Case report Intractable hiccups and syncope in multiple sclerosis

A patient with multiple sclerosis (MS) who developed intractable hiccups and syncope due to a cervical cord lesion is reported. Previous case reports of intractable hiccups occurring in MS have all been located in the medulla oblongata. Our patient is the first case with the responsible lesion in the cervical cord. The pathophysiological mechanism of the syncopal attacks in this case were thought to be same as that of cough syncope.     

Intractable vomiting and hiccups as the presenting symptom of neuromyelitis optica

Vomiting and hiccups can be due to peripheral or central causes. Neurological diseases causing vomiting and hiccups are due to lesions of medulla involving area postrema and nucleus tractus solitarius. Neuromyelitis optica (NMO) is one such disease which involves these structures. However refractory vomiting and hiccups as the presenting symptom of NMO is unusual. Here we report a patient with NMO in whom refractory vomiting and hiccups were the sole manifestation of the first attack. Diagnosis can be missed at this stage leading to delay in treatment and further complications. This case demonstrates the importance of considering NMO in any patient presenting with refractory vomiting and hiccups and with local and metabolic causes ruled out and linear medullary lesion on magnetic resonance imaging may indicate the diagnosis even when the classical clinical criteria are not met. Anti NMO antibody testing should be done and if positive appropriate treatment should be initiated to prevent further neurological damage.     

Intractable pain treated with intrathecal isotonic iced saline

Hitchcock's original method of hypothermic subarachnoid irrigation employed both temperature and osmolarity. Spinal cooling was then abandoned in favour of intrathecal injection of normothermic hypertonic salilne. Modifications of the procedure that followed have continued to accept hyperosmolarity as the factor causing pain relief. Fifty patients were treated by a technique evolved to enhance the effect of hypothermia while avoiding the complications associated with hyperosmolar solutions. For the cases of terminal carcinoma and others considered to be poor surgical risks, the results have been quite satisfactory. For non-neoplastic painful syndromes, rapid perfusion cooling of the subarachnoid space offers an alternative therapeutic approach.     

A case of predominantly nocturnal soiling treated with amitriptyline

The case of a 6 year old with soiling along with looseness of bowel and nocturnal soiling is reported. After failing to respond to conventional treatments, his symptoms remitted on a small dose of amitriptyline. Within the diversity of presentations of soiling, there may be a subgroup, not usually amenable to treatment, who can benefit from symptomatic treatment with tricyclic antidepressants. Accepted: 27 August 1997     

Intractable chronic inflammatory demyelinating polyneuropathy treated successfully with ciclosporin

BACKGROUND: Chronic inflammatory demyelinating polyneuropathy (CIDP) is a heterogeneous disorder and both clinical course and response to treatment vary widely. Because of the propensity for relapse, CIDP requires maintenance therapy after the initial response to treatment. There is no consensus regarding this in the published literature. PRESENT REPORT: A patient with CIDP was treated with oral prednisolone and cyclophosphamide pulse therapy but required repeated plasma exchange and intravenous immunoglobulin (IVIg). Treatment with ciclosporin freed the patient from repeated IVIg administration. Therapeutic responses in 14 subsequent cases including three patients who showed improvement with ciclosporin are also presented along with an algorithm of the authors' suggested protocol for treatment. CONCLUSION: Ciclosporin should be considered for patients with intractable CIDP who require repeated IVIg.     

Intractable hiccups and sleep apnea syndrome in multiple sclerosis: report of two cases

Two cases of multiple sclerosis associated with intractable hiccups (IH) and sleep apnea syndrome (SAS) are reported. Lesions were detected in the tegmentum of the medulla oblongata by magnetic resonance imaging. In one case, high dose methylprednisolone was remarkably effective for the IH. For the SAS, amitriptyline was effective in one case. The IH and SAS are thought to be important symptoms when a lesion occurs in the tegmentum of the medulla oblongata, including the paramedian and lateral reticular formations. If IH appears in conjunction with a lesion in the tegmentum of the medulla oblongata, one must be vigilant for the development of SAS.     

Platelet counts in depressed patients treated with amitriptyline or paroxetine.

OBJECTIVE: To assess whether therapy with two widely used antidepressants influences platelet counts. SUBJECTS AND METHODS: In 90 patients hospitalized for treatment of a major depressive episode according to DSM-IV, platelet counts were performed after a 6 d antidepressant-free run-in period and again after 35 d of active standardized treatment with amitriptyline (n = 40) or paroxetine (n = 50). RESULTS: There was a trend for platelet counts to increase during treatment with amitriptyline (from 245.5 +/- 68.6 to 256.8 +/- 69 cells x 10(9) L(-1), P < 0.06); no change was observed during treatment with paroxetine (from 232.6 +/- 58.3 to 234.6 +/- 68.9 cells x 10(9) L(-1), n.s). CONCLUSION: Treatment with amitriptyline tends to be associated with elevated platelet counts. The cause for this increase is not known, but may be relevant in terms of patients' long-term thromboembolic risk.     

Changes in slow evoked potentials in depressed patients treated with amitriptyline and oxaprotiline

Using a simple S1S2-R paradigm, acoustically evoked potentials, CNV, and PINV were recorded in 59 patients with major depressive disorder before and during a 4 week double blind pharmacological treatment with either amitriptyline (AT) or oxaprotiline (OT). In parallel, 30 healthy subjects were investigated 3 times, in identical intervals of 2 weeks. In the depressed state patients exhibited significantly smaller CNVs than the controls. In the AT-group clinical improvement and drug plasma levels of nortriptyline (NT, the principal metabolite of AT and an active antidepressant by itself) were positively related to increases in CNV-area; in the OT-group the reverse was true: increase in CNV-area was related to smaller OT plasma levels and less favourable outcome. The control group displayed a steady decline in CNV area during the 3 test sessions. N1P2 amplitude and PINV were not significantly different between groups and exhibited only minor variations during treatment.     

A healthy man with intractable hiccups

We present a patient with intractable hiccups. Medical treatment decreased the frequency of the hiccups to only 5–10 per minute. After exclusion of gastrointestinal reasons for the hiccups, cranial MRI revealed a small lesion in the right rhomboid fossa, close to the vagal trigone. Microsurgical resection of the lesion was performed via a suboccipital median craniotomy. The histopathological diagnosis was a cavernoma. Promptly after surgery the patient was free of symptoms. Intractable hiccups can be associated with intracranial pathologies, including lesions in the brain stem, which we highlight with the presentation of this patient.     

Symptom reduction in depressed outpatients treated with amitriptyline or maprotiline: Repeated measurement analysis

Preliminary open-labeled studies¹ had characterized maprotiline (Ludiomil^®) as a tetracyclic antidepressant that enhanced both mood and drive, reduced the symptoms of agitation and retardation, and had a fast onset of action. These effects might appear in patients as an increased interest in the environment and decreased apathy during the initial weeks of treatment. To test this observation, maprotiline was compared to amitriptyline hydrochloride (Elavil^®), a conventional tricyclic, in a 4-week double-blind clinical trial with outpatient depressives.No difference between these two compounds in timing of response, efficacy, or side effects was shown after 1 week of treatment or at the completion of the trial,² when utilizing a standard analysis of covariance. Using a repeated measurement analysis, we then examined the differences in rates of change between the drugs. Since the repeated measurement analysis uses the total period of observation instead of discrete points in time, it may be more sensitive to detecting those differences that were hypothesized prior to initiating the study.This paper will demonstrate the use of repeated measurement analysis to compare rates, pattern, and timing of symptom change between maprotiline and amitriptyline over the 4 weeks of treatment.     

Treatment of intractable hiccups with intramuscular haloperidol

Two patients with intractable hiccups were treated with intramuscular haloperidol; remission occurred within 1 hour. With its rapid action and low incidence of adverse effects, intramuscular haloperidol should be considered a therapeutic alternative in the treatment of intractable hiccups.     

Intractable reflex audiogenic epilepsy successfully treated by peri-insular hemispherotomy.

We report a case of an infantile hemiplegia seizure syndrome (IHSS) that presented with intractable reflex audiogenic startle epilepsy which in itself is an uncommon form of seizure disorder. Peri-insular hemispherotomy provided complete seizure control. Also of particular interest was that this syndrome resulted from an iatrogenic brain injury sustained during the course of a caesarian section. We review the different mechanisms of birth injury reported in the literature and, discuss the physiopathogenesis of the hemispheric damage in this patient. We also review the literature on "reflex epilepsy" as it applies to this case. Intractable reflex audiogenic (startle) epilepsy in IHSS submitted to hemispherotomy has not previously been reported.     

Intractable epilepsy in patients treated for childhood acute lymphocytic leukemia

PurposeIn the 1970s and 80s, standard treatment for childhood acute lymphocytic leukemia (ALL) included both intrathecal methotrexate and whole-brain irradiation. During acute treatment, seizures were not uncommon. The development of intractable epilepsy years after treatment, however, has not been well described in the literature. We describe five patients who were treated for acute lymphocytic leukemia as children, who later developed intractable epilepsy.ResultsAll of the patients were diagnosed with leukemia before age seven. Treatment included both whole-brain irradiation and intrathecal chemotherapy. All five received intrathecal methotrexate; in addition, two also received intrathecal cytosine arabinoside. The first seizure occurred at a mean of 7.5 years after diagnosis. Four patients have multiple seizure types, and all patients have been on multiple antiepileptic drugs. All five patients are cognitively impaired.ConclusionsSuccessful treatment for childhood leukemia may be followed by signs of late cerebral injury including intractable epilepsy. We propose that neurotoxicity resulting from exposure to intrathecal methotrexate and cranial irradiation may have contributed to the intractable epilepsy seen in our five patients.     

Changes in urinary catecholamines and their metabolites in depressed patients treated with amitriptyline or imipramine

The effects of treatment with amitriptyline (AMI) or imipramine (IMI) on changes in catecholamines and their metabolites in urine were studied in 95 unipolar and bipolar depressed patients. For the entire group, not separated by drug, substantial reduction in concentrations of all metabolites, but not catecholamines, occurred. Although catecholamine and metabolite change was similar for most substances assayed, there were some specific drug and diagnostic group differences. Vanillylmandelic acid (VMA) reduction was limited to bipolar patients; metanephrine (M) reduction to unipolar patients. Greater M and 3-methoxy-4-hydroxyphenylglycol (MHPG) reduction were associated with response in unipolar, but not bipolar patients. In bipolar, but not unipolar patients, norepinephrine (NE) rose in responders in contrast to reductions among nonresponding bipolar patients. The results suggest that effectiveness of blockade of reuptake of norepinephrine may be relatively more important for recovery in bipolar than in unipolar patients. Study of a battery of amine substances may contribute more information to our understanding of antidepressant drug effects on aminergic systems than analyses of MHPG alone.