Central pontine myelinolysis after liver transplantation. Report of five cases Background: Central Pontine Myelinolysis (CPM) is the most severe neurological complication after liver transplantation and apparently is not related to changes in osmolarity. Aim: To report five transplanted patients with CPM. Patients and Methods: In a series of 27 patients subjected to liver transplantation between 2005 and 2008, we found five patients who developed CPM. Results: All patients presented a severe hepatic encephalopathy. In the absence of alterations in osmolality, they developed, between the second to seventh day after transplantation, a central quadriplegia, hyperreflexia and Babinski sign, with preservation of sensorium. Magnetic resonance imaging showed demyelination of the motor pathway only in the protuberance. Motor recovery first began in the fingers and hands, followed by forearms, toes, feet, arms and finally the legs, defining a somatotopic recovery of the cortico-spinal pathway. Conclusions: This form of regaining motility shows that the selective involvement of the pyramidal tract in CPM, is according to its location in the pons and suggests a local entrapment. It is due to the structural rigidity of the protuberance that limits the expansive requirements of cytotoxic and vasogenic edema, and only affects the long fibers of cortico-spinal tracts, sensitized by encephalopathy. The entrapment syndromes generally preserve the axons, injure myelin and have no inflammatory reactions.
Background: Nocardiosis is caused by several strains of Nocardia, Gram-positive bacteria that infects humans and animals likewise. They develop a systemic infection of pulmonary or cutaneous origin that can spread to the Central Nervous System. It frequently affects immunosupresed patients, in which parvosymptomatic cerebral abscess has been described, visible in magnetic resonance imaging but without focal symptoms. Patients and Methods: We want to communicate two women with renal transplant in immunosupresor treatment who were admitted to our hospital for acute pulmonar disease, during which patient A presented a convulsive episode and patient B headache and stupor, after which CT and MRI were obtained. In both cases multiple cerebral abscesses were found, of different sizes and location, with no clinical manifestations. Nocardia diagnosis was made in patient A by biopsy from a cutaneous mycetoma and in patient B after surgery of a cerebellar abscess. In both cases antimicrobial treatment was initiated with good response, but had to be interrupted due to adverse effects. This reactivated the infection, which had a complicated course and finally lead to the death of both patients. Conclusions: The fact that several cases of parvosymtomatic cerebral Nocardiosis in immunosupresed patients have been published suggest that cellular immunosupresion is key in the development of cerebral infections by Nocardia. It probably allows the access and multiplication of the bacteria inside the encephalon without an immediate clinical response. The development of symptoms is probably related to a late alteration of the blood-brain barrier rather than to the slow progression of Nocardia disease.
l compromiso vesical no forma parte del síndrome meníngeo y es un hallazgo infrecuente en pacientes con meningitis. La aparición en el año 2005 del concepto 'síndrome meningitis-retención' (SMR) acuñado por Sakakibara y colaboradores, definió una entidad que involucraba una inhabitual asociación de meningitis y vejiga neurogénica, en la que después de desaparecido el cuadro meníngeo la disfunción vesical se prolonga como enfermedad independiente por varias semanas y en ausencia de etiopatogenia identificable 1 . La urodinamia, en la mayoría de estos pacientes, ha establecido la ausencia de actividad en el detrusor y la conservación funcional del esfínter externo de la vejiga.Otro síndrome que también expresa una retención urinaria aguda como el SMR y con el que se puede confundir es el síndrome de Elsberg. Sin embargo, este último no se acompaña de meningitis, el daño involucra atonía vesical y del esfínter externo, que es la expresión de una poliradiculopatía sacra vinculada a una infección por el virus Herpes Simplex 2 2 .La vejiga es un órgano hueco destinado a la acumulación de orina, mientras el esfínter externo se mantiene ocluido y el músculo detrusor está en reposo; al llenarse, la vejiga se distiende y el deseo miccional surge debido a la contracción automática del músculo detrusor como consecuencia del aumento de presión intravesical, condición informada a la médula por las fibras propioceptivas que activan la respuesta del detrusor. En la emisión de orina se asocia: la contracción del detrusor, la relajación voluntaria del esfínter externo, y la contracción voluntaria de la prensa abdominal que mantiene una presión intravesical conveniente 3 .La compleja inervación del tracto urinario
Adverse reactions to intravenous immunoglobulin (ivIg) therapy. Dalacas y cols han postulado que la administración de inmunoglobulina produciría un aumento de la viscosidad de la sangre, sugiriendo que las complicaciones trombo-embólicas tendrían su origen en esta condición hematológica 7 . Sekul y cols, en una serie de 54 pacientes en los que usaron Igev, encontraron el desarrollo de meningitis aséptica en 6 enfermos (11%). Ellos postularon que el mecanismo patogénico de estas meningitis sería el paso incidental de inmunoglobulinas al espacio subaracnoídeo, condición que generaría la reacción meníngea 6 . Por otra parte, se ha descrito una gran variedad de cambios hematológicos transitorios en relación al suministro de Igev 9 . Si bien la encefalopatía aguda resulta la complicación menos frecuente, parece necesario comunicar un caso con estudio clínico completo, que podría hacer más comprensible los mecanismos patogénicos asociados a la mayoría de estas complicaciones y sugerir el manejo terapéutico en la etapa crítica.
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