SUMMARYThe most common cause of apparent inefficiency or resistance to oral therapy with levothyroxine for hypothyroidism is nonadhesion. However, in some subjects in whom the control of hypothyroidism is extremely difficult, levothyroxine bioavailability defects should be considered. We report here the case of a 57-year-old woman with hypothyroidism that was well-controlled for the previous 6 years but suddenly presented with poor hormonal control and abdominal symptoms, despite repeatedly reporting good compliance to therapy. Adequate control of thyroid function was only obtained after intestinal giardiasis was diagnosed and treated. Arq Bras Endocrinol Metab. 2011;55(1):81-4 SUMÁRIO A causa mais comum de aparente ineficácia ou resistência ao tratamento do hipotireoidismo com levotiroxina oral é a má adesão. No entanto, em alguns pacientes nos quais o controle do hipotireoidismo é extremamente difícil, defeitos na biodisponibilidade da levotiroxina devem ser considerados. Relatamos aqui o caso de uma mulher de 57 anos de idade com hipotireoidismo que vinha previamente bem controlado durante 6 anos, mas que, abruptamente, começou a apresentar mau controle hormonal, apesar de insistentemente relatar boa adesão ao tratamento. O controle adequado da função tireoidiana só foi possível depois que uma giardíase intestinal foi diagnosticada e tratada. Arq Bras Endocrinol Metab. 2011;55(1):81-4
Myasthenia gravis (MG) is the most frequent neuromuscular transmission disorder with incidence of 2-20 patients per million. Its pathophysiology is autoimmune, with acetylcholine receptors (AChR) autoantibodies damaging the post-synaptic fold at the muscle membrane. MG often presents with isolated ocular symptoms, including diplopia and ptosis, at least at the onset. Even in patients with generalized symptoms, ocular signs occur in almost all patients in some point during the course of the disease. In up to 15% of the patients the disease remains confined to the eyes 1 . Other clinical features include bulbar symptoms (dysphagia, dysarthria), proximal limb muscles weakness and fatigue. Unusual presentations as distal limb muscles weakness can also be found in a minority of cases 2,3 . The main characteristic of the MG is the fluctuating weakness during the day, being milder during the morning and more severe at the evening. Physical activity usually worsens the weakness. The diagnostic confirmation of MG is often challenging. The tests usually performed to confirm the diagnosis of MG are the edrophonium test (Tensilon®), repetitive nerve stimulation (RNS), single fiber EMG and serum acetilcholine receptors (AchR) antibodies. The most traditional bedside diagnostic test for myasthenia gravis is the edrophonium test. It has been considered diagnostic of MG in the past, however false-positive results have been reported in other neurologic disorders like amyotrophic lateral sclerosis, botulism and brain tumor 4,5 . Furthermore, it carries a risk of serious cardiac adverse reations. Its sensitivity is about 86% in pure ocular disease 6 . Unfortunately it is not easily available in Brazil. Another bedside test that can be done is the sleep test, however this test is time consuming and probably not practical for the busy physician, since the patient has to take a nap of 15 to 20 minutes in a dark room for clinical comparison 7 . The other complementary tests have variable sensitivity and specificity. The diagnostic field of the RNS and AchR antibodies for pure ocular disease is quite low. The AChR antibodies are the most specific test for myasthenia gravis, however the sensitivity varies from 56% in pure ocular myasthenia according to Tabassi et al. 8 to 70% in Oh et al. 9 study. The repetitive nerve stimulation has even lesser sensitivity, varying from 35% in distal muscles to 45% in proximal muscles 10 . The most sensitive test for ocular myasthenia is single fiber EMG, reaching up to 80% in pure ocular cases and 95% in generalized disease 9 , however its specificity is low, the test is expensive, technically demanding and not widely available.The ice pack test is a very simple, safe and cheap procedure that can be performed by the physician at the bedside 10 . Moreover, the ice pack test does not require medications or expensive equipment and is free of adverse effects 11 . It consists of the application of an ice pack on the patient symptomatic eye for 3 to 5 minutes. The response is positive when there is improv...
Several neurological complications have been described after influenza vaccination. Oculomotor palsy has not been yet related with influenza vaccine. We report a 79-year-old man who developed an acute transient right oculomotor palsy two days after a routine influenza vaccination, for which no other cause was identified. There was no evidence of diabetes, glucose intolerance, high blood pressure, hipercholesterolemia, smoking, obesity, systemic vasculitis, or other risk factor for ischemic neuropathy. The cerebrospinal fluid was normal as well as the MRI and MRA scans. The differential diagnosis and the possible relationship between the vaccine and the oculomotor palsy are discussed.
a b s t r a c tThe dysbetalipoproteinemia is a rare genetic disorder which usually requires the presence of a metabolic factor for expression of their phenotype. We report a patient with this disease in an age group different from usual, probably triggered by a postpartum hypopituitarism. This association is described in just a few case reports in the medical literature. Síndrome de Sheehan e disbetalipoproteinemia: uma incomum associaç ãoPalavras-chave: Síndrome de Sheehan Disbetalipoproteinemia Xantoma palmar r e s u m o A disbetalipoproteinemia é uma desordem genética rara que usualmente requer a presenç a de um fator metabólico para a expressão do seu fenótipo. Reportamos uma paciente com esta doenç a em uma idade diferente da usual, provavelmente desencadeada por um hipopituitarismo pós-parto. Esta associaç ão tem poucos relatos de caso na literatura médica.
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