Letter to the Editor
Recurrent diaphoresis, acute confusional state, and pleural mesothelioma
Diaforesis recurrente, estado confusional agudo y mesotelioma pleural
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Domínguez, E.M. Cárdenas, Y.H.S. Marulanda, E.L. Bartolomé" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R.O." "apellidos" => "Domínguez" "email" => array:1 [ 0 => "dominguezraulo@yahoo.com.ar" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E.M." "apellidos" => "Cárdenas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Y.H.S." "apellidos" => "Marulanda" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "E.L." "apellidos" => "Bartolomé" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neurología, Hospital Sirio Libanés, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Sirio Libanés, Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diaforesis recurrente, estado confusional agudo y mesotelioma pleural" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 745 "Ancho" => 1600 "Tamanyo" => 114246 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Simple chest radiography showing a large radiopaque mass on the left hemithorax, very close to the mediastinum. No pleural effusion was found. (B) Mesothelioma with typical cells and fibrosis (haematoxylin and eosin stain ×1000).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Daytime and nigh-time excessive, generalised recurrent sweating is an infrequent and under-reported symptom in elderly patients. When present, however, it may point to a number of conditions, including tumours.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> Acute confusional state (ACE) or delirium is frequent among elderly patients and may be the reason for institutionalisation or an intercurrent condition in institutionalised patients. Cancer is a possible diagnosis for this manifestation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Both diaphoresis and delirium are regarded as syndromes due to the wide range of causes potentially triggering them.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 79-year-old man who was brought in the morning to the emergency department of our hospital due to behavioural changes, inattention, incoherent thinking, and visual hallucinations. The night before he had displayed normal behaviour and cognition. He had no history of vascular risk factors and had previously been diagnosed with right bundle branch block. Our patient had been taking 50<span class="elsevierStyleHsp" style=""></span>μg levothyroxine during fasting for the last 20 years and was not receiving any psychoactive drugs. Over the previous year he had experienced episodes of excessive sweating in the evening and night 2-3 times per week, which forced him to change clothes. These episodes were not associated with hyperthermia; complete blood counts performed on 2 occasions in the previous months revealed normal results. He displayed diaphoresis the night before admission. Physical examination revealed no abnormalities except for mild gait instability, increased base of support, and side stepping. Our patient displayed cognitive and behavioural alterations and was inattentive; we were unable to perform more specific tests due to lack of patient cooperation. He met the diagnostic criteria for ACE.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Results from the heart examination were normal except for right bundle branch block; he displayed normal heart rate and blood pressure level, and required no additional medications. A brain CT scan revealed moderate cortical and central atrophy, a typical finding for his age, and no lesions in or around the brain parenchyma. A complete blood count showed normal results except for low glucose levels (26<span class="elsevierStyleHsp" style=""></span>mg per cent). We suspected a typing error since our patient was not diabetic and was not taking any antidiabetic drugs. A blood sugar test revealed a glucose level of 28<span class="elsevierStyleHsp" style=""></span>mg per cent; we therefore started treatment with glucose 10%. Chest radiography revealed a large radiopaque mass on the left side (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). ACE resolved 2<span class="elsevierStyleHsp" style=""></span>hours after glucose infusion. An insulin test disclosed 7.5<span class="elsevierStyleHsp" style=""></span>mIU/mL (normal range: <10<span class="elsevierStyleHsp" style=""></span>mIU/mL). A lung biopsy revealed mesothelioma with typical cells and reactive fibrosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). We ruled out asbestos exposure based on reports from our patient's relatives. Our patient was discharged one week later. We decided not to excise the mesothelioma in view of its proximity to the mediastinum and our patient's advanced age. He received medications similar to those prior to admission, started a carbohydrate-rich diet, and was instructed to eat every 3<span class="elsevierStyleHsp" style=""></span>hours, even at night. Our patient was followed-up every 3 months for 5 years; he experienced no further episodes of diaphoresis or ACE, his cognitive function was normal, and he was independent for daily living activities. Follow-up chest radiographies were performed every 4 months and revealed no changes compared to the image shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A. Our patient was diagnosed with benign pleural fibrous mesothelioma associated with occasional episodes of hypoglycaemia<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a>; these episodes were responsible for long-term diaphoresis and ACE. Low glucose levels triggers an exaggerated adrenergic response which may cause behavioural disorders and profuse sweating. Insulinoma causes similar symptoms but is associated with hyperinsulinaemia.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Benign or malignant mesothelioma and other types of tumours produce a peptide with similar structure and activity to insulin (insulin-like growth factor 2).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Diaphoresis and ACE in elderly patients may be helpful for early diagnosis and treatment of some types of tumours.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0015" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare. The study and figures were approved for publication by the Training and Research Committee at our hospital. Confidentiality of patient data was preserved.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Domínguez RO, Cárdenas EM, Marulanda YHS, Bartolomé EL. Diaforesis recurrente, estado confusional agudo y mesotelioma pleural. Neurología. 2017;32:484–485.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 745 "Ancho" => 1600 "Tamanyo" => 114246 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Simple chest radiography showing a large radiopaque mass on the left hemithorax, very close to the mediastinum. No pleural effusion was found. (B) Mesothelioma with typical cells and fibrosis (haematoxylin and eosin stain ×1000).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosing night sweats" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.J. Viera" 1 => "M. Bond" 2 => "S.W. 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Hogendoorn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Curr Diagn Pathol" "fecha" => "2004" "volumen" => "10" "paginaInicial" => "229" "paginaFinal" => "235" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0075" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lesson of the month 2: An unusual presentation of hyperinsulinaemic hypoglycaemia with possible underlying diagnosis of glucose-sensitive insulinoma or islet cell hyperplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Maguire" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Med (Lond)" "fecha" => "2015" "volumen" => "15" "paginaInicial" => "495" "paginaFinal" => "496" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypoglycemia associated with non-islet cell tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Kantarova" 1 => "I. Sagova" 2 => "M. Stancik" 3 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 1 | 7 |
| 2024 October | 16 | 3 | 19 |
| 2024 September | 33 | 13 | 46 |
| 2024 August | 39 | 8 | 47 |
| 2024 July | 17 | 5 | 22 |
| 2024 June | 24 | 3 | 27 |
| 2024 May | 17 | 5 | 22 |
| 2024 April | 15 | 5 | 20 |
| 2024 March | 26 | 7 | 33 |
| 2024 February | 26 | 7 | 33 |
| 2024 January | 25 | 4 | 29 |
| 2023 December | 23 | 8 | 31 |
| 2023 November | 27 | 12 | 39 |
| 2023 October | 38 | 7 | 45 |
| 2023 September | 17 | 6 | 23 |
| 2023 August | 5 | 2 | 7 |
| 2023 July | 19 | 6 | 25 |
| 2023 June | 28 | 5 | 33 |
| 2023 May | 22 | 8 | 30 |
| 2023 April | 20 | 5 | 25 |
| 2023 March | 20 | 3 | 23 |
| 2023 February | 22 | 0 | 22 |
| 2023 January | 23 | 11 | 34 |
| 2022 December | 37 | 14 | 51 |
| 2022 November | 25 | 13 | 38 |
| 2022 October | 33 | 8 | 41 |
| 2022 September | 17 | 12 | 29 |
| 2022 August | 27 | 8 | 35 |
| 2022 July | 16 | 8 | 24 |
| 2022 June | 18 | 8 | 26 |
| 2022 May | 18 | 11 | 29 |
| 2022 April | 32 | 8 | 40 |
| 2022 March | 16 | 9 | 25 |
| 2022 February | 21 | 6 | 27 |
| 2022 January | 24 | 4 | 28 |
| 2021 December | 24 | 10 | 34 |
| 2021 November | 28 | 7 | 35 |
| 2021 October | 33 | 12 | 45 |
| 2021 September | 28 | 11 | 39 |
| 2021 August | 29 | 10 | 39 |
| 2021 July | 29 | 7 | 36 |
| 2021 June | 31 | 14 | 45 |
| 2021 May | 25 | 13 | 38 |
| 2021 April | 71 | 13 | 84 |
| 2021 March | 48 | 4 | 52 |
| 2021 February | 31 | 7 | 38 |
| 2021 January | 26 | 13 | 39 |
| 2020 December | 33 | 4 | 37 |
| 2020 November | 26 | 9 | 35 |
| 2020 October | 21 | 3 | 24 |
| 2020 September | 17 | 8 | 25 |
| 2020 August | 26 | 7 | 33 |
| 2020 July | 17 | 6 | 23 |
| 2020 June | 17 | 9 | 26 |
| 2020 May | 21 | 10 | 31 |
| 2020 April | 25 | 4 | 29 |
| 2020 March | 29 | 4 | 33 |
| 2020 February | 22 | 4 | 26 |
| 2020 January | 33 | 8 | 41 |
| 2019 December | 56 | 7 | 63 |
| 2019 November | 40 | 7 | 47 |
| 2019 October | 25 | 10 | 35 |
| 2019 September | 19 | 3 | 22 |
| 2019 August | 13 | 4 | 17 |
| 2019 July | 21 | 13 | 34 |
| 2019 June | 56 | 6 | 62 |
| 2019 May | 106 | 26 | 132 |
| 2019 April | 35 | 13 | 48 |
| 2019 March | 11 | 6 | 17 |
| 2019 February | 14 | 11 | 25 |
| 2019 January | 7 | 4 | 11 |
| 2018 December | 5 | 2 | 7 |
| 2018 November | 17 | 2 | 19 |
| 2018 October | 16 | 6 | 22 |
| 2018 September | 8 | 3 | 11 |
| 2018 August | 25 | 5 | 30 |
| 2018 July | 6 | 5 | 11 |
| 2018 June | 15 | 5 | 20 |
| 2018 May | 19 | 3 | 22 |
| 2018 April | 5 | 2 | 7 |
| 2018 March | 10 | 0 | 10 |
| 2018 February | 4 | 1 | 5 |
| 2018 January | 15 | 3 | 18 |
| 2017 December | 25 | 2 | 27 |
| 2017 November | 16 | 2 | 18 |
| 2017 October | 8 | 0 | 8 |
| 2017 September | 23 | 8 | 31 |
| 2017 August | 3 | 4 | 7 |
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