DULOXETINE-RELATED PANIC ATTACKS

Side-effects arising on the grounds of antidepressant administration pose as a substantial obstacle hindering successful depressive disorder treatment. Side-effects, especially those severe or those manifested through dramatic clinical presentations such as panic attacks, make the treatment far more difficult and shake patients’ trust in both the treatment and the treating physician. This case report deals with a patient experiencing a moderately severe depressive episode, who responded to duloxetine treatment administered in the initial dose of 30 mg per day with as many as three panic attacks in two days. Upon duloxetine withdrawal, these panic attacks ceased as well. The patient continued tianeptine and alprazolam treatment during which no significant side-effects had been seen, so that she gradually recovered. Some of the available literature sources have suggested the possibility of duloxetine administration to the end of generalised anxiety disorder and panic attack treatment. However, they are outnumbered by the contributions reporting about duloxetine-related anxiety, aggressiveness and panic attacks. In line with the foregoing, further monitoring of each and every duloxetine-administered patient group needs to be pursued so as to be able to evaluate treatment benefits and weigh them against risks of anxiety or panic attack onset

Pitfalls and Benefits of Serological Diagnosis of Lyme Borreliosis From a Laboratory Perspective

Lajmska borelioza (LB) je bolest koju u Europi najčešće uzrokuju borelije kompleksa Borrelia burgdorferi sensu lato, dok je u Sjevernoj Americi jedino patogena B.burgdorferi sensu stricto. Kliničke manifestacije LB su polimorfne. Postavljanje dijagnoze temelji se na kliničkoj slici i epidemiološkim podacima o vjerojatnosti kontakta s krpeljima uz primjenu mikrobiološke dijagnostike. Najčešća je rutinska dijagnostika serologija za određivanje i praćenje dinamike specifičnih protutijela IgM i IgG. Nakon primarnog testiranja, rezultate je potrebno potvrditi dodatnim testom visoke specifičnosti. U područjima visoke prevalencije, specifičnost rezultata visoko osjetljivog i specifičnog testa nije obvezno dodatno potvrđivati. I pozitivni i negativni nalazi moraju se interpretirati klinički. Serološka dijagnostika predstavlja dobrobit za prepoznavanje i liječenje bolesnika samo ako se rezultati interpretiraju temeljem poznavanja patogeneze, kliničke slike i imunosnog odgovora kao i karakteristika korištenog testa. Karakteristike samih borelija i prezentacije antigena, izbjegavanje imunosnog odgovora, dostupnost različitih testova kao i Interneta predstavljaju zamke, posebno ako se slijede neprovjerene informacije.Lyme borreliosis (LB) in Europe is most commonly caused by different borrelia of Borrelia burgdorferi sensu lato complex , while in North America the only pathogen is B.burgdorferi sensu stricto. Clinical manifestations of LB are polymorphic. Diagnosis is based on the clinical presentation and epidemiological data on the likelihood of contact with ticks and with the application of microbiological diagnostics. The most common routine diagnosis is serology to determine and monitor the dynamics of specific IgM and IgG antibodies. After primary testing, the results need to be confirmed by an additional high-specificity test. In regions with a high prevalence, the specificity of the results of a highly sensitive and specific test does not need to be further confirmed. Both positive and negative findings must be interpreted clinically. Serological diagnosis is beneficial for the recognition and treatment of patients only if the results are interpreted on the basis of knowledge of the pathogenesis, clinical presentation and immune response as well as the characteristics of the test used. The characteristics of borrelia itself and the presentation of the antigen, the avoidance of the immune response, the availability of various tests as well as the Internet are pitfalls, especially if unverified information is followed

VENLAFAXINE WITHDRAWAL SYNDROME

Dual-action antidepressants serotonin–norepinephrine reuptake inhibitors (SRNIs) are widely used to treat depression. Owing to its efficiency and safety, venlafaxine holds a prominent place in this group of depressants. Abrupt venlafaxine discontinuation involves a high risk of withdrawal syndrome. Mechanism of its development is similar to that of selective serotonin reuptake inhibitors (SSRIs), but of higher intensity. Venlafaxine withdrawal symptoms may include several somatic symptoms as well as several psychiatric symptoms. In some cases, symptoms may look like a stroke. A treatment option is re-inclusion of venlafaxine or a SSRI antidepressant. The paper presents the case of a 70-year-old patient who discontinued of her own accord to take venlafaxine, which she had been taking regularly at a daily dose of 225 mg for more than a year. A few hours after taking the last dose, withdrawal syndrome occurred with severe symptoms resembling a stroke. The patient was examined by a neurologist and the CT and laboratory parameters showed no irregularities. Diagnosis was made after psychiatric observation. Venlafaxine, 150 mg per day, was prescribed, the symptoms disappeared relatively quickly, and the patient fully recovered. Withdrawal syndrome is a real risk for each venlafaxine treated patient. The possibility of its occurrence should be always kept in mind and patients should be timely informed about it. In this way, the risk of venlafaxine withdraw syndrome could be reduced, unnecessary stress to patients prevented and the costs of medical treatment lowered

SPECIFICITY OF LYME NEUROBORRELIOSIS DIAGNOSTICS

Lajmska neuroborelioza (LNB) nastaje hematogenim rasapom borelija u središnji živčani sustav (SŽS), a opisan je i prodor putem perifernog živca. Razvija se serozni meningitis sa ili bez pareze kranijalnog živca što je prevladavajuća klinička slika. Najčešće je zahvaćen n. facialis. Za razliku od Sjeverne Amerike, u Europi mogu biti zahvaćeni i drugi kranijalni živci, što se povezuje s prevaliranjem različitih vrsta borelija - u Europi najčešće B. garinii, B. bavariensis i B. afzelii, a u Sjevernoj Americi samo B. burgdorferi sensu stricto. Meningoradikulitis ili Bannwarthov sindrom tipična je slika LNB samo u Europi. Simptomi LNB većinom nisu tipični i mogu sličiti različitim neurološkim bolestima, pa dijagnozu često nije jednostavno definirati. Dijagnostika LNB mora uključivati analizu likvora u kojem je značajan nalaz pleocitoze, što upućuje na serozni meningitis kojem je potrebno dokazati povezanost s borelijama. Mikrobiološka dijagnostika LNB obuhvaća kultivaciju, zahtjevnu i dugotrajnu metodu (9-12 tjedana) koja se radi isključivo u referentnim centrima, te molekularnu (PCR) i serološku dijagnostiku. Zbog malog broja borelija u likvoru kao i relativno male količine likvora koja se šalje za analizu, molekularna je dijagnostika često lažno negativna. Stoga je serološka dijagnostika ključna za dokazivanje LNB. Serologija se radi iz istovremeno uzetih uzoraka seruma i likvora u kojima se određuju specifična protutijela IgM i IgG te ukupni imunoglobulini i/ili albumini. Serum i likvor moraju se analizirati istom metodom u istim uvjetima kako bi se mogla odrediti intratekalna sinteza specifičnih protutijela, tj. izračunati indeks protutijela (antibody index, AI). Specifična protutijela u lajmskoj boreliozi nastaju relativno sporo, a s duljinom trajanja infekcije njihova količina se povećava. U ranoj LNB protutijela u likvoru ne može se uvijek otkriti, iako je prisutna pleocitoza. Kasnu LNB u pravilu prati jaki imunosni odgovor i uz pleocitozu često se nalazi pozitivan AI. Nakon infekcije, vremenom se likvor normalizira i pleocitoza se više ne nalazi, iako specifična protutijela u likvoru mogu ostati dugo prisutna, čak i uz pozitivan AI. Stoga je potrebno pratiti imunosni odgovor u krvi i likvoru od dana kada se bolesnik javi zbog simptoma i zatim nakon npr. jednog, tri, šest i dvanaest mjeseci, radi procjene korelacije nalaza i bolesti. Dijagnoza LNB mora biti u skladu s kliničkim, epidemiološkim i anamnestičkim podatcima te laboratorijskim nalazima, posebno u likvoru. LNB je 1) potvrđena ako uz kliničku sliku postoji pleocitoza i intratekalna sinteza specifičnih protutijela; 2) vjerojatna ako intratekalna sinteza nije potvrđena, a specifična protutijela su prisutna u krvi bolesnika; 3) LNB nije vjerojatna ako nema pleocitoze ili nema analize likvora, iako su prisutna specifična protutijela u krvi bolesnika, ali klinička slika i epidemiološka anamneza nisu karakteristični. CXCL13 je biljeg koji može biti koristan kao dodatni test premda nije specifičan za LNB - u likvoru je povišen i prati akutnu upalu. Ako postoji mogućnost, LNB bi trebalo potvrditi kultivacijom i molekularnom dijagnostikom. Interpretacija laboratorijskih i kliničkih nalaza zahtijeva znanje i iskustvo. Informacije se trebaju sagledati u skladu s okolnostima i specifičnosti bolesnika, tako da je svaki bolesnik poseban dijagnostički izazov.Lyme neuroborreliosis (LNB) is caused by hematogenous spread of Borrelia into the central nervous system (CNS), but entry through a peripheral nerve has also been described. Aseptic meningitis develops with or without cranial nerve palsy, which is the predominant clinical presentation. Facial nerve is most frequently affected. Unlike North America, other cranial nerves can be affected in Europe, which is related to the prevalence of different types of Borrelia. Borrelia (B.) garinii, B. bavariensis, and less frequently B. afzelii are most common in Europe, while B. burgdorferi sensu stricto is the only North American strain. Meningoradiculitis or Bannwarth syndrome is a typical LNB presentation described only in Europe. The symptoms of LNB can resemble various neurological diseases, which makes the diagnosis of LNB difficult. The diagnosis of LNB must include analysis of cerebrospinal fluid (CSF) in which pleocytosis is significant to support aseptic meningitis, and the association with Borrelia must be proven. Microbiological diagnosis of LNB includes cultivation, a demanding and long-term method (9-12 weeks), which is performed exclusively in reference centers, and molecular (polymerase chain reaction, PCR) and serological diagnostics. PCR is often false-negative due to the low number of strands in the CSF. Thus, serological diagnosis remains crucial to confirm LNB. Serology is performed on simultaneously collected serum and CSF samples, from which specific IgM and IgG antibodies, total immunoglobulins and/or albumins need to be determined. Serum and CSF samples must be analyzed by the same method under the same conditions in order to assess the intrathecal synthesis of specific antibodies, i.e., to calculate the antibody index in CSF (antibody index, AI). In patients with Lyme borreliosis, specific antibodies are produced relatively slowly, and their quantity increases with the duration of the infection. In early LNB, antibodies in the CSF are not always detectable while pleocytosis is present. In late LNB, a strong immune response is present in the CSF, as well as pleocytosis, and a positive AI can be determined. Over time, CSF normalizes and pleocytosis is no longer detected, but CSF antibodies can remain present for a long period of time. Therefore, the immune response in the blood and CSF has to be monitored from the day the patient presented with symptoms, and then, for example, at one, three, six and twelve months to assess the correlation of laboratory findings with the disease. The diagnosis of LNB must be in accordance with clinical, epidemiological and history data and laboratory findings, especially in CSF. LNB is confirmed if the clinical picture is accompanied by pleocytosis and intrathecal synthesis of specific antibodies; LNB is probable if intrathecal synthesis is not confirmed while specific antibodies are present in the patient’s blood; and LNB is unlikely if there is no pleocytosis or no CSF analysis, although specific antibodies are present in the patient’s blood but the clinical picture and epidemiological history are not characteristic. If there is a possibility, LNB should be confirmed by culture and molecular diagnostics. CXCL13 is a marker that can be useful as an additional test, even though it is not specific for LNB as it is elevated in CSF and observed during acute inflammation. Interpretation of laboratory and clinical findings in LNB requires knowledge and experience. The findings should be interpreted in accordance with the circumstances and condition of the patient, and therefore each patient represents a special diagnostic challenge

Comparison of PCR methods and culture for the detection of Borrelia spp. in patients with erythema migrans

ABSTRACTThe sensitivities of two PCR assays and culture were compared for the detection of Borrelia spp. in skin specimens of 150 patients with typical erythema migrans. In addition, the accuracy of the methods for the identification of Borrelia spp. was compared by analysing culture isolates and material obtained directly from skin biopsy specimens. Borrelia burgdorferi sensu lato was isolated from 73 (49%) of 150 skin biopsy specimens. Using a nested PCR targeting the rrf–rrl region and a PCR targeting the flagellin gene, 107 (71%) and 36 (24%) specimens, respectively, were positive. With both PCRs, positive results were more frequent with culture-positive samples (67/73 (92%) and 24/73 (33%) for the nested and flagellin PCRs, respectively) than with culture-negative samples (40/77 (52%) and 12/77 (16%) for nested and flagellin PCR, respectively). Pulsed-field gel electrophoresis after MluI restriction identified 69/73 (95%) isolates, of which 58/69 (84%) were Borrelia afzelii and 11/69 (16%) were Borrelia garinii. After MseI restriction of PCR products amplified from the intergenic rrf–rrl region, B. afzelii was identified in 73/107 (68%) samples, B. garinii in 22/107 (21%) samples, and both species in 11/107 (10%) samples. The corresponding results for culture-positive specimens were 41/69 (59%), 14/69 (20%), and 7/69 (10%). Comparison of the results for specimens positive according to both approaches revealed complete uniformity in 80% of the cases. Overall, nested PCR was the most sensitive method for the demonstration of Borrelia spp. in erythema migrans skin lesions, followed by culture and PCR targeting the flagellin gene. The congruence of identification results obtained by analyzing culture isolates and material obtained directly from skin biopsies was relatively high but incomplete

First isolation of Borrelia sp. (Borrelia afzelii) from cerebrospinal fluid in a patient with neuroborreliosis in Croatia

Opisan je bolesnik s lajmskom boreliozom koja se manifestirala eritemom migrans na licu mjesec dana nakon uboda krpelja te poslije jednog mjeseca razvitkom faciopareze po perifernom tipu uz limfocitni meningitis (127 stanica/μL i 78% limfocita). Klinička slika neuroborelioze bila je razmjerno blaga. Bolesnik je liječen parenteralno ceftriaksonom kroz tri tjedna, uz dobar učinak antibiotske terapije te gotovo potpuno povlačenje klijenuti ličnog živca do kraja hospitalizacije. Bolesnik je imao reaktivna protutijela IgG na B. burgdorferi u serumu. Utvrđen je pozitivan indeks intratekalne sinteze protutijela IgM i IgG za borelije (specifičan test IDEIA Lyme Neuroborreliosis Oxoid, Velika Britanija). Imunosne pretrage na krpeljni meningoencefalitis, varicela-zoster virus i herpes simplex bile su negativne u serumu i u likvoru. U Mikrobiološkom institutu Medicinskog fakulteta u Ljubljani obra|en je likvor specifičnim uzgojnim metodama te je kultivirana B. burgdorferi sensu lato. Poslije kultivacije uzročnika izvršena je identifikacija borelijske vrste restrikcijom cjelokupnog borelijskog genoma enzimom MluI čime je utvrđen uzročnik bolesti: Borrelia afzelii. Premda se u Hrvatskoj neuroborelioza dijagnosticira i liječi preko dvadesetak godina, borelija dosada nije bila izolirana iz cerebrospinalnog likvora u naših pacijenata.We describe a patient with lyme borreliosis that manifested with facial erythema migrans one month after tick bite and consequently with peripheral facial paresis with lymphocyte meningitis (127 cells/μL and 78 % lymphocytes). Clinical picture of neuroborreliosis was relatively mild. The patient received ceftriaxone parenterally for three weeks, with beneficial effect of antibiotic therapy and almost complete resolution of facial paresis until discharge from hospital. Reactive IgG antibodies to B. burgdorferi were found in the patient’s serum. A positive index of intrathecal synthesis of IgM and IgG antibodies to borreliae was determined (specific test IDEIA Lyme Neuroborreliosis Oxoid, Great Britain). Immunological examination for detection of tick-borne meningoencephalitis, varicella-zoster virus and herpes simplex proved negative in both serum and cerebrospinal fluid (CSF). B. burgdorferi sensu lato was isolated from CSF using specific culturing techniques at the Institute of Microbiology and Immunology of the Medical Faculty, University of Ljubljana. After cultivation of the pathogen, identification of Borrelia species was performed by using restriction enzyme MluI thus determining the causative agent of neuroborreliosis: Borrelia afzelii. Although neuroborreliosis has been diagnosed and treated for over twenty years in Croatia, so far Borrelia has never been isolated from cerebrospinal fluid in our patients

Guillain-Barre Syndrome in Patients with Seroconversion of IgG Antibodies to Borrelia Burgdorferi sensu lato

A case of polyneuroradiculitis (Guillain-Barre Syndrome) is presented, which was diagnosed in a 62 year-old man after progressive weakness in the legs and arms and double vision, preceded by severe pain in the back. Diagnosis was made on the basis of electromioneurography, a specific finding of cerebrospinal fluid (albumino-citological dissociation), and the clinical course of the disease. Serological analysis of serum included Borellia Burgdorferi sensu lato (BBSL). Positive findings (slowing of conduction velocity of sensor and motor neurones, and marked albumino-citological dissociation), together with the dynamics of these findings on the 33rd, 67th and 101st days and one year and a half after the first clinical signs of disease, indicated the possibility of BBSL infection. Because of the absence of clear clinical and serological signs of other infections it was assumed that BBSL might be the possible trigger for Guillain-Barre Syndrome. The fact that there were no obvious clinical signs of infection with BBSL, only serological, suggests that in the case of unclear aetiology of Guillain-Barre Syndrome BBSL should not be excluded

WEIGHT GAIN - AS POSSIBLE PREDICTOR OF METABOLIC SYNDROME

Rapid weight gain among patients with mental disorders can further compound psychological distress and negatively influence compliance. Weight gain associated with treatment with atypical antipsychotic medication has been widely recognized as a risk factor for the development of diabetes type II and cardiovascular diseases. This paper describes a 33-year old female patient treated for schizoaffective disorder. Within two months after introducing quetiapine the patient experienced considerable weight gain amounting to 19 kg. The replacement of antipsychotic during inpatient psychiatric care resulted in weight loss

SWITCHING AMONG ANTIPSYCHOTICS - FOCUS ON SIDE EFFECTS

Depression is a disorder held responsible for high morbidity in the overall population. Causes of depression vary, but lifestyle and stress can greatly contribute to its morbidity. Consumption of antidepressants is showing a trend in the economically developed countries. Apart from antidepressants, the treatment of depression can consist of other psychopharmaca. Depending on the severity of a disorder, that is - of psychotic symptoms, antipsychotics can be introduced in the treatment. Among those atypical antipsychotics have an advantage. This paper will illustrate a course of treatment of a female patient, diagnosed with psychotic depression and treated with antipsychotics (i.e. olanzapine, ziprasidone), to which she developed side effects. To each of the antypsychotics the patient developed side effechts, causing in prolonged treatment and affected its course