Deficiency of glucose-6-phosphate dehydrogenase (G6PD) is the commonest enzyme deficiency in humans with a wide range of possible clinical manifestations depending on the specific genetic variant in each case. Here we present the case of an 86-year-old male of African descent who acutely developed symptoms of G6PD deficiency immediately after he received methylene blue for treating methemoglobinemia. The contrast between a low SO2 on pulse oximetry and a normal arterial gas sampling raised the possibility of methemoglobinemia. The patient was treated with packed red blood cells and folic acid, and a rapid clinical improvement followed by normalization of the red blood cell count ensued. In view of the patient's advanced age, the lack of a history of similar episodes in the past, and the normal laboratory results during the hemolytic crisis, this case remained a diagnostic challenge for over three months, when a follow-up measure of G6DP activity eventually confirmed the diagnosis. A latent deficiency of G6PD may become clinically manifest under the appropriate triggering conditions even in elderly patients and in the absence of past or current clinical and laboratory evidence of G6PD deficiency.
Objective -To evaluate the influence of systolic or diastolic dysfunction, or both on congestive heart failure functional class. Methods -
RESUMO -Um senhor aposentado veio à consulta com história de desmaios há vários meses e uma série de exames cardiológicos e de neuroimagem inconclusivos. Medicado com carbamazepina, os desmaios persistiram, ocasionando ferimentos na face e nos braços. Durante o "tilt test" não sensibilizado farmacologicamente, a massagem do seio carotídeo na posição ortostática (mesa inclinada a 60°) produziu assistolia, perda da consciência e queda drástica da pressão arterial por 5 segundos. A mesma manobra na posição supina não provocou sintomas ou alterações hemodinâmicas. Implantado marca-passo de dupla câmara e suspensa a carbamazepina, os desmaios não se repetiram ao longo dos 18 meses de acompanhamento, confirmando o diagnóstico de hipersensibilidade do seio carotídeo com resposta cárdio-inibitória. Este caso ilustra e reafirma a utilidade do "tilt test" e da inclusão da massagem dos seios carotídeos na posição ortostática no protocolo de investigação de todo paciente com síncope de causa inaparente.PALAVRAS-CHAVE: síncope, desmaios, hipersensibilidade do seio carotídeo, tilt test.Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test Syncope in the elderly: diagnostic utility of carotid sinus massage in the head-up tilt test ABSTRACT -A 71-year-old man presented with a 6-month history of fainting. Consciousness was quickly regained without clouding or confusion. Ancillary investigations were inconclusive and he was treated with carbamazepine. The fainting spells did not cease and he was referred for a tilt-table test exam. In the head-up position (table tilted at 60°), massage of the carotid sinus was immediately followed by asystole, unconsciousness, and a sharp drop in arterial pressure for 5 seconds. The same procedure in the lying position did not elicit clinical symptoms or haemodynamic imbalance. A diagnosis of carotid sinus hypersensitivity with a cardio-inhibitory response pattern was made. Carbamazepine was withdrawn and a double-chamber pacemaker was implanted in his right ventricle. He remained symptom-free for the ensuing 18 months. This case supports the diagnostic utility of carotid sinus massage during the head-up tilt test in patients with unexplained non-convulsive loss of consciousness.KEY WORDS: syncope, faintness, carotid sinus hypersensitivity, tilt test.Hospital Universitário Gaffrée e Guinle, Universidade do Rio de Janeiro, Rio de Janeiro RJ, Brasil: O termo "síncope" (gr. synkope, pausa) se refere à perda súbita da consciência e do tônus postural seguida de recuperação imediata e espontânea. Benditt 1 classificou a síncope em cinco grandes grupos: a) cardiogênica: aórtica, miocardiopatia hipertrófica; b) Arritimias: taqui ou bradiarritimias; c) Neurocardiogênicas: vaso-vagal; d) Postur...
Carotid sinus massage at 60 masculine under controlled conditions should be included in the assessment of patients with non-convulsive faints or unexplained falls. Routine cardiovascular exams, including the HUTT, are not useful for the diagnosis in such cases. Further studies in normal individuals are needed to establish the significance of a positive response to carotid sinus massage in the absence of a history of fainting or falling.
An 81-year-old woman developed left hemiplegia and coma due to a right hemisphere infarct and died 6 days later. When first seen in coma she had the classical signs of descending central herniation in the diencephalic stage. The CT scan of the third day showed a large hypodense area occupying the superficial and deep territories of the middle and anterior cerebral arteries on the left as well as a frontal cortico-subcortical hypodense area indicative of an older infarct on the opposite hemisphere. No mass effects were apparent. She followed a downhill course with signs of brainstem deterioration. A second CT scan a few hours before death revealed the expected pattern of brain shift and herniations. This case adds to the available evidence showing that the clinical signs of encroachment of supratentorial structures upon the basal forebrain can be reproduced by an acute mono-hemispheral lesion without visible mass effects. It indicates, further, that the role of intracranial displacements in the genesis and short-term prognosis of coma remains an unsettled matter. In at least a few number of cases, diaschisis might play a major role.
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