Rita Silva

First Case of Severe Enterovirus 71 Infection in Portugal

W read with great interest the results of the randomized placebo-controlled trial from Laoprasopwattana and coworkers regarding the effectiveness of ciproflaxacin prophylaxis for preventing fever in neutropenic children with acute leukemia or lymphoma. In this study, there was a 23% reduction of febrile episodes in patients receiving ciprofloxacin, with a consequent decrease in the number of patients who needed to be treated to prevent 1 febrile episode to 4. In a similar, multicenter study comparing amoxicillin–clavulanate with placebo in a homologous patient population, we observed a 21% reduction of febrile events, with a number needed to be treated of 5. What becomes apparent from both studies is that for every 100 neutropenic patients receiving prophylaxis, 75–80 of them are treated unnecessarily to prevent the remaining 20–25 from developing fever and neutropenia. If we consider that the incidence of Gram-negative bacteremia, the most feared complication because of high mortality, generally represents no more than 10–15% of all febrile neutropenic episodes, we estimate that we would administer unnecessarily prophylaxis in 96–97 patients to prevent Gram-negative bacteremia in 3–4 patients. This number could still be considered as acceptable, if antibiotic resistance was not an emerging problem. In the Laoprasopwattana study, the proportion of ciprofloxacin resistant Gram-negatives colonizing patients after 2 weeks of intervention was 95%, whereas it was 27% in those randomized to receive placebo. To the contrary, in our institution where ciprofloxacin is not administered for prophylaxis, resistance to ciprofloxacin is 17% (25/145) of Gram-negative organisms causing bacteremia in children with cancer during an 8-year period (2004 to 2011). We consider this proportion as worrisome and worth strictly monitoring. The prolonged use of fluoroquinolone prophylaxis is associated with appearance of resistant strains, with the emergence of bacteria displaying cross-resistance to β-lactams, and aminoglycosides. This limits its use for empirical therapy, at least in low-risk conditions. Moreover, there is no proof of its efficacy in repeated episodes of neutropenia. We believe that now is the time when antibacterial prophylaxis in neutropenic children with cancer should be abandoned at least during chemotherapeutic regimens.

N170 asymmetry as an index of inferior occipital dysfunction in patients with symptomatic occipital lobe epilepsy

OBJECTIVE Localizing epileptic foci in posterior brain epilepsy remains a difficult exercise in surgery for epilepsy evaluation. Neither clinical manifestations, neurological, EEG nor neuropsychological evaluations provide strong information about the area of onset, and fast spread of paroxysms often produces mixed features of occipital, temporal and parietal symptoms. We investigated the usefulness of the N170 event-related potential to map epileptic activity in these patients. METHODS A group of seven patients with symptomatic posterior cortex epilepsy were submitted to a high-resolution EEG (78 electrodes), with recordings of interictal spikes and face-evoked N170. Generators of spikes and N170 were localized by source analysis. Range of normal N170 asymmetry was determined in 30 healthy volunteers. RESULTS In 3 out of 7 patients the N170 inter-hemispheric asymmetry was outside control values. Those were the patients whose spike sources were nearest (within 3cm) to the fusiform gyrus, while foci further away did not affect the N170 ratio. CONCLUSIONS N170 event-related potential provides useful information about focal cortical dysfunction produced by epileptic foci located in the close neighborhood of the fusiform gyrus, but are unaffected by foci further away. SIGNIFICANCE The N170 evoked by faces can improve the epileptic foci localization in posterior brain epilepsy.

Importância das alterações cutâneas no diagnóstico de doenças neurológicas

DOI: 10.1590/S1679-45082014AI2931 Crianca de 7 anos, do genero masculino, previamente saudavel, recorreu ao servico urgencia por cefaleia occipital e despertar noturno com 1 semana de evolucao. Apresentava manchas hipopigmentadas lineares segundo as linhas de Blaschko no hemitorax e membro superior esquerdos (Figura 1); macrocrânia, fenda palpebral antimongoloide, alteracao do contorno pupilar no olho esquerdo e sindactilia. Sem alteracoes no exame neuFigura 1. Manchas hipopigmentadas no membro superior, segundo as linhas de Blaschko Figura 2. Ressonância magnetica coronal T2 (A) e axial fluid attenuated inversion recovery (FLAIR) (B). Hipersinal T2 e FLAIR da substância branca dos hemisferios cerebrais, com predominio periventricular e central, de forma quase simetrica e difusa. Incontaveis imagens quisticas dispersas por toda a substância branca lesada, em algumas regioes com configuracao mais linear, parecendo corresponder a dilatacao de espacos perivasculares A B