol fermentation of lactose using a recombinant flocculent Saccharomyces cerevisiae strain expressing both the LAC4 (coding for beta-galactosidase) and LAC12 (coding for lactose permease) genes of Kluyveromyces lactis. In this model, the values of different metabolic pathways are calculated applying a modified Monod equation rate in which the growth rate is proportional to the concentration of a key enzyme controlling the single metabolic pathway. In this study, three main metabolic routes for S. cerevisiae are considered: oxidation of lactose, reduction of lactose (producing ethanol), and oxidation of ethanol. The main bioprocess variables determined experimentally were lactose, ethanol, biomass, and dissolved oxygen concentrations. Parameters of the proposed kinetic model were established by fitting the experimental data obtained in a small lab-scale fermentor with the initial lactose concentrations ranging from 5 g/dm3 to 50 g/dm3. A very good agreement between experimental data and simulated profiles of the main variables (lactose, ethanol, biomass, and dissolved oxygen concentrations) was achieved.

Anaerobic-aerobic sewage treatment using the combination UASB-SBR activated sludge

The performance of a pilot scale sewage treatment system composed of an upflow anaerobic sludge blanket (UASB) digester and a sequencing batch activated sludge reactor (SBR) is described. The system constitutes a simple, economic, and compact treatment option and is able to produce consistently a final effluent quality that is equal or better than that of a conventional activated sludge plant. The entire treatment system had a retention time of only 9h and an average operational temperature of 25 degrees C. Due to the efficient anaerobic pre treatment the aerobic sludge production was low and could easily be accommodated for stabilisation in the UASB reactor. The system exhibited excellent operational stability with full nitrification for aerobic sludge ages longer than 9 days. At shorter sludge ages there was excessive wash out of sludge particles and the sludge mass could not be maintained in the SBR reactor. Sludge settleability was good throughout the experimental investigation period of one year. The reduction of the reactor volume and oxygen consumption was more than 50% compared to conventional activated sludge. The anaerobic excess sludge had a high concentration and good stability so that its dewatering and final disposal was a relatively minor problem.

[Infection due to Mycoplasma pneumoniae: three cases with neurological complications]

INTRODUCTION

Mycoplasma pneumoniae infection has been associated with severe central nervous system diseases. The pathogenesis of these disorders is unknown and the treatment uncertain.

CASE REPORTS

The authors present three cases of central nervous system diseases: acute transverse myelitis, cerebellitis and encephalomyelitis associated with M. pneumoniae infection.

CONCLUSIONS

M. pneumoniae infection should be considered in all cases of severe acute central nervous system symptomatology.

Quantitative analysis of modes of invasion and lymph node metastases in oral squamous cell carcinoma

The mode of tumor invasion has been suggested to have a relationship to the occurrence of cervical metastasis and to prognosis in oral squamous cell carcinoma (OSCC). However, a tumor usually does not have a single mode of invasion, and the importance, if any, of the relative proportions of different modes for metastatic potential has not been studied. Forty two cases of OSCC resected with cervical lymph nodes were selected, 20 of which had nodal metastases and 22 which had not. The mode of invasion in the tumor-host interface was classified as: I - pushing borders, II - bands, III - thin cords, IV - single cells and analyzed in 20 consecutive medium power fields. Also studied were other morphological parameters: perineural and angiolymphatic invasion, tissue eosinophilia, mitosis and intensity of inflammatory infiltrate at the tumor-host interface. The majority of the cases (95.2%) showed two or more modes of invasion. Modes I, II and III occurred with similar frequency in cases with and without metastases. Mode II was the commonest and most extensive in both groups. No mode of invasion was significantly associated with metastases, independent of its extension. The other morphological parameters were neither significantly associated with cervical metastasis. In conclusion, OSCC usually shows two or more modes of tumor invasion if a large extension of tumor-host interface is analyzed. However, the relative proportions of the modes have no correlation with the metastatic potential.

[Transient hypertrophic neonatal myocardiopathy after acute fetal distress]

Hypertrophic cardiomyopathy is rare in neonates. The causes include metabolic disease, maternal diabetes, dexamethasone therapy in premature newborns for bronchopulmonary dysplasia and idiopathic hypertrophic cardiomyopathy. The authors present a case report regarding a neonate with transient hypertrophic cardiomyopathy, after acute fetal distress. Signs of congestive cardiac failure appeared at day 1. Echocardiography showed signs of mild pulmonary hypertension and normal ventricular wall thickness. Echocardiography on day 2 showed hypertrophy of myocardial walls affecting first the right ventricular anterior wall and the interventricular septum, followed by the left ventricular posterior wall. With therapy, clinical improvement was noted on day 4. The ventricular wall thickness was almost normal at three weeks. The authors alert physicians to the importance of echocardiographic examination of these neonates.

[Hydro-electrolyte changes induced by transurethral prostatic resection]

Transurethral resection prostatectomy (TURP) has been associated with severe hyponatremia due to massive absorption of bladder irrigation fluid (IF). TURP was performed in 41 patients using Sorbitol-Mannitol IF (Group A) and in 6 patients using distilled water (Group B). Six other patients were operated upon using surgical procedures identical in time and type of anesthesia to TURP (Group C). The three groups were studied with the same protocol that included blood collected before (time I), immediately after (time II) the procedure and 1 hour later (time III). Serum sodium decreased significantly in the 3 groups from time I to time II, an average of 3.4 mEq/l with Mannitol-Sorbitol, 2.3 mEq/l with distilled water, and 4.4 mEq/l in group C. Osmolality did not change significantly between the 3 times of collection and Osmolar Gap only increased from time I to II in the Sorbitol-Mannitol group. In conclusion, mild decrements in serum sodium with no clinical relevance are a common post-TURP finding, but should not be greater than in other similar general surgery without bladder irrigation. Hyposmolality did not constitute a problem.