[A young boy with periodic strange behavior and hypersomnia: Kleine-Levin syndrome]

Kleine-Levin syndrome is a rare neuro-psychiatric disease. Most of the young patients are males who present with hypersomnia, cognitive dysfunction, altered perception, eating disorder (e.g. hyperphagia) or disinhibited behaviour (e.g. hypersexuality). Psychiatric symptoms such as apathy, delusions and hallucinations, depressed mood and compulsive behaviours also appear often and result frequently in a psychiatric referral. These symptoms, however, should be distinguished from those of psychiatric diseases as early as possible in order to ensure that patients do not receive the wrong treatment. We present the case of an 11-year-old boy in whom the psychiatric symptoms were initially the most prominent ones.

The influence of PAX-14 on activated sludge systems and in particular on Microthrix parvicella

The amount of wastewater treatment plants (WWTP) dealing with solid separation problems has significantly increased since the new requirements of the EU Directive 271/91 on nutrient removal. In Flanders a number of the nutrient removal WWTP are affected by solid separation problems mostly attributed to Microthrix parvicella being the most common dominant species. The effect of dosing polyaluminium chloride (PAX-14) on activated sludge is illustrated for WWTP solids separation problems, in particular because of Microthrix parvicella. The effects of the addition of PAX-14 on the microbiology and the morphology of Microthrix parvicella were studied in 9 full-scale WWTP. PAX-14 succeeded in reducing high SVI-values and controlled foaming problems whenever caused by Microthrix parvicella. Laboratory trials have shown that the dosage of PAX-14 should be less than 150 microL/L or 7 g Al3+/kg MLSS. At a dosage higher than 250 microL/L, an increase of free bacteria and a decrease of the protozoa activity are observed. In full-scale, PAX-14 is dosed at a concentration of 1.5 to 4.5 g Al3+/kg MLSS. Before addition, the mixed liquor scum layer--if present--should be removed. In our experience, the dosing should last for at least 3 weeks. During the first week, no drastic changes occur. At the end of the first week, an increase of SS and SVI is possible. The SVI and scum start to decrease after 10 to 15 days. The amount of filaments is reduced after 3 to 3 1/2 weeks. The morphological properties of Microthrix parvicella change, while other filaments such as Nostocoida limicola and Nocardia spp. are not affected. This study proves that PAX-14 is effective in controlling bulking and foaming problems at WWTPs when they are due to Microthrix parvicella. Prediction of when the SVI will decrease and when addition should be stopped is possible.

Comparative sensitivity of exercise, cold pressor and ergonovine testing in provoking attacks of variant angina in patients with active disease

Exercise, ergonovine and the cold pressor test have been used to provoke variant angina attacks. The sensitivity of these three tests was compared in 34 hospitalized patients with well documented, active variant angina who had recently undergone coronary arteriography. The three tests were usually performed on three consecutive days, and 28 of the 34 had the three tests within 1 week. Angina was provoked by ergonovine in all 34 patients, by exercise in 17 and by cold pressor test in only five (p less than 0.005). ST elevation developed during the ergonovine test in 32 (94%), during exercise in 10 (29%) and during the cold pressor test in only three (9%). With ergonovine, one patient had only ST depression and one had no ECG changes. During the cold pressor test two patients had pseudonormalization of abnormally negative T waves and 29 had no ECG changes. Exercise induced T-wave pseudonormalization in four patients, ST depression in nine others and no ECG changes in 11. ST elevation was more frequent with ergonovine than with either of the other tests (p less than 0.0001). ST elevation or T-wave pseudonormalization occurred more often with exercise than with cold (p less than 0.05), but both occurred less often than with ergonovine (p less than 0.0001). We conclude that the sensitivity of the ergonovine test is very high in patients with active variant angina and that exercise will provoke angina with ST elevation in about 30% of these cases. In contrast, the sensitivity of the cold pressor test is too low to be of much clinical value in the diagnosis of variant angina.

Ergonovine testing to detect spontaneous remissions of variant angina during long-term treatment with calcium antagonist drugs

A subgroup of 22 patients with variant angina who had responded well to calcium antagonist drugs were studied to determine if ergonovine testing could help assess the need for continued therapy. Before treatment all 22 patients exhibited angina with S-T elevation during ergonovine testing done in the coronary care unit according to a previously described protocol with sequential ergonovine doses of 0.0125, 0.025, 0.05, 0.1, 0.2, 0.3 and 0.4 mg administered at 5 minute intervals. After 9.4 +/- 4.7 (range 1 to 24) months of treatment (nifedipine 7 patients, diltiazem 3, verapamil 8, perhexiline 3, nifedipine and diltiazem 1), all patients were free from anginal attacks. Medication was discontinued and ergonovine testing repeated 24 to 48 hours later (3 weeks for perhexiline). In 12 of the 22 patients, angina or S-T segment shifts did not occur during the second ergonovine test to a maximal dose of 0.4 mg. Treatment was not restarted in these patients and all 12 remain free of variant anginal attacks 4.2 +/- 2.9 (range 1 to 13) months later. In seven patients angina and S-T elevation occurred during the second ergonovine test, in the same electrocardiographic leads as during the test before treatment. In three patients the ergonovine test induced angina with S-T depression in the leads where S-T elevation had occurred during the previous test. Treatment was reinstituted in these 10 patients with a positive test. No complications resulted from ergonovine testing in any patient. We conclude that in many patients with variant angina, symptoms will disappear spontaneously and the ergonovine test will revert to negative. Treatment with calcium antagonist drugs can probably be safely discontinued in some patients with variant angina; ergonovine testing appears to be helpful in identifying such patients. Longer periods of follow-up are required to confirm that symptoms do not recur.

Ergonovine testing in a coronary care unit

This study describes the results of ergonovine testing in 100 consecutive patients who underwent this procedure in a coronary care unit. All patients had recently undergone coronary arteriography. A bolus injection of ergonovine was administered at 5 minute intervals in the following doses (mg): 0.0125, 0.025, 0.05, 0.1, 0.2, 0.3 and 0.4. The criterion for a positive test was the appearance of S-T elevation greater than 1 mm. The test was positive in all 17 patients known to have variant angina and in 18 (40 percent) of 45 patients who had a history of chest pain judged strongly suggestive of variant angina but who had no electrocardiogram recorded during pain. Of 38 patients with a history of chest pain classified as not entirely typical of variant angina, only 1 (2.6 percent) had a positive test. Of the 64 patients with a negative ergonovine test, 47 had chest pain and 25 had nausea but none had more serious complications. Ventricular arrhythmia accompanied S-T elevation in 18 of the 36 patients with a positive test but occurred in only 4 of the 64 with a negative test (p < 0.0005). No patient needed treatment with antiarrhythmic drugs. Four of the 36 patients with a positive test had serious complications: severe transient hypotension (2 patients), recurrent episodes of angina with S-T elevation (1 patient) and a subendocardial infarction (1 patient). Thus, ergonovine testing is useful in patients with a typical clinical history of variant angina but without an electrocardiogram recorded during pain. In this study, a small but definite incidence of serious complications occurred during a positive test.

Previously undiagnosed variant angina as a cause of chest pain after coronary artery bypass surgery

Variant angina was diagnosed after coronary artery bypass surgery in six patients over a 22-month period. Although all six patients had at least occasional angina at rest preoperatively, all but one had predominantly exertional angina. After surgery, rest angina with transient ST-segment elevation appeared in all six after an asymptomatic interval of 1 week to 4 years. In two patients the involved artery had not been bypassed, in two patients it was perfused by a patent graft and in two patients the graft to the involved vessel was occluded. Treatment with calcium antagonist drugs (four cases) or isosorbide dinitrate (one case) eliminated symptoms; one patient spontaneously became asymptomatic. The diagnosis of variant angina should be considered when rest angina occurs after bypass surgery, particularly if exertional angina is absent and grafts are patent.

Refractory variant angina controlled with combined drug therapy in a patient with a single coronary artery

A young man with a single left coronary artery and refractory variant angina is described. Spontaneous coronary artery spasm developed during coronary arteriography at the site of a 50% fixed left anterior descending coronary artery stenosis. Frequent episodes of rest angina with transient ST segment elevation persisted in hospital in spite of treatment with three different calcium antagonist drugs. Symptoms disappeared only when the combination of nifedipine, diltiazem, isosorbide dinitrate, and nitroglycerin ointment were given. Ergonovine testing was used to objectively assess the response to treatment.