Charles Bell initially described the numb chin syndrome (NCS) in 1830 [ [1] Furukawa T. Charles Bell's description of numb chin syndrome. Neurology. 1988; 38: 331 Crossref Scopus (46) Google Scholar ]. Facial numbness localized in the distribution of mental nerve has been labelled the NCS. Numb Chin is a syndrome which initially presents with unilateral numbness (anesthesia or hypoesthesia), paresthesias or orofacial pain over the chin, in the area supplied by the mental nerve and its branches [ [2] Sweet J.M. The numb chin syndrome: a critical sign for primary care physicians. Arch Intern Med. 2004; 164: 1347-1348 Crossref PubMed Scopus (23) Google Scholar ].

Los pacientes con mieloma multiple (MM) raramente presentan ascitis. La misma puede responder a diversos mecanismos, siendo las causas mas frecuentes el aumento de permeabilidad del peritoneo y la hipertension portal por infiltracion hepatica. La ascitis mielomatosa (AM) ocurre con mas frecuencia en pacientes con paraproteina de tipo Ig-G e Ig-A y su pronostico es sombrio. Se presenta el caso de una paciente de sexo femenino de 50 anos con diagnostico de MM IgA-kappa que evoluciona con insuficiencia cardiaca (IC), leucemia de celulas plasmaticas y ascitis de causa mixta, por infiltracion peritoneal por celulas mielomatosas, compromiso hepatico e IC. Se realiza una revision de las distintas causas de ascitis en pacientes con MM. Asimismo se resumen todos los casos publicados en la literatura mundial de AM. Nuestro reporte representa el primer caso de AM en un paciente con leucemia de celulas plasmaticas.

Vocal cord dysfunction (VCD), is characterized by a paradoxical adduction of the vocal cords during inspiration, and occurs predominantly in young women. Common symptoms are cough, wheezing, episodic dyspnea, and inspiratory stridor. The true incidence and course of the disease are unknown, and it is usually self limited. It can coexist with, or mimic refractory asthma. Psychological disorders were thought to be the principal cause, subsequently multiple organic diseases have also been reported, like gastroesophageal reflux disease (GERD). Diagnosis is made by clinical suspicion and direct observation. The Gold standard for diagnosis is laryngoscopy with visualization of the paradoxical motion of the vocal cords when the patient is symptomatic. Speech therapy and psychotherapy have been used extensively without any prospective study. We report two cases of VCD associated with GERD, both with excellent respond to treatment.

The serotonin syndrome is a clinical condition associated with serotonin agonists. Is due to an overstimulation of central and peripheral serotonin receptors that leads to mental, autonomic and neuromuscular changes. Usually the disorder resolves within the first 24 hours after the medications are discontinued, however some patients progress to a multiple organ failure and die. We describe four elderly patients that presented with the classic triad. They presented the symptoms in average at the third day after the initiation or variation of the treatment with serotonin reuptake inhibitors. All had a favorable response with the suspension of medications and, in three cases, with the treatment with chlorpromazine. We believe it is a potentially fatal but reversible condition, probably underdiagnosed that requires a high index of suspicion.

INTRODUCCIÓNLa disfunción de cuerdas vocales (DCV) se caracteriza por la aducción de las mismas durante la inspiración, lo que resulta en una limitación al flujo aéreo a nivel de la laringe (1).La primera descripción se atribuye a Dunglison (2), quien en 1842 describió un desorden de los músculos laríngeos en mujeres con histeria, denominándolo "croup histérico".Si bien la DCV, es la expresión que mejor explica este síndrome, existen otras denominaciones a saber: estridor de Munchausen, pseudoasma, obstrucción de la vía aérea superior (VAS) no orgánica o funcional, asma facticio, croup espasmódico, sibilancias laríngeas emocionales, obstrucción de VAS psicógena, disquinesia laríngea episódica, laringoespasmo paroxístico episódico, estridor laríngeo funcional, laringoespasmo inducido por ejercicio y síndrome de laringe irritable (1,3).La verdadera incidencia y el curso clínico de la enfermedad son desconocidos.Los síntomas más comunes son sibilancias, tos, disnea episódica, estridor inspiratorio, disfonía, y dolor torácico (3).Históricamente se atribuyo esta enfermedad a distintos desordenes psicológicos, en los últimos años se han encontrado múltiples causas orgánicas entre las que se encuentra el reflujo gastroesofágico (RGE).Se han descrito hasta la fecha aproximadamente 1.500 casos (1,3).Se presentan dos pacien-

569 rienced headache, lethargy, and projectile vomiting. Physical examination revealed sleepiness and flapping, temperature of 37.4 oC, blood pressure of 180/120 mmHg, rhythmic heart sound with panfocal systolic murmur (III/VI), and unremarkable pulmonary auscultation and abdominal examination. Normal neurological examination, with no meningeal signs. Laboratory test results included: blood glucose 82 mg/dL, urea 158 mg/dL, creatinine 14.16 mg/dL, GOT 61 U/L, GPT, 279 U/L, LDH 864 U/L, GGT 298 U/L, CRP 42.9, hemoglobin 12.0 g/dL, WBCs 5.38 10(9)/L with normal differential, and platelet count 167 10(3)/L. All other laboratory parameters were within normal ranges. Ophthalmoscopy: right eye with normal disc and macula, nasal bleeding, and temporal superior arcade with cotton wool exudates; left eye with normal disc. Patient was diagnosed of grade III hypertensive retinopathy. No pathological findings were made in CT and MRI of the brain. Diagnosis of accelerated arterial hypertension led to start intravenous antihypertensive treatment that achieved optimal control of pressure values, but neurological symptoms persisted. Cerebrospinal fluid (CSF) pressure was increased to 33 mg (normal, up to 20 mmHg), with leukocytosis (36 WBCs/mm) with a predominance of lymphocytes (70%), increased protein levels (87 g/dL), and low glucose (84 mg/dL). Serologic testing was positive for Brucella, Bengal rose, agglutination with anti-brucella antibodies 1/160, and immune capture with anti-brucella antibodies > 1/5120. CSF and blood cultures were positive for Brucella spp. Neurobrucellosis was diagnosed, and specific antibiotic therapy was started with doxycycline, rifampin, and trimethoprim-sulfamethoxazole. After five days of treatment, patient experienced a clear improvement, showing no fever or symptoms. Incidence of brucellosis in Europe is low. In Spain, however, brucellosis is the main zoonosis, and endemic areas continue to exist, particularly in rural cattleraising areas. Clinical signs of brucellosis are very diverse, and genitourinary, gastrointestinal, and cardiological manifestations are most common. Central nervous system involvement by brucellosis (neurobrucellosis) is uncommon and mainly causes meningeal signs, although papilledema, optic neuropathy, radiculitis, and stroke may also occur. Cases of neurobrucellosis have been reported in patients with CKD living in endemic areas. In our patient, the condition occurred as intracranial hypertension and fever. Diagnosis of neurobrucellosis should be considered in a patient with CKD who also has fever of unknown origin and neurological signs. When the disease is suspected based on clinical signs, serologic tests allow for confirming diagnosis, and germ isolation from culture is an even more definitive evidence, as in the reported case. While this is an uncommon condition, it should be kept in mind because early diagnosis and treatment decrease the high mortality associated to neurobrucellosis. Long-term treatment should be administered with two or three antibiotics able to cross the blood-brain barrier. Our patient received treatment for three months and has no neurological sequelae.

Ascites is rare in patients with multiple myeloma (MM). It may be due to diverse mechanisms, most frequently because of an increased permeability of the peritoneum or because of portal hypertension due to liver infiltration. Myelomatous ascites occurs more frequently in patients having Ig-G or Ig-A paraprotein and their prognosis is poor. It is submitted the case of a female patient aged 50 years with IgA-kappa MM, who evolved with cardiac failure (CF), plasma cells leukemia and ascites of mixed cause, because of peritoneal infiltrate of myelomatous cells, hepatic compromise and CF. A review of the different causes of ascites in patients with MM is performed. There are also summarized all myelomatous ascites cases published in the literature. Our report presents the first case of myelomatous ascites in a patient with plasma cells leukemia.

The serotonin syndrome is a clinical condition associated with serotonin agonists. Is due to an overstimulation of central and peripheral serotonin receptors that leads to mental, autonomic and neuromuscular changes. Usually the disorder resolves within the first 24 hours after the medications are discontinued, however some patients progress to a multiple organ failure and die.We describe four elderly patients that presented with the classic triad. They presented the symptoms in average at the third day after the initiation or variation of the treatment with serotonin reuptake inhibitors. All had a favorable response with the suspension of medications and, in three cases, with the treatment with chlorpromazine.We believe it is a potentially fatal but reversible condition, probably underdiagnosed that requires a high index of suspicion.

Night sweats has been defined as drenching sweats that require the patient to change bedclothes. In current studies night sweats appear in 30% of non-obstetric patients and affects approximately 60% of pregnant women. Differential diagnoses include infections, malignancy, medications, hot flashes and panic attacks, making of each patient a challenge. We present two patients with night sweating. After excluding systemic diseases the diagnosis of gastroesophageal reflux was made, with excellent response to anti-reflux treatment. The presentation of our two patients coupled with a deep literature review, underscores the importance of gastroesophageal reflux as a cause of night sweating.

Background: Nonconvulsive status epilepticus (NCSE) is a usually underdiagnosed and potentially treatable cause of altered awareness in the elderly. To assess etiologies, associations with other medical problems, and prognosis of NCSE in a population aged > 75 years we performed a nested case-control study.Methods: We retrospectively evaluated the clinical manifestations and EEG findings in 19 consecutive elderly patients (mean age 83.3 years) presenting with NCSE and compared them with 34 elderly patients (mean age 83.3 years) with altered mental status but without EEG evidence of NCSE. The variables compared included brain lesions on CT or MRI, number of concomitant chronic active diseases, previous neurological disorders, acute medical problems, the use and withdrawal of medications, and outcome. Statistical analysis was performed using chi-square test, t-test, Fisher's exact two-tailed test, and Wilcoxon rank sum test.Results: The etiology of NCSE was epilepsy in 2, acute medical disorders in 14, and a cryptogenic cause in 4. The NCSE group had a more frequent history of epilepsy, 35% versus 8.8% (p = 0.028); tramadol use, 31% versus 0% (p = 0.00151); longer hospitalization, 25 days versus 7 days (p = 0.0004); and unfavorable outcome, 50% versus 5.8% (p = 0.00031). No significant differences were found in the other variables. Unfavorable outcome was associated with a higher number of comorbidities (> 2) and to a severely altered mental status.Conclusions: NCSE is a serious cause of altered mental status in the elderly. Although its direct role in brain damage is controversial, elderly patients with NCSE have higher morbidity and worst prognosis than those with altered mental status without NCSE.

Graves disease is by far the most common cause of hyperthyroidism. Is an immunologic disorder and it is distinguished clinically from other forms of hyperthyroidism by the presence of diffuse thyroid enlargement, ophthalmopathy, and occasionally pretibial myxedema. In this paper we summarize the prolific life of Robert Graves and we also describe the signs and symptoms of hyperthyroidism. In today s medicine, were technology plays a very important role, we would like to remark the value of anamnesis and physical exam as some of the most useful tools.

Obstetricia y Ginecología, que presentaban sudoración nocturna en los tres meses previos a la internación y el porcentaje de pacientes no obstétricos con sudoración nocturna fue del 33% y hasta en un 60% de las mujeres embarazadas.No existen hasta el momento estudios de prevalencia e incidencia de esta entidad (2).En 1989 Reynolds publica una serie de 200 pacientes con sudoración nocturna, encontrando que un 44% presentaba reflujo gastroesofágico (RGE) y que el 80% de este grupo respondía satisfactoriamente al tratamiento antireflujo (5).Cabe destacar que esta serie incluía sólo pacientes con sudoración nocturna sin fiebre.Se describen dos casos atendidos

Graves disease is by far the most common cause of hyperthyroidism. Is an immunologic disorder and it is distinguished clinically from other forms of hyperthyroidism by the presence of diffuse thyroid enlargement, ophthalmopathy, and occasionally pretibial myxedema. In this paper we summarize the prolific life of Robert Graves and we also describe the signs and symptoms of hyperthyroidism. In today s medicine, were technology plays a very important role, we would like to remark the value of anamnesis and physical exam as some of the most useful tools.

A syndrome of apical ballooning, with ECG mimicking acute myocardial infarctation, mild or no enzymatic changes, and normal coronary angiogram was described in 1990. It presents mainly in middle aged and elderly women and it is preceded by stress triggering circumstances. Several mechanisms have been proposed although the precise cause remains unclear. The most accepted theory proposes the interaction of catecholamines and an inadequate inotropic response. We report four cases that presented with chest pain and sudden onset of heart failure, all patients had physical or emotional stress as a triggering factor. On ECG, ST segment elevation and inverted T waves were observed in the acute phase. All patients had typical echocardiogram image and normal coronary angiogram. Both ECG and echocardiogram returned to normal within two weeks.

An earlier study demonstrated a strong correlation between low-density lipoprotein-lipid peroxide (LDL-LPO) content and serum triglyceride levels (TG), as well as a significant inverse correlation between LDL-LPO and high-density lipoprotein cholesterol (HDL-C). In the present study, 15 hypertriglyceridemic patients were treated with bezafibrate for 8 weeks in an attempt to normalize their elevated levels of LDL-LPO. At study end, the following significant variations were found: TC (-67%, P<.0001), LDL-LPO (-58%, P<.002), total cholesterol (-19%, P<.0015), very-low-density lipoprotein cholesterol (VLDL-C, -62%, P<.0002), fibrinogen (-23%, P<.01), HDL-C (+34%, P<.0002), and HDL, (+38%, P<.0003). The parallel reductions in TC and LDL-LPO, with a rise in HDL-C, reinforced the close association among these parameters and showed an antioxidant effect of bezafibrate. The additional decreases of other lipid compounds and fibrinogen previously noted support the antiatherothrombotic profile of this lipid-lowering agent.