Klaus-Henning Krause

Biotin status of epileptics.

Microbiologically determined plasma biotin levels in 404 epileptics under long-term treatment with anticonvulsants were markedly lower than in 112 controls (p less than 0.0005). Patients with partial epilepsy had lower biotin levels and higher average daily intake of AC than those with generalized epilepsy. Epileptics treated with valproate sodium in monotherapy showed considerably higher biotin levels than epileptics with monotherapy of primidone (PRM), carbamazepine (CBZ), phenytoin (PHT) or phenobarbital (PB). The group of epileptics with high average daily dose of anticonvulsants had lower biotin levels than the group with low dose. In three patients with newly recognized epilepsy biotin levels were normal before starting anticonvulsant medication, increased during the first week and fell under the starting level in the following weeks. Four epileptics treated with PHT, PB, PRM or CBZ had an increased urinary excretion of organic acids, as found in patients with a deficiency of biotin-dependent carboxylases. In 37 epileptics undergoing long-term treatment plasma lactate concentrations were determined; they had a higher mean concentration than that found in controls. Our results suggest, that the lowering of biotin in epileptics is caused by intake of anticonvulsants and has a biochemical effect in these patients. It is discussed, whether this could be a factor in the mode of action of anticonvulsants.

The Anterior Tarsal Tunnel Syndrome

SummaryThe anterior tarsal tunnel syndrome, first described in 1968 by Marinacci, is characterized by a compression of the deep peroneal nerve under the inferior extensor retinaculum. The patients complaint of pains on the dorsum of the foot, especially at night. Clinically result sensory deficits in the involved area between the first and second toes as well as paresis and atrophy of the extensor digitorum brevis. The distal latency of the deep peroneal nerve is increased, the EMG shows active and chronic denervation of the extensor digitorum brevis. In cases with partial anterior tarsal tunnel syndrome only the motoric branch to the extensor digitorum brevis or only the sensory branch of the deep peroneal nerve after the division under the inferior extensor retinaculum is compressed. Two cases with complete and one with partial anterior tarsal tunnel syndrome are presented, etiology, symptomatology, differential diagnosis and therapeutic possibilities are discussed.ZusammenfassungDas 1968 erstmals von Marinacci beschriebene vordere Tarsaltunnelsyndrom besteht in einer Kompression des N. peronaeus profundus unter dem Ligamentum cruciatum. Subjektiv werden heftige, vor allem nachts auftretende Schmerzen im Fußrückenbereich geklagt. Klinisch resultieren sensible Ausfallserscheinungen im entsprechenden Hautareal zwischen der ersten und zweiten Zehe sowie Parese und Atrophie des M. extensor digitorum brevis. Elektroneurographisch findet sich eine erhöhte distale motorische Latenz des N. peronaeus profundus, elektromyographisch ist aktive und chronische Denervierung im M. extensor digitorum brevis nachweisbar. In Fällen mit partiellem vorderen Tarsaltunnelsyndrom wird entweder nur der motorische Ast zum M. extensor digitorum brevis oder nur der sensible Anteil des N. peronaeus profundus nach der Teilung unter dem Ligamentum cruciatum komprimiert. Zwei Fälle mit vollständigem sowie ein Fall mit partiellem vorderen Tarsaltunnelsyndrom werden vorgestellt; Ätiologie, Symptomatologie, Differentialdiagnose und therapeutische Möglichkeiten werden erörtert.

Serum lipids and anticonvulsants

The serum lipid levels of 200 epileptics (aged 20 to 40 years) undergoing long‐term treatment with anticonvulsants were measured and compared with the levels of a normal population of the same age. The epileptics had higher serum lipid levels (especially of apolipoprotein B and HDL‐cholesterol) but no higher incidence of hyperlipemias. A correlation between LDL‐cholesterol and vitamin E has been found in epileptics, but it was not as significant as in normals. In male epileptics, positive correlations between the average daily dose of anticonvulsants (especially of those with a well‐known enzyme‐inducing effect) and triglycerides, cholesterol and LDL‐cholesterol were found; in females there were no significant correlations.

Plasma arginine vasopressin concentrations in epileptics under monotherapy

SummaryPlasma arginine vasopressin concentrations were determined by radio-immunoassay in 112 adult epileptics who were taking carbamazepine, phenytoin, primidone, or sodium valproate in long-term monotherapy, and in 19 controls. No significant difference was found between the groups, but some epileptics taking carbamazepine and primidone showed low values. Serum concentrations of carbamazepine did not correlate with the concentrations of plasma arginine vasopressin. In conclusion, there was no evidence of a stimulating effect of chronic carbamazepine medication or a special inhibiting effect of phenytoin on the release of vasopressin arginine from the posterior pituitary.ZusammenfassungBei 112 unter Monotherapie mit Carbamazepin, Phenytoin, Primidon oder Valproat stehenden erwachsenen Anfallskranken sowie bei 19 gleichaltrigen Kontrollpersonen wurden radioimmunologisch die Vasopressin-Plasma-Konzentrationen bestimmt. Es wurden keine signifikanten Unterschiede zwischen den Gruppen gefunden. Einige der mit Carbamazepin und Primidon monotherapierten Epileptiker wiesen niedrige Vasopressin-Werte auf. Die Carbamazepin-Serumspiegel korrelierten nicht mit den Vasopressin-Konzentrationen. Somit ergab sich weder ein Hinweis auf eine vermehrte Vasopressin-Ausschüttung unter Langzeittherapie mit Carbamazepin noch eine besondere Hemmung der Ausschüttung durch Phenytoin.

Antiepileptic drugs reduce serum uric acid

Uric acid examination in 554 epileptic out-patients under long-term anticonvulsant medication revealed significantly lower serum concentrations compared to a group of normal controls. In patients taking enzyme-inducing drugs, uric acid levels were found to be lower than in those under valproate sodium. In addition, uric acid concentrations showed a negative correlation with duration of therapy in epileptic males. At this time, we can only speculate on the mechanism involved in the reduction of uric acid by enzyme-inducing anticonvulsants as well as on the possible implication of this finding in the treatment of hyperuricemia.

New Aspects of Thromboangiitis obliterans (von Winiwarter-Buerger's Disease)

The existence of thromboangiitis obliterans as a clinical entity has been a matter of debate for many years. In contrast to other immunovasculitides there is no organ involvement while peripheral vessels are affected. Heavy smokers under 40 years of age have a high predisposition for the disease. The cerebral form shows relapsing brain infarctions which can be visualized in CCT while panarteriography remains negative. Apart from unspecific inflammatory signs in blood and CSF there are distinctive laboratory findings proving the autoimmunological character of von Winiwarter-Buergers disease. In the serum anti-elastin antibodies, IgE and anticollagen antibody activity are detectable. In 3 patients the authors detected specific immunohistochemical findings in a biopsy specimen of the temporal artery. In addition to platelet-inhibiting substances corticoids in acute and azathioprine in chronic treatment becomes necessary.

Bone mineral content after renal transplantation

SummaryForearm bone mineral content (BMC), as evaluated by photonabsorption densitometry, was measured in 28 cadaver kidney donor recipients who entered the study 8 weeks postoperatively and were followed up for 18 months. BMC decreased signifiantly (p<0.05) but marginally in placebo-treated patients (n=14) (initial BMC 1.09±0.25 g/cm; final BMC 1.05±0.24). Fourteen patients were prophylactically given 1,25(OH)2vitamin D3 in a dose which avoided hypercalcemia and hypercalciuria (∼0.25 µg/day); under 1,25(OH)2 vitamin D3 prophylaxis a significant decrease of forearm BMC was observed no longer (initial BMC 0.94±0.21 g/cm; final BMC 0.95±0.21), but the difference between placebo and 1,25(OH)2 vitamin D3 narrowly missed statistical significance (p=0.066).It is concluded that the decrease of forearm BMC is negligible in transplant recipients with low steroid regimens. The data suggest a trend for prophylaxis with 1,25(OH)2 vitamin D3 to slightly ameliorate forearm (cortical) BMC loss.

Plasma catecholamines during activation of the sympathetic nervous system in a patient with shy-drager syndrome

SummaryPlasma catecholamines and circulation parameters were studied in a patient with a Shy-Drager syndrome. Basal values of free noradrenaline and dopamine were within the normal range, whereas the adrenaline level was decreased. The response of plasma catecholamines to different kinds of physical activity was pathological. The inability to maintain elevated catecholamine levels during prolonged activity corresponded to impaired circulatory regulation and may provide an additional tool for diagnosis and monitoring of the Shy-Drager syndrome.ZusammenfassungBei einer Patientin mit Shy-Drager-Syndrom wurden Plasmakatecholamine und Kreislaufparameter untersucht. Die basalen Werte an freiem Noradrenalin und Dopamin waren im Normbereich, Adrenalin erniedrigt. Die Reaktion der Plasmakatecholamine auf verschiedene Arten körperlicher Belastung war deutlich pathologisch. Die Unfähigkeit, die Plasmakatecholamine vor allem während längerer Aktivität auf erhöhtem Niveau zu halten, entsprach der beeinträchtigten Kreislaufregulation und kann als weiteres diagnostisches Kriterium angesehen werden.

Immunglobuline unter antiepileptischer Langzeitmedikation

Bei 492 Anfallskranken (288 Manner, 204 Frauen) im Alter von 20–40 Jahren unter antiepileptischer Langzeitmedikation wurden im Plasma mittels immunnephelometrischer Endpunktbestimmung (Lasernephelometer, Behringwerke, Marburg) die Immunglobuline A, G und M bestimmt und mit denen von 287 gleichaltrigen Normalpersonen verglichen (Wilcoxon-Test). Die Korrelationen mit durchschnittlicher Tagesdosis und Gesamtmenge an Antiepileptika sowie Therapiedauer wurden errechnet, die Werte bei den unter Monotherapie mit Phenytoin (n = 45), Primidon (n = 72), Carbamazepin (n = 50) und Valproat (n = 29) stehenden Patienten verglichen (auserdem mit den Medikamentenspiegeln korreliert), ebenso wie die Immunglobulinkonzentrationen bei idiopathischer und symptomatischer Epilepsie sowie bei bis zu 2 Jahren und uber 10 Jahren behandelten Epileptikern. Moglichen Beziehungen zu Gingivahyperplasie und Leukozyten- sowie Lymphozytenzahl wurde nachgegangen.

External carotid steal and lateral medullary infarction--is there a pathogenetic connection?

SummaryThe case of a patient with occlusion of the external carotid artery is reported; he suffered from vertebrobasilar insufficiency with Wallenbergs syndrome. Arteriography showed stealing of intracranial blood from the vertebral artery via the occipital artery, and thromboendarterectomy was successfully performed. Since no localised processes could be demonstrated could the lateral medullary infarction be due to the haemodynamic changes? In cases of external carotid steal thromboendarterectomy might be the appropriate treatment.ZusammenfassungEs wird der Fallbericht eines Patienten mitgeteilt, der bei einem Verschluß der A. carotis externa das Bild einer vertebrobasilären Insuffizienz mit Wallenberg-Syndrom bot. Die Arteriographie zeigte ein Steal-Syndrom aus der A. vertebralis über die Occipitalarterie. Eine erfolgreich durchgeführte Thrombendarteriektomie brachte Beschwerdefreiheit. Bei fehlenden lokalisierten Gefäßveränderungen muß die Möglichkeit der hämodynamischen Verursachung des lateralen Oblongatasyndromes diskutiert werden. In solchen Fällen könnte die Thrombendarteriektomie eine kausale Behandlungsmethode darstellen.