1/8. Catecholamine-induced hypertension in lumbosacral paraplegia: five case reports.hypertension in the patient with SCI is relatively rare and generally restricted to patients with high-level injuries where autonomic dysreflexia can occur. Resting blood pressure in individuals with SCI has been described as lower than that in the normal population. This report describes five previously normotensive teenagers with subsequent paraplegia as a result of gunshot wounds who presented with hypertension secondary to idiopathic elevation of plasma or urinary catecholamine levels. A clonidine suppression test was used as a neuroprobe to inhibit centrally mediated sympathetic outflow, excluding the probability of an extra-axial autonomous catecholamine-secreting tumor as the possible source of hypertension. Positive suppression was achieved in four patients (41%, 37.2%, 4.8%, and 37.2% decreases). One patient had values corresponding to orthostatic changes (an increase of 63%) because of poor compliance with the test. This patient was lost to follow-up; in the remaining four, hypertension resolved at 12, 8, 9, and 6 weeks postinjury. The increased circulating catecholamine level appears to be promoted by a centrally mediated response to the SCI. Elevated blood pressure probably results from an upgraded receptor regulation or an increased receptor sensitivity on the affected cells in the absence of restraining spinal reflexes. The pathophysiology of such hypertension seems to be secondary to autonomic dysfunction and, although it may be transient, it should be treated promptly and reevaluated periodically until stabilization is achieved.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
2/8. acromegaly and pheochromocytoma: report of a rare coexistence.OBJECTIVE: To describe a patient with the rare coexistence of acromegaly and pheochromocytoma. methods: We report a case of a 57-year-old woman, who was initially examined because of polyarthritis, she was also diagnosed with type 2 diabetes mellitus and hypertension at age 56 years. Her history, clinical findings, laboratory results, and management are summarized, and etiologic hypotheses are discussed. RESULTS: The patient had recurrent headaches and reported an increasing size of her shoes and gloves during the previous 4 years. Enlargement of her hands and feet and a bilateral temporal field defect were noted on examination. Laboratory studies revealed high levels of insulin-like growth factor i (IGF-I) and growth hormone (GH). magnetic resonance imaging (MRI) showed a 3-cm sellar mass with impingement on the optic chiasm. The plasma level of growth hormone-releasing hormone (GHRH) was normal. She underwent transsphenoidal adenomectomy. Histologic examination confirmed a pituitary adenoma, immunoreactive for GH. Postoperatively, her headaches and arthritic pain diminished, and her levels of IGF-I and GH normalized; however, labile hypertension persisted. The urinary metanephrines and plasma catecholamines were increased. A 3-cm left adrenal mass, seen on abdominal MRI, was removed laparoscopically, after which urinary metanephrines normalized and both the diabetes and the hypertension resolved. Histopathologic analysis confirmed the diagnosis of pheochromocytoma. Immunohistochemical staining was negative for GHRH. CONCLUSION: The finding of a pheochromocytoma and acromegaly could be a fortuitous coexistence of two separate endocrine tumors; however, the probability of such an event is extremely low. A cause-and-effect relationship has been suggested because of previous reports of GHRH production by pheochromocytomas. Some investigators have also suggested that this coexistence might be a multiple endocrine neoplasia variant. Our patient had no evidence of GHRH production, nor did we document any familial autosomal dominant transmission pattern.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
3/8. Valsartan-induced angioedema.OBJECTIVE: To report a case of dose-dependent angioedema secondary to the use of the angiotensin-receptor blocker (ARB) valsartan. CASE SUMMARY: A 64-year-old Hispanic woman presented with swelling of the lips shortly after an increase in her valsartan dose for uncontrolled hypertension. Other potential causes were not identified. The angioedema subsequently resided after a dosage reduction and observation. Use of the Naranjo probability scale indicated a probable relationship between the angioedema and valsartan therapy in this patient. DISCUSSION: Drug-induced angioedema is often associated with the use of angiotensin-converting enzyme (ACE) inhibitors and is probably secondary to their effects on bradykinin levels. ARBs are thought to produce few, if any, cases of angioedema if excess bradykinin levels are the root cause of angioedema secondary to ACE inhibitor use. Several potential ARB-induced cases of angioedema have been reported. The exact mechanism of angioedema induced by drugs in both of these classes is unknown. Animal data suggest that there may be a relationship between ARB use and increased tissue bradykinin levels secondary to stimulation of angiotensin ii AT2 receptors. CONCLUSIONS: This is the third reported case of valsartan-induced angioedema and the first thought to be dose dependent. Practitioners should be aware of this potential adverse effect of valsartan, although the underlying cause is still not known.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
4/8. Fetal toxic effects of angiotensin ii receptor antagonists: case report and follow-up after birth.OBJECTIVE: To report a child born with renal impairment following severe anhydramnios due to maternal exposure to an angiotensin ii receptor type 1 (AT1) antagonist, valsartan, and hydrochlorothiazide during the first 28 weeks of pregnancy. CASE SUMMARY: A hypertensive woman treated with valsartan 80 mg/day, hydrochlorothiazide 12.5 mg/day, prazosin 10 mg/day, lysine acetylsalicylate 100 mg/day, and levothyroxine 250 microg/day became pregnant. At 28 weeks' gestational age, severe anhydramnios associated with high beta2-microglobulin levels in the fetal blood cord was observed. Upon discontinuation of valsartan, fetal renal prognosis improved. In this case, using the Naranjo probability scale, the renal insufficiency of the child was probably related to valsartan. At the age of 2.5 years, the child presented with only mild chronic renal insufficiency. Growth parameters were within the normal range, and there was no evidence of developmental delay. DISCUSSION: Exposure to AT1 antagonists during the second part of pregnancy can lead to abnormalities similar to those observed after exposure to angiotensin-converting enzyme inhibitors, that is, reduced fetal kidney perfusion that may result in oligoamnios and neonatal renal insufficiency. Fourteen previous reports of maternal exposure to AT1 antagonists during this period have been published. In 6 cases, fetal or neonatal death occurred; in 2 cases, pregnancy was terminated because of complete anhydramnios or fetal abnormalities; in 1 case, renal insufficiency persisted at 8 months of age; in 2 cases, kidney function was fairly normal at birth; and in 4 cases, including the one described here, neonatal renal failure improved in the first year of life. CONCLUSIONS: AT1 antagonists should be avoided throughout pregnancy. If these agents are prescribed accidentally to a pregnant woman, monitoring of amniotic fluid volume and beta2-microglobulin fetal blood levels after discontinuation of the AT1 antagonist can provide critical data for advising parents on pregnancy and fetal outcome.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
5/8. pheochromocytoma unmasked by amisulpride and tiapride.OBJECTIVE: To describe the unmasking of pheochromocytoma in a patient treated with amisulpride and tiapride. CASE SUMMARY: A 42-year-old white man developed acute hypertension with severe headache and vomiting 2 hours after the first doses of amisulpride 100 mg and tiapride 100 mg. Both drugs were immediately discontinued, and the patient recovered after subsequent nicardipine and verapamil treatment. Abdominal ultrasound showed an adrenal mass, and postoperative histologic examination confirmed the diagnosis of pheochromocytoma. DISCUSSION: Drug-induced symptoms of pheochromocytoma are often associated with the use of substituted benzamide drugs, but the underlying mechanism is unknown. In our case, use of the Naranjo probability scale indicated a possible relationship between the hypertensive crisis and amisulpride and tiapride therapy. CONCLUSIONS: As of March 24, 2005, this is the first reported case of amisulpride- and tiapride-induced hypertensive crisis in a patient with pheochromocytoma. physicians and other healthcare professionals should be aware of this potential adverse effect of tiapride and amisulpride.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
6/8. atenolol-induced breast pain in a woman with hypertension.OBJECTIVE: To describe a case of atenolol-induced breast pain and swelling in a patient receiving atenolol. CASE SUMMARY: A 54-year-old woman was diagnosed with hypertension with no existing comorbidity. The patient was not taking any prescription medications, but was using an herbal supplement and several other over-the-counter supplements. After diet and exercise failed to control the woman's blood pressure, atenolol 25 mg daily was initiated. She reported symptoms of insomnia 9 days after starting the medication. During a follow-up visit 5 weeks later, the patient reported continued insomnia, as well as a 6 day history of breast pain, swelling, and tenderness. atenolol was quickly titrated to discontinuation, and a thiazide diuretic was prescribed. Subsequently, the pain and swelling gradually resolved. DISCUSSION: Assessment using the Naranjo probability scale revealed that the adverse reaction was probably associated with atenolol. While rare cases of hyperprolactinemia and galactorrhea have been reported with beta-blocker use, no reports of breast pain caused by this drug class were identified in the literature. CONCLUSIONS: atenolol has many reported adverse reactions, both common and rare; however, until this report, breast pain and swelling had not been documented adverse reactions. Clinicians should be aware that atenolol may be a cause of nonorganic breast pain and swelling in women.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
7/8. choriocarcinoma of the mesosalpinx masquerading as congestive heart failure: ultrastructural observations of the tumor.A 45-year-old woman suffered from hypertension and congestive heart failure for 5 months. She was found to have a choriocarcinoma of the left mesosalpinx. The final event was, in all probability, a massive pulmonary tumor embolus which occurred shortly after removal of the uterus and adnexae. The tumor was studied by immunohistochemical methods as well as ultrastructurally, and the findings are illustrated and described.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
8/8. Physical recovery after severe closed head trauma in children and adolescents.Three hundred forty-four patients under 18 years of age with severe closed head injuries, comatose over 24 hours, were followed prospectively for a minimum of one year. motor vehicles were involved in 82% of the injuries. Seventy-three percent of the patients regained independence in ambulation and self-care, 10% remained partially dependent in self-care and achieved only limited ambulation, 9% regained consciousness but were totally dependent, and 8% remained comatose. A favorable prognosis for recovery of motor function can be made if the duration of coma is less than three months. Complications of prolonged hypertension, ventricular enlargement, and seizures significantly decrease the probability of achieving physical independence. Although mortality following severe head injury is decreasing, neurologic sequelae in the survivors are statistically unchanged since 1970. Improved neurosurgical management in recent years has not increased the percentage of severely disabled survivors.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |