Carbamazepine, a widely used anticonvulsant, can induce hepatotoxicity, usually evolving with an acute hepatitis that ceases after drug withdrawal. Carbamazepine-induced vanishing bile duct syndrome (VBDS) is a rare complication and has seldom been reported in the medical literature. This report presents a case of a 26-year-old male who had onset of epilepsy at 12 months of age and was initially treated with phenobarbital. Carbamazepine (1200 mg/day) was added in June 1996 when he was 22 years old to control the frequency of seizures. Two years later, during a routine investigation, elevation of serum gamma-glutamyltransferase (GGT) levels was detected. For this reason, the patient was weaned off carbamazepine, followed 6 months later by complete withdrawal of the drug. The first liver biopsy disclosed total absence of interlobular bile ducts (IBD) in 30 portal tracts. Fourteen months later, a control biopsy showed the presence of IBD in eight of 14 portal tracts. There was also a decrease of GGT levels detected 27 months after withdrawal of carbamazepine. This case illustrates the ductopenic effect of carbamazepine when used for a prolonged time, as reported in three previous publications. However, this is the first case in which there was a remission of the VBDS and bile duct regeneration after withdrawal of the drug.
RESUMO -Os autores revisam 58 casos de hemorragia localizada nos lobos cerebrais, observados entre 264 pacientes com hemorragia intracerebral em período de 6 anos. Os fatores etiológicos foram hipertensão em 29 pacientes, outras etiologias em 9; em 20 pacientes não se determinou ia causa. Dentre os sintomas mais importantes observaram-se cefaléia em 56% e convulsão em 12% dos casos. Coma foi infrequente. Os sinais clínicos dependiam d a localização do hematoma. O lobo parietal foi o mais afetado. A mortalidade foi de 8,6%. A evolução correlacionava-se ao tamanho do hematoma e ao nível de consciência à internação.PALAVRAS-CHAVE: hemoragia lobar cerebral, clínica, etiologia, evolução.Lobar cerebral hemorrhage): clinics, etiology and follow-up (a 58-cases revision) SUMMARY -Fifty eight patients with spontaneous lobar hemorrhage of a 264 patients series with intracerebral hemorrhage seen during a six years period are reviewed. Twenty nine had arterial hypertension, 9 had other etiologies, and in the remaining 20 cases no apparent etiology was detected. Headache w a s a prominent symptom and occurred in 56%. Seizures occurred in 12%. Coma was infrequent. Clinical findings on admission depended on the location of the hematoma. Lobar hemorrhage occurred most commonly in the parietal region. Mortality rate was 8.6%. Size of hematoma (larger than 4 cm) on CT and altered consciousness on admission correlated with poor outcome.
RESUMO -Os autores apresentam um caso de síndrome de Guillain-Barré (SGB), com tetraplegia e ventilação mecânica, que foi tratado com imunoglobulina humana endovenosa (IgEV), 2 g/kg, apresentando melhora clínica inicial, tendo piorado na segunda semana. Foi realizada uma segunda sessão de IgEV, também com melhora inicial, seguida de piora aos 65 dias de doença. Uma terceira etapa de IgEV foi realizada, sendo a melhora definitiva e sem outros episódios após 3 anos de seguimento. Os autores revisam a literatura sobre flutuações relacionadas ao tratamento. Concluem que na SGB é importante uma observação clínica rigorosa nas primeiras semanas após tratamento com IgEV e que seriam necessários estudos para elaborar protocolos alternativos de prevenção nesses casos.PALAVRAS-CHAVE: síndrome de Guillain-Barré, imunoglobulina endovenosa, flutuações relacionadas ao tratamento. Fluctuations in Guillain-Barré syndrome related to treatment with intravenous human immunoglobulin (trifasic course): case reportABSTRACT -The authors report the case of a patient with severe Guillain-Barré syndrome (tetraplegic and on mechanical ventilation), that was treated with intravenous immunoglobulin (IVIg), 2 g/Kg. At first, there was clinical improvement, followed by clinical deterioration two weeks later. On the second course of IVIg there was, again, clinical improvement and then deterioration, 65 days after treatment. Finally, on the third course of treatment definitive recovery was achieved and no more relapses happened so far (three years after the treatment). The authors review the literature about fluctuations related to treatment with IVIg. Conclusions are that these patients should be closely observed during the first weeks after IVIg treatment, and that further studies are still necessary to elaborate alternative protocols on the prevention of these cases.KEY WORDS: Guillain-Barré syndrome, intravenous immunoglobulin, treatment related fluctuations.A síndrome de Guillain-Barré (SGB) é caracterizada por inflamação e desmielinização dos nervos periféricos, provavelmente secundária a processo mediado imunologicamente contra antígenos mielínicos [1][2][3] . O seu diagnóstico é clínico, apoiado por estudos complementares (líquor e eletroneuromiografia). Trata-se de doença monofásica e que raramente recidiva 3,4 . Com a introdução de duas formas de tratamento, plasmaferese (PF) e imunoglobulinas humanas endovenosas (IgEV), Estudo realizado no Setor de Investigação em Doenças Neuromusculares da UNINEURO-Natal: *neurologista. Aceite: 25-março-1998. Dr. Mário Emílio Dourado -UNINEURO -Rua Tuiuti 268 -59014-160 Natal RN -Brasil. FAX 084 211 8527.
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