RESUMO

Introduction: Bradykinesia, characterized by slowed movement, stands out as a primary symptom observed in individuals with Parkinson's disease (PD). Nonetheless, there are instances where PD patients exhibit sudden and effective movements despite the presence of bradykinesia. This phenomenon, referred to as paradoxical kinesia, has remained a subject of interest for neuroscientists, who have struggled to unravel its underlying neural mechanisms for decades. Case Presentation: We describe a patient who is suffering from advanced PD. The patient has severe motor limitations, including difficulty rising from bed and walking, as well as cognitive decline and visual impairment. However, an interesting occurrence took place during a nightmare episode. Surprisingly, the patient was able to get out of bed and quickly run away from the perceived threat within the nightmare, without any assistance. Conclusion: This report presents the first documented case of paradoxical kinesia induced by nightmares in a patient with PD. This phenomenon raises questions about the neurological mechanisms involved, which are still not fully understood. Based on existing research conducted on both animal and human subjects, we propose that after processing the emotion of fear, the brain aversive system activates motor outputs to generate appropriate behavior. Thus, the brain aversive system converts the emotion of fear into action through projections from the inferior colliculus to motor-related areas such as the mesencephalic locomotor region, pontine nuclei, and substantia nigra.

RESUMO

PURPOSE: To present paradoxical reaction (PR) in three cases with ocular tuberculosis (OTB) treated with antitubercular therapy (ATT), highlighting diagnostic challenges and treatment strategies. METHODS: We retrospectively reviewed clinical records of three OTB patients presenting with paradoxical worsening after ATT initiation at two Brazilian university hospitals. RESULTS: The patients (2 males, 1 female) experienced worsening clinical presentation (increased inflammation, vision loss) within two to three weeks after initiating ATT. One patient who was HIV-positive with unilateral multifocal choroiditis developed PR soon after starting antiretroviral therapy. The second patient presented with a choroidal tuberculoma in both eyes. The third patient also had multifocal choroiditis and developed a localized choroidal elevation with a double-layer sign as a manifestation of PR. All patients were maintained on ATT therapy in association with corticosteroids and experienced improvement of inflammatory signs. CONCLUSION: This case series highlights the potential for PR in OTB patients. Close monitoring and prompt therapeutic adjustments are crucial for management success.

RESUMO

Paradoxical embolism due to an isolated pulmonary arteriovenous malformation (PAVM) is a rare cause of ischemic stroke. PAVMs are abnormal high-flow connections between pulmonary arteries and veins, diverting deoxygenated blood into the systemic circulation and they represent a less common source of paradoxical embolisms, especially in young individuals. Endovascular embolization is the preferred treatment for clinically significant PAVMs. We present the case of a 34-year-old woman with a left thalamic ischemic stroke. Severe contrast passage was detected in cerebral arteries through transcranial Doppler. Intracardiac ultrasound did not reveal a patent foramen ovale, prompting further investigation with pulmonary CT angiography, confirming the presence of PAVM. The patient underwent successful endovascular treatment. It is essential to consider PAVM in the etiological diagnosis of ischemic stroke, especially in young patients with signs of abnormal right-to-left communication. Periodic follow-up imaging is recommended to assess potential recurrence or changes in PAVM, emphasizing the importance of appropriate management of these malformations.

La embolia paradojal debido a una malformación arteriovenosa pulmonar (MAVP) aislada es una causa infrecuente de accidente cerebrovascular (ACV) isquémico. Las MAVP son conductos anómalos de alta circulación entre arterias y venas pulmonares, desviando sangre desoxigenada hacia la circulación sistémica y representan una fuente menos común de embolias paradojales, especialmente en personas jóvenes. La embolización endovascular es el tratamiento preferido para MAVP clínicamente significativas. Presentamos el caso de una mujer de 34 años con ACV isquémico talámico izquierdo. Se detectó pasaje de burbujas "en cortina" en arterias cerebrales mediante Doppler transcraneal. En ecografía intracardíaca no se encontró foramen oval permeable, motivo por el cual se avanzó con realización de angiotomografía pulmonar, la cual confirmó la presencia de MAVP. La paciente recibió tratamiento endovascular exitoso. Es esencial considerar la MAVP en el diagnóstico etiológico del ACV isquémico, especialmente en pacientes jóvenes con signos de comunicación anormal de derecha a izquierda. Se recomienda un seguimiento periódico mediante imágenes para evaluar la posible recurrencia o cambios en la MAVP, resaltando la importancia del manejo adecuado de estas malformaciones.

Assuntos

RESUMO

Introducción. La embolia paradójica es un evento trombótico originado en la circulación venosa, que se manifiesta como embolismo arterial por medio de un defecto anatómico a nivel cardíaco o pulmonar. Se asocia principalmente a eventos cerebrovasculares, aunque se han encontrado casos de infarto agudo de miocardio, infarto renal y otros eventos isquémicos. Caso clínico. Paciente de 47 años, quien consultó por cuadro de dolor abdominal, que requirió manejo quirúrgico de urgencia, donde identificaron isquemia intestinal importante. Los estudios adicionales hallaron déficit de proteína S y persistencia de foramen oval permeable. Resultados. La presencia de trombosis arterial se conoce como trombosis de sitios inusuales y requiere de estudios para descartar trombofilias asociadas u otros estados protrombóticos. El déficit de proteína S es una trombofilia infrecuente, la cual se asocia en la vida adulta a eventos trombóticos de origen venoso. En presencia de defectos anatómicos, como un foramen oval permeable, puede progresar a embolia arterial, configurando un cuadro de embolismo paradójico. La estratificación de estos pacientes requiere imágenes que demuestran el defecto mencionado, así como el posible origen de los émbolos. El manejo se basa en anticoagulación plena, manejo de soporte, resolver las manifestaciones trombóticas existentes y un cierre temprano del defecto anatómico. Conclusiones. El embolismo paradójico debe sospecharse en caso de trombosis de sitios inusuales. Requiere de un estudio exhaustivo con imágenes y su manejo debe basarse en anticoagulación y cierre del defecto.

Introduction. Paradoxical embolism is a thrombotic event originating in the venous circulation, which manifests as arterial embolism through an anatomical cardiac or pulmonary defect. It is mainly associated with stroke, also presenting as acute myocardial infarction, renal infarction, and other ischemic events. Clinical case. A 47-year-old patient was admitted due to abdominal pain, which required emergency surgical management, finding significant intestinal ischemia. Additional studies found protein S deficiency and evidence of a patent foramen ovale. Discussion. Arterial thrombosis is known as unusual thrombosis; this situation requires to rule out associated thrombophilia or other prothrombotic diseases. Protein S deficiency is a rare thrombophilia, which in adults causes venous thrombosis. In the presence of anatomical defects, such as a patent foramen ovale, it can progress to arterial embolism, presenting a picture of paradoxical embolism. The study work of these patients requires imaging that demonstrates the aforementioned defect, as well as the possible origin of the emboli. Management is based on full anticoagulation, treatment of existing thrombotic manifestations, and management of the anatomical defect. Conclusions. Paradoxical embolism should be suspected in case of unusual thrombosis. It requires exhaustive studies based on imaging, and management should consist of anticoagulation and closure of the defect.

Assuntos

RESUMO

OBJECTIVES: When air irrigation is used for caloric stimulation in patients with a perforated ear, warm irrigation may elicit a nystagmus that initially beats in the opposite direction of what is expected for warm irrigations, which is referred to as "caloric inversion". This study aimed to investigate the disease group in which caloric inversion appeared in patients who underwent caloric testing and to classify the patterns of caloric inversion. METHODS: We conducted a retrospective review of bithermal caloric test results that were collected in our dizziness clinic between 2005 and 2022. Caloric inversion was defined when nystagmus induced by caloric stimulation appeared in the opposite direction to that expected. The incidence of caloric inversion among all patients who underwent bithermal caloric tests was calculated. To confirm the clinical diagnoses of the patients with caloric inversion, their clinical records were reviewed. RESULTS: Out of 9923 patients who underwent bithermal caloric tests, 29 patients (0.29%) showed a caloric inversion. The most common clinical diagnosis was chronic otitis media (21 of 29, 72%). Of the 21 patients with chronic otitis media, 20 patients showed a caloric inversion by warm air irrigation and one patient showed caloric inversion by cold air stimulation. Patients with clinical diagnoses other than chronic otitis media such as sudden sensorineural hearing loss, benign paroxysmal vertigo of childhood and recurrent vestibulopathy showed caloric inversion by warm air irrigation. Caloric inversion by warm water irrigation was observed in patients with lateral semicircular canal cupulopathy and recurrent vestibulopathy. Two patients (one with Meniere's disease and one with age-related dizziness) showed caloric inversion by cold water irrigation. CONCLUSION: Caloric inversion can be observed in various diseases other than chronic otitis media with tympanic membrane perforation. Special care should be taken in the interpretation of caloric test results. LEVEL OF EVIDENCE: Level 4.

Assuntos

RESUMO

RESUMEN La embolia cerebral paradójica siempre requiere la presencia de foramen oval; en nuestro caso, este evento sucedió por un fenómeno temporal, el cual fue la sobrecarga aguda de las cavidades derechas y la apertura del foramen oval debido al aumento de presiones como consecuencia de un tromboembolismo pulmonar masivo. Luego de una artroscopía, nuestra paciente presentó pérdida del campo visual y disnea, esta última progresiva, hasta llegar a la ventilación mecánica y shock obstructivo grave. Se realizó una angiotomografía, la cual evidenció un trombo obstructivo en la arterial pulmonar derecha; la paciente fue trombolizada con éxito y fue dada de alta de la unidad de cuidados intensivos después de 45 días. Finalmente se le diagnosticó una deficiencia de proteína C y se inició anticoagulación de manera permanente. La presencia de déficit motor y disnea en una paciente post-cirugía de rodilla, debe hacer sospechar de una tromboembolia pulmonar, la trombólisis sigue siendo el tratamiento de elección, su indicación debe ser precoz.

ABSTRACT Paradoxical cerebral embolism always requires the presence of a patent foramen ovale (PFO); in our case, this event occurred due to a transient phenomenon, which was the acute overload of the right heart chambers and the opening of the PFO due to increased pressures as a consequence of massive pulmonary thromboembolism. After undergoing arthroscopy, this patient presented with visual field loss and progressive dyspnea, ultimately leading to mechanical ventilation and severe obstructive shock. An angiotomography was performed, revealing an obstructive thrombus in the right pulmonary artery. The patient successfully underwent thrombolysis, and she was discharged from the intensive care unit after 45 days. Ultimately, protein C deficiency was diagnosed, and permanent anticoagulation was initiated. The presence of motor deficit and dyspnea in a post-knee surgery patient should raise suspicion of pulmonary thromboembolism. Thrombolysis remains the treatment of choice, and it should be timely prescribed and performed.

RESUMO

Air embolism (AE) is a subtype of embolism, caused by the entry of air into the vascular system. It is a predominantly iatrogenic complication, and its symptomatic form is severe, although uncommon. In some cases, a venous thrombi may pass into the arterial system through a venous-arterial shunt, characterizing a paradoxical embolism. Here, we describe the case of a previously healthy 44-year-old female who underwent cauda equina decompression and lumbar epidural abscess drainage. The patient suffered a paradoxical AE intraoperatively and died after 4 days. The occurrence of AE in lumbar spine surgeries in the prone position is rare, but the surgical team must be attentive to its clinical signs and quickly institute initial management when necessary.

A embolia gasosa (EG) é um subtipo de embolia, causada pela entrada de ar no sistema vascular. É uma complicação predominantemente iatrogênica e sua forma sintomática é grave, embora incomum. Em alguns casos, um trombo venoso pode migrar para o sistema arterial através de um shunt venoso-arterial, caracterizando uma embolia paradoxal. Aqui, descrevemos o caso de uma mulher de 44 anos, previamente saudável, submetida a descompressão da cauda equina e drenagem de abscesso peridural lombar. A paciente sofreu uma EG paradoxal no intraoperatório e morreu 4 dias depois. A ocorrência de EG em cirurgias da coluna lombar em posição prona é rara, mas a equipe cirúrgica deve estar atenta aos seus sinais clínicos e, quando necessário, instituir o manejo inicial rapidamente.

RESUMO

Abstract Objectives When air irrigation is used for caloric stimulation in patients with a perforated ear, warm irrigation may elicit a nystagmus that initially beats in the opposite direction of what is expected for warm irrigations, which is referred to as "caloric inversion". This study aimed to investigate the disease group in which caloric inversion appeared in patients who underwent caloric testing and to classify the patterns of caloric inversion. Methods We conducted a retrospective review of bithermal caloric test results that were collected in our dizziness clinic between 2005 and 2022. Caloric inversion was defined when nystagmus induced by caloric stimulation appeared in the opposite direction to that expected. The incidence of caloric inversion among all patients who underwent bithermal caloric tests was calculated. To confirm the clinical diagnoses of the patients with caloric inversion, their clinical records were reviewed. Results Out of 9923 patients who underwent bithermal caloric tests, 29 patients (0.29%) showed a caloric inversion. The most common clinical diagnosis was chronic otitis media (21 of 29, 72%). Of the 21 patients with chronic otitis media, 20 patients showed a caloric inversion by warm air irrigation and one patient showed caloric inversion by cold air stimulation. Patients with clinical diagnoses other than chronic otitis media such as sudden sensorineural hearing loss, benign paroxysmal vertigo of childhood and recurrent vestibulopathy showed caloric inversion by warm air irrigation. Caloric inversion by warm water irrigation was observed in patients with lateral semicircular canal cupulopathy and recurrent vestibulopathy. Two patients (one with Meniere's disease and one with age-related dizziness) showed caloric inversion by cold water irrigation. Conclusion Caloric inversion can be observed in various diseases other than chronic otitis media with tympanic membrane perforation. Special care should be taken in the interpretation of caloric test results. Level of Evidence: Level 4.

Assuntos

RESUMO

Resumen Globalmente, los fármacos son el tipo de agente más frecuentemente implicado en las intoxicaciones pediátricas y las Ben-zodiacepinas el grupo farmacológico más frecuente. La reacción paradojal, secundaria a la exposición a Benzodiacepinas se caracteriza por la presencia de signosintomatología contraria a los efectos sedativos hipnóticos esperados, pudiendo presentarse con inquietud, ansiedad, hostilidad y alteraciones de la conducta, entre otros. La mayoría de los trabajos hallados acerca de este síndrome en pediatría lo describen secundario a Midazolam endovenoso, en contexto de sedación consciente para la realización de diferentes procedimientos. Las causas por los cuales se puede generar este fenómeno de desinhibición no han sido clarificadas, postulándose tres hipótesis: la desregulación colinérgica central, el aumento del tono gabaérgico en el sistema límbico, tálamo e hipotálamo y el desbalance de serotonina. Se expone una serie de 15 pacientes de entre 1 año y 5 años, expuestos accidentalmente a Benzodiacepinas, principalmente Clonazepam y Lorazepam, a fin de describir las características de esta reacción. En esta serie se observó con latencia breve y duración variable, de hasta 11 horas, la presencia en orden de frecuencia, de: ansiedad, irritabilidad, gritos, hostilidad y conductas agresivas, llanto inconsolable, incapacidad de contención por familiares, conductas irracionales, excitación psicomotriz, desinhibición emocional, alucinaciones y aumento de locuacidad, asociado frecuentemente a ataxia.

Abstract Globally, medicines are the most frequently toxins involved in pediatric poisonings, and Benzodiazepines are the most fre-quent pharmacological group in those poisonings. The paradoxical reaction, secondary to Benzodiazepines exposure, is characterized by the presence of contrary expected sedative-hypnotic effects, and may present with restlessness, increased anxiety, hostility, and behav-ioral alterations, among others. The studies we found about this syndrome in pediatric patients describe it most frequently secondary to endovenous Midazolam, in the context of the conscious sedation to perform different procedures. The reasons why this reaction is generated have not been clarified, three hypotheses are postulated: the central cholinergic dysregulation, the increased Gabaergic tone in the limbic system, thalamus and hypothalamus and the serotonin imbalance. A series of 15 patients, between 1 year and 5 years old, accidentally exposed to Benzodiazepines, mainly Clonazepam and Lorazepam, to describe the characteristics of the paradoxical reaction secondary to Benzodiazepines exposure. In this case series, we observed with short latency and variable duration, up to 11 hours, the presence in order of frequency of: anxiety, irritability, screams, hostility and aggressive behaviors, inconsolable crying, inability to con-tain by their family members, irrational behaviors and psychomotor excitement, emotional disinhibition, hallucinations and increased talkativeness, frequently associated with ataxia.

RESUMO

Abstract A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Resumen Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

RESUMO

A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

Assuntos

RESUMO

The fungal cell wall (FCW) is a dynamic structure responsible for the maintenance of cellular homeostasis, and is essential for modulating the interaction of the fungus with its environment. It is composed of proteins, lipids, pigments and polysaccharides, including chitin. Chitin synthesis is catalyzed by chitin synthases (CS), and up to eight CS-encoding genes can be found in Aspergillus species. This review discusses in detail the chitin synthesis and regulation in Aspergillus species, and how manipulation of chitin synthesis pathways can modulate fungal growth, enzyme production, virulence and susceptibility to antifungal agents. More specifically, the metabolic steps involved in chitin biosynthesis are described with an emphasis on how the initiation of chitin biosynthesis remains unknown. A description of the classification, localization and transport of CS was also made. Chitin biosynthesis is shown to underlie a complex regulatory network, with extensive cross-talks existing between the different signaling pathways. Furthermore, pathways and recently identified regulators of chitin biosynthesis during the caspofungin paradoxical effect (CPE) are described. The effect of a chitin on the mammalian immune system is also discussed. Lastly, interference with chitin biosynthesis may also be beneficial for biotechnological applications. Even after more than 30 years of research, chitin biosynthesis remains a topic of current interest in mycology.

RESUMO

The glycoprotein (GP) IIb/IIIa receptor is found integrin present in platelet aggregations. GP IIb/IIIa antagonists interfere with platelet cross-linking and platelet-derived thrombus formation through the competition with fibrinogen and von Willebrand factor. Currently, three parenteral GP IIb/IIIa competitors (tirofiban, eptifibatide, and abciximab) are approved for clinical use in patients affected by percutaneous coronary interventions (PCI) in the location of acute coronary syndrome (ACS). GP IIb/IIIa antagonists have their mechanism of action in platelet aggregation prevention, distal thromboembolism, and thrombus formation, whereas the initial platelet binding to damage vascular areas is preserved. This work is aimed to provide a comprehensive review of the significance of GP IIb/IIIa inhibitors as a sort of antiplatelet agent. Their mechanism of action is based on factors that affect their efficacy. On the other hand, drugs that inhibit GP IIb/IIIa already approved by the FDA were reviewed in detail. Results from major clinical trials and regulatory practices and guidelines to deal with GP IIb/IIIa inhibitors were deeply investigated. The cardiovascular pathology and neuro-interventional surgical application of GP IIb/IIIa inhibitors as a class of antiplatelet agents were developed in detail. The therapeutic risk/benefit balance of currently available GP IIb/IIa receptor antagonists is not yet well elucidated in patients with ACS who are not clinically evaluated regularly for early cardiovascular revascularization. On the other hand, in patients who have benefited from PCI, the antiplatelet therapy intensification by the addition of a GP IIb/IIIa receptor antagonist (intravenously) may be an appropriate therapeutic strategy in reducing the occurrence of risks of thrombotic complications related to the intervention. Development of GP IIb/IIIa inhibitors with oral administration has the potential to include short-term antiplatelet benefits compared with intravenous GP IIb/IIIa inhibitors for long-term secondary preventive therapy in cardiovascular disease. But studies showed that long-term oral administration of GP IIb/IIIa receptor inhibitors has been ineffective in preventing ischemic events. Paradoxically, they have been linked to a high risk of side effects by producing prothrombotic and pro-inflammatory events.

Assuntos

RESUMO

Abstract: Coronary artery disease continues to be the leading cause of death in modern society; the most frequent cause is atherosclerosis. There are other causes such as coronary embolism and coronary dissection, among others. This article presents the case of a young patient with acute myocardial infarction in whom a coronary embolism was documented as the cause of infarction.

Resumen: La enfermedad arterial coronaria continúa siendo una causa de mortalidad en nuestro medio; la causa más frecuente es la aterosclerosis. Existen otras causas como embolia coronaria, disección coronaria. En este artículo se describe el caso de un paciente joven, quien presentó un infarto agudo de miocardio y se documentó un embolia conoraria como causa.

RESUMO

INTRODUCTION: Paradoxical vocal fold movement (PVFM) is a respiratory disorder related to inadequate movement of vocal folds during inspiration or expiration. Its epidemiology and pathogenesis are unknown. The present study describes the standardization of the examination performed in our service and the main endoscopic changes found, evaluating the prevalence of PVFM in patients with suggestive symptoms and describing the association of PVFM with asthma and other diseases. MATERIALS AND METHODS: Retrospective observational study of a series of cases over a 13-year period - adult patients referred for outpatient bronchoscopy due to suspected PVFM. RESULTS: We analyzed 1131 laryngoscopies performed on patients referred for suspicion of PVFM from May 2006 to June 2019. Of these, 368 cases were excluded from the study. A total of 255 patients (33%) had a confirmed diagnosis of PVFM, 224 women (88%). The most frequent comorbidities found were asthma (62%), rhinitis (45%), gastro-oesophageal reflux disease (45%), obesity (24%), and psychiatric disorders (19%). Among the endoscopic findings concomitant with the diagnosis of PVDM, we highlight posterior laryngitis (71%), diseases of the nasal septum (18%), nasal polyps (7%). DISCUSSION: Female sex is more affected. There are several associations with other diseases, the main one being asthma, followed by rhinitis and psychiatric disorders. Obesity appears as a comorbidity in 24% of patients, as does sleep apnoea in 13%. Posterior laryngitis was the most common endoscopic finding. PVFM is an underdiagnosed disease, little known as it is a rare entity that still needs prospective studies. Exam standardization is important.

Assuntos

RESUMO

Aspergillus fumigatus is the main etiological agent of aspergillosis. The antifungal drug caspofungin (CSP) can be used against A. fumigatus, and CSP tolerance is observed. We have previously shown that the transcription factor FhdA is important for mitochondrial activity. Here, we show that FhdA regulates genes transcribed by RNA polymerase II and III. FhdA influences the expression of tRNAs that are important for mitochondrial function upon CSP. Our results show a completely novel mechanism that is impacted by CSP.

Assuntos

RESUMO

In animal models, the administration of the dopaminergic D2 antagonist haloperidol affects the nigrostriatal pathway, inducing catalepsy, a state of immobility similar to Parkinson's disease (PD) bradykinesia and akinesia. In PD, the motor impairments are due to difficulties in selecting and executing motor actions, associated with dopamine loss in basal ganglia and cortical targets. Motor and affective limbic networks seem to be integrated via a striato-nigro-striatal network, therefore, it is not surprising that the motor impairments in PD can be influenced by the patient's emotional state. Indeed, when exposed to aversive stimuli or life-threatening events, immobile patients are capable of performing sudden movements, a phenomenon known as paradoxical kinesia. Thus, the present study investigated the effects of unconditioned and conditioned aversive stimulation on haloperidol-induced catalepsy in rats. First, male Wistar rats received intraperitoneal administration of saline or haloperidol (1 or 2 mg/kg) and were evaluated in the catalepsy bar test to assess the cataleptic state induced by the different doses of haloperidol over time. Next, we evaluated the effects of two types of unconditioned aversive stimuli-100 lux light (1 and 20 s) or 0.6 mA footshock (1 s)-on the catalepsy. Finally, we evaluated the effects of light conditioned stimuli (Light-CS), previously paired with footshocks, on the cataleptic state. Catalepsy was observed following haloperidol 1 and 2 mg/kg administration. Exposure to footshocks, but not to light, significantly reduced step-down latency during the catalepsy test. Although unconditioned light did not affect catalepsy, paired Light-CS did reduce step-down latency. Here, we have provided evidence of face validity for the study of paradoxical kinesia. In addition to demonstrating that immediate exposure to an aversive stimulus is capable of disrupting the cataleptic state, our findings show that haloperidol-induced catalepsy seems to be differently influenced depending on the modality of aversive stimulation. Our data suggest that the selective recruitment of threat response systems may bypass the dysfunctional motor circuit leading to the activation of alternative routes to drive movement.

RESUMO

BACKGROUND: Tuberculous meningitis (TBM) is the most frequent, severe, and disabling form of central nervous system (CNS) tuberculosis (TB). TBM paradoxical manifestations are characterized by clinical or paraclinical worsening after 1 month of effective anti-TB treatment in patients who initially responded to treatment despite the use of adjunctive corticosteroids. METHODS: Retrospective descriptive study of consecutive HIV-negative adult patients (≥ 18 years) with definitive TBM who developed a paradoxical manifestation following anti-TB in a tertiary-care hospital in Mexico from 2009 to 2019; we also conducted a literature review of published cases/series of paradoxical manifestations in HIV-negative patients from 1980 to 2020. RESULTS: We detected 84 cases of definitive TBM; 55 (68.7%) HIV-negative patients and 29 (36.3%) HIV-infected patients. Among HIV-negative patients, four (7.3%), three female and one male (19-49 years old), developed a paradoxical manifestation within 4-14 weeks following treatment initiation despite receiving adequate corticosteroid doses; Mycobacterium bovis was isolated from the cerebrospinal fluid of three cases and Mycobacterium tuberculosis in one more. Two patients developed vasculopathy-related cerebral infarctions, one severe basilar meningitis, and hydrocephalus, one more a tuberculoma. Two were treated with intravenous cyclophosphamide, and two with steroids. One of the patients treated with steroids died; patients who received cyclophosphamide had a good clinical response. CONCLUSIONS: This case series illustrates the diverse clinical/radiologic paradoxical manifestations of TBM in HIV-negative patients. Cyclophosphamide may be safe and effective in treating TBM-associated paradoxical manifestations. Specific diagnostic and care protocols for these patients are needed.

Assuntos

RESUMO

Resumen Se presenta el caso de una paciente ingresada por cuadro clínico de infarto agudo de miocardio con elevación del segmento ST. Tras la realización de una coronariografía emergente en la que se evidencia un trombo en la arteria coronaria derecha, sin objetivar lesiones ateroscleróticas, es diagnosticada de infarto de probable origen embólico. Tras realizar un ecocardiograma transtorácico, se detecta la presencia de trombos en las cavidades derechas e izquierdas del corazón. Por ello se realiza angiografía por tomografía computarizada con protocolo de embolia pulmonar, que confirma la presencia de embolia pulmonar bilateral masiva. Tras esto, se repitió el ecocardiograma transtorácico, hallándose un aneurisma del septo interauricular, con aparente protrusión de una masa trombótica a través de él. Se inició terapia anticoagulante con buena evolución por parte de la paciente, habiendo desaparecido los trombos en el ecocardiograma con test de burbujas que se realizó días después, en el que se demostró la presencia de un foramen oval permeable. Con la presentación de este caso se pretende, en primer lugar, ilustrar una afección que en contadas ocasiones se puede objetivar mediante prueba de imagen, y en segundo lugar, hacer una breve revisión del diagnóstico y el manejo del foramen oval permeable como parte del estudio de fuente embólica.

Abstract The authors describe a case of a patient admitted with ST elevation myocardial infarction. An emergent coronariography was done, showing a thrombus in the right coronary artery, without evidence of atherosclerotic lesions in the coronary bed. Due to this, she is diagnosed with probable embolic myocardial infarction. When she was performed a transthoracic echocardiography, the presence of free thrombi was detected in right and left chambers of the heart. Due to this, a CT angiography with pulmonary embolism protocol was done, confirming the presence of a massive bilateral pulmonary embolism. After that, a new trans-thoracic echocardiography was done, finding an aneurism at interatrial septum, with an apparent protrusion of thrombotic mass through it. The decision taken was initiating therapeutic anticoagulation, having the patient a positive evolution with disappearance of thrombi in the bubble test performed days later, and showing the presence of a patent foramen ovale. The purpose of the presentation of this case report is, firstly, illustrating an entity which in very few occasions can be demonstrated by imaging tests, and secondly, making a brief review of the diagnosis and management of the patent foramen ovale as a part of the study of embolic sources.