Isolated tongue angioedema after alteplase infusion in acute ischemic stroke

BACKGROUND

Angioedema, like anaphylaxis, has been reported as a rare adverse event of alteplase infusion in acute ischemic stroke.

OBJECTIVE

We report the case of a patient with acute ischemic stroke who after treatment of alteplase developed angioedema.

METHODS

We report the case of an 81-year-old woman who presented to our observation with acute ischemic stroke. The patient was on therapy with 100 mg acetylsalicylic acid and a triple combination antihypertensive drug (perindopril 10 mg + 2.5 mg indapamide + 5 mg amlodipine). The patient was treated with alteplase infusion.

RESULTS

Five minutes after the end of the alteplase infusion (0.9 mg/kg for 1 hour) the patient developed isolated angioedema of the lips and tongue.

CONCLUSION

Although the incidence of alteplase-induced angiodema in these patients is rare, this case report suggests the need for routine inspection of the tongue in acute ischemic patient in treatment with alteplase infusion, especially in female patients in treatment with ACE inhibitors.

IER-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Thrombectomy for Stroke

Background and Purpose—

As a reliable scoring system to detect the risk of symptomatic intracerebral hemorrhage after thrombectomy for ischemic stroke is not yet available, we developed a nomogram for predicting symptomatic intracerebral hemorrhage in patients with large vessel occlusion in the anterior circulation who received bridging of thrombectomy with intravenous thrombolysis (training set), and to validate the model by using a cohort of patients treated with direct thrombectomy (test set).

Methods—

We conducted a cohort study on prospectively collected data from 3714 patients enrolled in the IER (Italian Registry of Endovascular Stroke Treatment in Acute Stroke). Symptomatic intracerebral hemorrhage was defined as any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline ≤24 hours or death. Based on multivariate logistic models, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve.

Results—

National Institutes of Health Stroke Scale score, onset-to-end procedure time, age, unsuccessful recanalization, and Careggi collateral score composed the IER-SICH nomogram. After removing Careggi collateral score from the first model, a second model including Alberta Stroke Program Early CT Score was developed. The area under the receiver operating characteristic curve of the IER-SICH nomogram was 0.778 in the training set (n=492) and 0.709 in the test set (n=399). The area under the receiver operating characteristic curve of the second model was 0.733 in the training set (n=988) and 0.685 in the test set (n=779).

Conclusions—

The IER-SICH nomogram is the first model developed and validated for predicting symptomatic intracerebral hemorrhage after thrombectomy. It may provide indications on early identification of patients for more or less postprocedural intensive management.

Leukoencephalopathy in 21-beta hydroxylase deficiency: report of a family

21-hydroxylase deficiency is the most common cause of congenital adrenal hyperplasia, an autosomal recessive disorder characterized by impaired synthesis of cortisol from cholesterol by the adrenal cortex. Subclinical involvement of brain white matter has been reported in subjects with congenital adrenal hyperplasia. Here we report a woman with a genetically assessed classic congenital adrenal hyperplasia and brain white matter abnormalities. Both the carrier parents also showed signs of leucoencephalopathy. Common causes of leukoencephalopathy were excluded by appropriate analyses. Our observation suggests that white matter anomalies may also be present in carriers of a mutation in the CYP21 gene. We therefore suggest performing CYP21 gene analysis in subjects with brain MRI evidence of white matter abnormalities that cannot otherwise be explained.

Muscle biopsy and in vitro contracture test in subjects with idiopathic HyperCKemia

BACKGROUND

Persistent high creatine kinase (CK) levels may reflect underlying subclinical myopathies. In most cases, pathogenesis is unknown and clinical management is unclear. Though clinically asymptomatic, these subjects are potentially susceptible to malignant hyperthermia.

METHODS

The authors analyzed 37 subjects with persistent elevation of CK without significant weakness or other neurologic symptoms. Neurologic examination was performed according to manual muscle testing. Muscle biopsy and the in vitro contracture test were performed in all subjects.

RESULTS

Twenty-three subjects (51.1%) were completely asymptomatic. The others had minor symptoms such as occasional cramps (11 subjects, 24.4%), fatigue (5 subjects, 11.1%), a combination of cramps and fatigue (5 subjects, 11.1%), and muscle pain (1 case, 2.2%). Muscle biopsy enabled precise diagnosis in 3 cases and was normal in 3 cases. The more frequent changes were variation in fiber size (31.1%), a combination of nuclear internalization and variation in fiber size (26.6%), nuclear internalization (6.6%), minor mitochondrial changes (4.4%), and neurogenic atrophy (4.4%). Immunocytochemical analysis was normal in all patients. In vitro contracture testing detected one malignant hyperthermia-susceptible and one malignant hyperthermia-equivocal subject.

CONCLUSIONS

The evidence of malignant hyperthermia susceptibility by in vitro contracture test seems to be relatively infrequent among subjects with idiopathic hyperCKemia, but the incidence of true malignant hyperthermia in idiopathic hyperCKemia is unknown. Muscle biopsy should be considered a useful, though not very sensitive, diagnostic tool in idiopathic hyperCKemia, because it enables potentially treatable disorders, such as inflammatory myopathies, to be discovered. No uniform morphologic finding typical of idiopathic hyperCKemia or malignant hyperthermia susceptibility was identified by muscle biopsy.

Motor-sensory neuropathy without minifascicles in a patient with 46XY gonadal dysgenesis

We report a 36-year-old patient with 46XY pure gonadal dysgenesis (GD), who manifested a syndrome of progressive motor-sensory neuropathy. Sural nerve biopsy showed severe axonal neuropathy. Since reported cases of chronic motor-sensory neuropathy and pure gonadal dysgenesis have been characterized by nerve biopsy evidence of minifascicle formation, we suggest that this clinical association may be a new type of hereditary motor-sensory neuropathy, not necessarily associated with minifascicle formation.

A novel heteroplasmic tRNASer(UCN) mtDNA point mutation associated with progressive external ophthalmoplegia and hearing loss

We sequenced all mitochondrial tRNA genes from a patient with sporadic external ophthalmoplegia (PEO) and 5% COX-negative fibers in muscle biopsy, who had no detectable large mtDNA deletions. Direct sequencing showed a heteroplasmic mutation at nucleotide 7506 in the dihydrouridine stem of the tRNA(Ser(UCN)) gene. RFLP analysis confirmed that 30% of muscle and 20% of urinary epithelium mtDNA harbored the mutation, which was absent in other tissues of the proband as well as in mtDNA of his mother and 100 patients with various encephalomyopathies. Several point mutations on mitochondrial tRNA genes have been reported in PEO patients without large-scale rearrangements of mtDNA but no point mutations have hitherto been found in the gene coding for tRNA(Ser(UCN)).

Nonspecific granulomatous prostatitis

Nonspecific granulomatous prostatitis (NSGP) is a relatively uncommon type of chronic inflammation of the prostate, frequently mistaken for carcinoma on digital rectal examination, trans-rectal ultrasound (TRUS) and serum PSA test. It is presently the most frequent variety of granulomatous prostatitis observed at histological examination. The present study reviews the trans-rectal US results and serum PSA levels of 20 patients with biopsy-proven NSGP. Physical findings, laboratory data and US indicated malignancy in all cases. Sonographically (TRUS), the lesions appeared as single or multiple hypoechoic nodules, mainly localised in the peripheral zone of the gland, mimicking carcinoma. Mean serum PSA values were 13.3 ng/ml (range from 3.5 to 34 ng/ml), and only one patient had a value lower than 4 ng/ml. A sufficiently long period of follow-up (mean 19 months; range from 7 to 48 months) with TRUS and PSA was only possible in 11/20 patients. In 8/11 cases, serum PSA returned within normal range, and in 5/11 patients the US features slowly resolved, the hypoechoic nodules disappearing. Final diagnosis can only be obtained by prostatic biopsy. Several questions remain unanswered regarding the relationship between chronic prostatitis and prostatic carcinoma, natural history, the need for specific therapy and also the follow-up of this disease.

Female paraurethral leiomyoma: ultrasonographic and magnetic resonance imaging findings

Primary benign paraurethral tumors in females are observed only rarely. They may occasionally be detected at physical examination or present with symptoms of bladder outlet obstruction. A leiomyoma originating from the smooth muscle fibers of the urethra in a 43-year-old woman is reported. The benign nature of the lesion was suspected on the basis of transvaginal ultrasonography and magnetic resonance imaging. Surgical enucleation was performed and light microscopy showed a well-differentiated smooth muscle tumor.

A syndrome of bilateral hemorrhage of the thalamus and myocarditis with fatal course

We report the case of a 41-year-old patient with bilateral hemorrhage of the thalamus, leading to death. Post-mortem examination showed acute myocarditis. Neuropathological study showed perivascular infiltrates in affected thalamic regions. Laboratory investigation failed to find any causal agent. We hypothesize an infective agent, affecting the heart and thalamus, as the cause of this syndrome. Diaschisis due to the strategic anatomical position of the thalamus may have been responsible for coma state and death.

Mitochondrial alterations in muscle biopsies of patients on statin therapy

Clinical and biopsy study of nine patients on statin therapy suffering from various myopathic syndromes is reported. Biopsy findings showed non specific myopathic signs and mitochondrial changes, such as subsarcolemmal accumulation, morphological alterations, lipid increase and Cox-negative fibers. These findings confirm that statins may cause muscle damage and impair oxidative metabolism.

Patients with neoplastic and nonneoplastic hematologic diseases acquire CTLA-4 antibodies after blood transfusion

BACKGROUND

The presence of antibodies to CTLA-4, a negative regulator of T-cell activation, was investigated in multiply transfused patients with malignant and non- malignant hematologic diseases. A previous study showed that, in multiply transfused patients, an immune response against nuclear matrix proteins can be induced by WBCs undergoing apoptosis during RBC unit storage. This study evaluated whether the same phenomenon could be involved in the induction of CTLA-4 antibodies in the patients analyzed.

STUDY DESIGN AND METHODS

Patient sera were tested for binding to the recombinant full-length CTLA-4 beta-galactosidase fusion protein by an ELISA. Immuno-fluorescence stainings were performed to analyze the CTLA-4 epitopes recognized by the antibodies and to detect such epitopes in the apoptotic cells present in the RBC units.

RESULTS

CTLA-4 antibodies were found in multiply transfused patients with beta-thalassemia (40%) and with other hemolytic diseases (33%) including leukemias (42%). A higher incidence of CTLA-4 antibodies was found in patients receiving non-WBC-reduced blood (88%) than in those receiving WBC-reduced blood (26%). Immunofluorescence staining showed that WBCs undergoing apoptosis in the RBC unit expressed CTLA-4 epitopes.

CONCLUSIONS

The apoptotic WBCs present in the RBC units, after cold storage, express CTLA-4 epitopes. These epitopes can be released and induce formation of CTLA-4 antibodies with profound implications in the development of autoimmune disorders and in facilitating tumor dissemination and metastasis.

HLA class II favors clearance of HCV infection and progression of the chronic liver damage

BACKGROUND/AIMS

This study was aimed to determine whether host-dependent genetic factors modulate the outcome of HCV infection.

METHODS

HLA class II DRB and DQB typing was performed in 184 infected patients and 200 healthy volunteers. Among the patients, 149 subjects had persistent HCV viremia (Group 1) and 35 subjects underwent spontaneous viral clearance (Group 2). Group 1 included cirrhotic patients with transfusion-acquired infections (n = 79), asymptomatic HCV carriers (n = 42), and patients with chronic hepatitis C responsive to interferon therapy (n = 28).

RESULTS

Spontaneous viral clearance was associated with HLA DRB1*1104 (pc = 0.054, OR = 4.51, 95% C.I. 2.02-10.1) and HLA DQB1*0301 (pc = 0.0039, OR = 4.52, 95% C.I. 2.15-9.51). In Group 1 the haplotype DRB1*1104/DQB1*0301 was less frequent (4.8%) than in Group 2 (18.3%) (pc = 0.009, OR = 7.38, 95% C.I. 2.58-21.59). At the HLA level, cirrhotic patients were not different from asymptomatic HCV carriers and patients with interferon-induced viral clearance. In cirrhotic patients infected with genotype 1b, the DQB1*0502 allele was more frequently found in those with rapidly progressive liver damage (OR = 8.15, 95% C.I. 1.49-44.44), but the corrected p-value was not significant (pc = 0.09).

CONCLUSIONS

The HLA haplotype DRB1*1104/DQB1*0301 appears to contribute to the spontaneous clearance of HCV infection. The predominance of the DQB1*0502 allele in cirrhotic patients with a rapidly progressive disease possibly reflects an influence of this allele on the progression of the HCV-related liver disease.

Network analyses of Y-chromosomal types in Europe, northern Africa, and western Asia reveal specific patterns of geographic distribution

In a study of 908 males from Europe, northern Africa, and western Asia, the variation of four Y-linked dinucleotide microsatellites was analyzed within three "frames" that are defined by mutations that are nonrecurrent, or nearly so. The rapid generation and extinction of new dinucleotide length variants causes the haplotypes within each lineage to diverge from one another. We constructed networks of "adjacent" haplotypes within each frame, by assuming changes of a single dinucleotide unit. Two small and six large networks were obtained, the latter including 94.9% of the sampled Y chromosomes. We show that the phenetic relationships among haplotypes, represented as a network, result largely from common descent and subsequent molecular radiation. The grouping of haplotypes of the same network thus fits an evolutionarily relevant criterion. Notably, this method allows the total diversity within a sample to be partitioned. Networks can be considered optimal markers for population studies, because reliable frequency estimates can be obtained in small samples. We present synthetic maps describing the incidence of different Y-chromosomal lineages in the extant human populations of the surveyed areas. Dinucleotide diversity also was used to infer time intervals for the coalescence of each network.