With Exposure to Drugs Or Toxins."'' We Report Kept Hounds Noted Fleeting
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Letters to the Editor 1123 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.12.1123 on 1 December 1991. Downloaded from and the neuropathological findings which to changes in posture. The blurring became Our patient stopped using lindane when Binswanger considered essential to a disease persistent after three months and then he the association of pseudotumour cerebri and which he called "encephalitis subcorticalis developed intermittent blurring in his left lindane was brought to his attention; this was chronica progressiva". These "reliable eye. Shortly after he noticed early morning coincidentally reinforced when a neighbour's criteria" were introduced to differentiate occipital headaches and tinnitus. He had used puppies convulsed and died after exposure to "encephalitis subcorticalis" from "arterio- benzene hexachloride at least twice a month a 20% solution. Despite discontinuation of sclerotic brain degeneration" (which also for about 30 years to rid his beagle hounds of the pesticide the patient's intracranial pres- affects the cortex), from the "general paralysis fleas and ticks. He said he used a 20% sure remained elevated (440 mm CSF) and of the insane" and from senile dementia, concentrate to make dip and spraying headaches continued 11 months later when a which he knew could also be accompanied by applications but wore a mask and appropriate lumbo-peritoneal shunt was inserted. white matter changes.2 protective clothing. He was well built but not Removal of the toxin should result in allevia- The similarities between Bennett's' and obese. His neurological examination yielded tion of increased intracranial pressure. Per- Binswanger's own criteria are obvious. normal results except for visual findings: his haps the lindane caused permanent or prolon- Nevertheless, several striking discrepancies best corrected visual acuity was 6/36 OD and ged alteration of the arachnoid villi. Alter- appear noteworthy. The white matter atro- 6/9 OS. He had a right relative afferent natively, lindane may be present in fat cells phy in Binswanger's patients was most pro- pupillary defect. Ocular motility and slit lamp for an extended period and have a long lasting nounced in the occipital and temporal lobes, examinations were normal. Intraocular pres- effect on CSF absorption. Whether the whereas radiological changes are most com- sures were 21 and 23 mm Hg respectively. patient's liver damage was caused by previous monly found in the frontal lobes. According Ophthalmoscopic examination showed dis- chronic alcohol consumption or exposure to to Binswanger, "encephalitis subcorticalis" tinct swollen optic discs with small cups, loss lindane is unclear. The relation with lindane slowly and relentlessly progressed to a state of the nerve fibre layer in the right eye, and a exposure may not be coincidental because of decerebration, whereas Bennett et al ex- small pseudodrusen in the left eye, typical of other pesticides have been linked to cluded patients with severe dementia. Bins- chronic papilloedema. Goldmann perimetry pseudotumour cerebri in the past.2 The use wanger assumed that arteriosclerosis was the showed visual field loss characteristic of of lindane should be discontinued when cause ofdisease and mentioned the invariable chronic papilloedema. patients have unexplained raised intracranial presence of cerebral arteriosclerosis (which MRI of the head was normal except for a pressure. was, however, very mild in the only case he few small periventricular white matter LISA VERDERBER described extensively). He did not describe lesions; venous sinus thrombosis was not PATRICK LAVIN or other evidence of RALPH WESLEY hypertension systemic seen. A spinal tap showed an opening pres- Departments ofNeurology and Ophthalmology, vascular disease. sure of 400 mm CSF with one monocyte per Vanderbilt University Medical Center, It has already been pointed out that the cu mm, protein 0-34 Gm/l, glucose 2 mmol/l, Nashville, TN 37212, USA. relationship between Binswanger's findings and no evidence of infection. Other Correspondence to: Dr Lavin, M.D., 2100 Pierce and the modem "Binswanger's disease" laboratory values were notable only for Ave., Nashville, TN 37212, USA. remains open to question.' Binswanger did elevated cholesterol and triglyceride concen- not present a full account of the histopath- trations and mildly abnormal results of liver ology in his cases. This was left to Alzheimer, function tests. Thyroid function tests were 1 Ireland B, Corbett JJ, Wallace B. The search of who first used the eponym "Binswanger's normal; rheumatoid factor and antinuclear causes ofidiopathic intracranial hypertension. disease",4 and to Nissl.' Inconsistencies in antibodies were negative. Toxic screens for Arch Neurol 1990;47:315-20. Binswanger's original description may sup- lead, mercury, and arsenic were negative. 2 Sanbom GE, Selhorst JB, Calabrese VP, et al. port the speculation that he eventually re- Management included Pseudotumour cerebri and insecticide intox- dietary advice (weight ication. Neurology 1979;29:1222-7. garded the differentiation of such vascular loss), diuretics, and prednisone, but he sub- 3 Pramanik AK, Hansen RC. Transcutaneous dementias as too difficult or too unrewarding.2 sequently had bilateral optic nerve sheath gamma benzene hexachloride absorption and HANS FORSTL fenestration because of progressive visual toxicity in infants and children. Arch Der- ROBERT HOWARD matol 1979;115:1224-5. RAYMOND LEVY field loss. Ten months after diagnosis his field 4 Lee B, Groth P. Scabies: transcutaneous poison- Section of Old Age Institute ofPsychiatry, defects were stable, but his visual acuity ing during treatment. Pediatrics 1979;59:643. London SE5 8AF, UK remained impaired. 5 Solomen LM, Fahrner L, West DP, et al. Lindane, a gamma isomer of hexachloro- Gamma benzene hexachloride toxicity. Arch 1 Bennett DA, Wilson RS, Gilley DW, Fox JH. Dernat 1977;113:353-7. Clinical diagnosis of Binswanger's disease. cyclohexane used as a pesticide and an 6 Danopoulos E, Melissinos K, Katsas G. Serious Neurol ectoparasiticide, is metabolised by the liver poisoning by hexachlorocyclohexene. Clinical J Neurosurg Psychiatry 1990;53: http://jnnp.bmj.com/ 961-5. and distributed and stored in depot fat and and laboratory observations on 5 cases. Arch 2 Binswanger 0. Die Abgrenzung der allgemeinen of Indust Hygien 1953;8:582-7. progressiven Paralyse, I-III. Berl Klin other lipophilic tissues. It is commonly pres- 7 Heuser M, Heuser H. Pseudotumour cerebri Wochenschr 1894;49:1103-5, 1137-9, 1180-6. cribed topically as a 1% solution for scabies following insecticide (lindane) intoxication. (Tranl. by H Forstd et al: Binswanger on but is available in concentrations of 0 5%- Acta Univ Carol Med. 1976;75:133-5. Binswanger's disease. Intern J Geriatr Psy- 99%; our patient used a 20% veterinary 8 Sufnol C, Tussell JM, Gelpi C, Rodriguez-Farre chiat 1991;6:529-35.) E. Convulsant effect of lindane and regional 3 Olszewski I. Subcortical arteriosclerotic ence- concentration for his dogs. Lindane is a brain concentration of GABA and dopamine. phalopathy: review of the literature on the so- powerful CNS stimulant known to cause Toxicology 1988;49:247-52. called Binswanger's disease and presentation headache, nausea, vomiting, diarrhoea, con- 9 St Omer V. Investigation into mechanisms res- of 2 cases. World Neurol 1962;3:359-75. ponsible for seizures induced by chlorinated 4 Alzheimer A. Die Seelenstrorungen auf vulsions, muscle spasms, respiratory failure hydrocarbon pesticides. J Neurochem 1971; on September 26, 2021 by guest. Protected copyright. arteriosklerotischer Grundlage. Allg Z Psy- with cyanosis, coma, and death.'5 "Optic 18:365-74. chiat 1902;59:695-701. (Transl: Mental dis- neuritis" after "improper use" of lindane turbances ofvascular origin.) Neuropsychiatry powder has also been reported.6 Heuser and Neuropsychol Behav Neurol (in print). 5 Nissl F. Zur Kasuistik der arteriosklerotischen Heuser briefly described "pseudotumour Demenz (ein Fall von sogenannter Ence- cerebri" in a farmer with localised brain phalitis subcorticalis). Z Ges Neurol Psychiat oedema, after "prolonged professional 1920;19:438-43. inhalation" oflindane;7 but the appearance of the optic discs and the spinal fluid pressure Motor neuron syndrome in the arms were not reported. The mechanism oflindane after radiation treatment toxicity is unknown, although it is highly Pseudotumour cerebri and chronic ben- lipid soluble and may act as a gamma-amino- Radiation myelopathy is a rare but well zene hexachloride (lindane) exposure butyric acid-A (GABA-A) receptor antagon- established complication of radiotherapy ist to produce convulsive effects and inter- leading to diagnostic difficulties with Pseudotumour cerebri, the syndrome of ference with the production and utilisation of neurological complications of the primary idiopathic intracranial hypertension and free ammonia in the brain.89 Chlordecone, a neoplasm, like epiduritis or spinal metas- papilloedema in the absence of a tumour or cyclodiene insecticide which also induces tasis.' We report a rare case of radiation obstructive hydrocephalus, may be associated seizures, has been implicated in causing myelopathy presenting as a cervical motor with exposure to drugs or toxins."'' We report pseudotumour cerebri by inhibition of ATP- neuron syndrome that developed three years a patient, repeatedly exposed to the pesticide ase activity, resulting in impaired resorption after local radiotherapy in which spinal cord benzene hexachloride (lindane), who de- of cerebrospinal fluid across the arachnoid magnetic resonance imaging (MRI) showed a veloped chronic intracranial hypertension. villi.' Lindane and chlordecone may have centrospinal cystic lesion. A 45 year old man (weighing 80 kg) who similar effects on the arachnoid villi as they A 44 year old man without relevant history kept hounds noted fleeting episodes of are both lipid soluble, neurotoxic chlorinated presented with dyspnoea and a rapidly grow- blurred vision in his right eye usually related hydrocarbons. ing cervical anterior mass. We found a mal-.