1/57. botulism: a case associated with pyramidal signs. botulism is a widespread neuroparalytic disease that may be confused with other neurological disorders. As it is potentially lethal, clinicians are required to be aware of its diagnosis and management. We report a case of botulism complicated by pyramidal signs in a 35-year-old woman. Clinical aspects, differential diagnoses and therapeutic problems are discussed. ( info) |
| ophthalmoplegic migraine is an uncommon disorder, usually starting in older childhood. Its physiopathology remains obscure and diagnosis is reliant on clinical grounds and exclusion of other disorders. We report four cases of childhood ophthalmoplegic migraine, one of them starting in infancy. association with other types of migraine is common. Two of the three patients studied by magnetic resonance imaging (MRI) showed enhancement and enlargement of the cisternal portion of the oculomotor nerve, which spontaneously resolved after 2 and 4 years, respectively. Persistence of clinical recurrences was associated with long-lasting presence of the MRI finding, and possibly with mild sequelae. These radiological abnormalities suggest a common physiopathological mechanism with other inflammatory diseases, except for a benign evolution which, added to its specific anatomic site, seems to be the only neuroradiological marker, besides normality, in ophthalmoplegic migraine. The very long potential duration of MRI changes and the scarcity of clinical episodes make feasible its incident discovery once the migraine attack has become a remote memory. ( info) |
| In this article, we describe a case of a subarachnoid hemorrhage (SAH) in an acute severe asthma patient following mechanical hypoventilation. A 49-year-old man was admitted to an intensive care Unit with an acute exacerbation of asthma. After 3 days of mechanical ventilation (hypercapnia and normoxaemia), it was noted that his right pupil was fixed, dilated, and unreactive to light. Computed tomography (CT) scan showed localized SAH within the basilar cisterns and diffuse cerebral swelling. On the fourth day, a new CT scan showed hemorrhage resorption and a cerebral swelling decrease. In the following days, the patient's condition continued improving with no detectable neurological deficits. A review of similar published reports showed that all patients performed respiratory acidosis, normoxaemia, and hypercapnia. The most frequent neurological sign was mydriasis, and all subjects showed cerebral edema. Since normoxaemic hypercapnia has been associated with absence, or less cerebral edema, we considered additional factors to explain cerebral edema and intracranial hypertension causes. Thus, intrathoracic pressures due to patient's efforts by forcibly exhaling, or during mechanical ventilation, would further increase intracranial pressure by limiting cerebral venous drainage. This case emphasizes the fact that patients with acute severe asthma who have developed profoundly hypercarbic without hypoxia before or during mechanical ventilation, may have raised critical intracranial pressure. ( info) |
4/57. mydriasis and acute pulmonary oedema complicating laparoscopic removal of phaechromocytoma. This report describes the perioperative management of an adrenergic crisis occurring following insufflation of the peritoneum for planned laparoscopic surgery for phaechromocytoma. Despite preoperative alpha and beta adrenergic blockade, the occurrence of acute severe hypertension, mydriasis and pulmonary oedema prior to direct surgical manipulation caused the procedure to be abandoned. The severity of the event was unusual and most likely contributed to by haemorrhagic necrosis of the tumour releasing catecholamines. serum levels of noradrenaline and adrenaline at the time were 744,600 and 166,940 pg.ml-1 respectively. Treatment included bolus doses of esmolol, nicardipine and urapidil (an alpha 1 adrenergic antagonist) by constant intravenous infusion and mechanical ventilation. Postoperative cerebral CT scan was normal. An abdominal CT showed central haemorrhagic necrosis of the tumour. Two weeks later, open surgical removal of the phaeochromocytoma was successfully performed under general anaesthesia. Induction of pneumoperitoneum for laparoscopy may be particularly hazardous in a patient with a phaeochromocytoma. ( info) |
5/57. Neonatal mydriasis due to effects of atropine used for maternal Tik-20 poisoning. A neonate was born to a mother who had consumed an organophosphorus(OPC) compound with suicidal intent. The mother was administered atropine and this caused mydriasis in the neonate without any other pharmacological effects. There was no evidence of placental dysfunction. There are no case reports of OPC consumed in pregnancy and its effect on neonates or of effects of massive doses of atropine in the mother and its effects on the fetus or the newborn. ( info) |
6/57. Acute onset of a bilateral areflexical mydriasis in Miller-Fisher syndrome: a rare neuro-ophthalmologic disease. Miller-Fisher syndrome (MFS) is characterized by variable ophthalmoplegia, ataxia, and tendon areflexia. It seems to be a variant of guillain-barre syndrome (GBS), but unlike in GBS, there is a primitive involvement of the ocular motor nerves, and in some cases there is brainstem or cerebellum direct damage. The unusual case of MFS in the current study started with a bilateral areflexical mydriasis and a slight failure of accommodative-convergence. Ocular-movement abnormalities developed progressively with a palsy of the upward gaze and a bilateral internuclear ophthalmoplegia to a complete ophthalmoplegia. In the serum of this patient, high titers of an IgG anti-GQ1b ganglioside and IgG anti-cerebellum. anti-purkinje cells in particular, were found. The former autoantibody has been connected to cases of MFS, of GBS with associated ophthalmoplegia, and with other acute ocular nerve palsies. The anti-cerebellum autoantibody could explain central nervous system involvement in MFS. The role of these findings and clinical implications in MFS and in other neuro-ophthalmologic diseases are discussed. ( info) |
7/57. munchausen syndrome presenting acutely in the emergency department. munchausen syndrome is a rare psychiatric disorder in which patients purposely harm themselves to gain medical attention. These patients may present to unsuspecting emergency department (ED) staff members with life-threatening signs and symptoms. We report a case of munchausen syndrome in which a young man with ties to the medical community and a history of substance abuse presented to our ED with refractory hypoglycemia and a dilated right pupil. The patient required large amounts of dextrose, endotracheal intubation, mechanical ventilation, and admission to the intensive care unit. Further investigation revealed that he had purposely injected himself with a large dose of insulin and instilled atropine drops in his right eye for the purpose of seeking hospitalization. The history, details, diagnosis, treatment, and prognosis are discussed in the context of this case. ( info) |
8/57. Persistent mydriasis following intravenous atropine in a neonate. A neonate whose mother had recently taken amitriptyline developed fixed dilated pupils after a modest dose of intravenous atropine. Interaction of atropine with neonatal amitriptyline levels is suggested and evidence of neonatal effects from maternal antidepressant use is examined. There were no neurological sequelae, and the neonate's pupils became reactive again after 7 h. ( info) |
9/57. Temporary uniocular blindness and ophthalmoplegia associated with a mandibular block injection. A case report. A mandibular block injection produced temporary uniocular blindness, total ophthalmoplegia, mydriasis, and ptosis of the eyelid, with diplopia developing as the sight returned. These effects lasted 25-30 minutes. The explanation offered as to the cause of the anaesthetic phenomenon is an intra-arterial injection into the maxillary artery with backflow of anaesthetic solution into the middle meningeal artery. The instantaneous blindness results from the anaesthetic agent being carried into the central artery of the retina through an anastomosis of the ophthalmic and middle meningeal arteries via the recurrent meningeal branch of the lacrimal artery. Although of short duration, the symptoms mimic a more serious carotid artery embolus occluding the ophthalmic artery. Complications of mandibular blocks have been reported in the literature, however total blindness and ophthalmoplegia are extremely rare. This case report highlights an event where individual anatomical variation of the maxillary and middle meningeal arteries has allowed anaesthetic solution to be delivered to an ectopic site. ( info) |
10/57. Unilateral mydriasis after nasal reconstruction surgery. PURPOSE: To present a case of iatrogenic, unilateral pupillary dilatation after general anesthesia for nasal surgery. Unilateral pupillary dilatation after general anesthesia has sinister implications, which might prompt further investigations. However, in patients undergoing nasal surgery, it might be caused by the action of drugs injected intranasally. Consideration of iatrogenic causes of pupillary dilatation might help clinicians to avoid time-consuming and costly investigations. CLINICAL FEATURES: A 24-yr-old healthy woman underwent a general anesthetic for septoplasty and bilateral turbinectomy. She was hemodynamically stable and did not suffer any hypoxia intraoperatively. At the end of the operation her right pupil was dilated (8 mm diameter). Her left pupil was normal. No other abnormality was detected. After she woke up, her vision was grossly normal. Neurological examination did not show any other abnormality. Six to eight hours later, both pupils were equal (2 mm in diameter) and reacting normally to light and accommodation. CONCLUSION: The patient was a healthy 24-yr-old who underwent an operation in which there was no incident of hypoxia or hemodynamic instability. Since the patient recovered completely within six to eight hours, the pupillary dilatation was probably caused by epinephrine, which could have entered the eye through the nasolacrimal duct. Although pupillary dilatation after general anesthesia has been described, this is the first case report where the most likely causative agent was epinephrine, injected into the nasal submucosa. ( info) |