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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2019;153:179-80" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Rhabdomyolysis and antipsychotics" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "179" "paginaFinal" => "180" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rabdomiólisis y antipsicóticos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laura Rodríguez Fernández, Miguel Martín Asenjo, Roberto González Fuentes" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Laura" "apellidos" => "Rodríguez Fernández" ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Martín Asenjo" ] 2 => array:2 [ "nombre" => "Roberto" "apellidos" => "González Fuentes" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775318307383" "doi" => "10.1016/j.medcli.2018.10.035" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775318307383?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619302967?idApp=UINPBA00004N" "url" => "/23870206/0000015300000004/v1_201908170832/S2387020619302967/v1_201908170832/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Acute neuropathy after gastric reduction surgery" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e17" "paginaFinal" => "e18" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Leire Isasa Rodríguez, María del Carmen Fernández López, Gonzalo Fernando Maldonado Castro" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Leire" "apellidos" => "Isasa Rodríguez" "email" => array:1 [ 0 => "leisaxi@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "María del Carmen" "apellidos" => "Fernández López" ] 2 => array:2 [ "nombre" => "Gonzalo Fernando" "apellidos" => "Maldonado Castro" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Álava, Vitoria-Gasteiz, Álava, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neuropatía relacionada con la cirugía bariátrica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">There has recently been a progressive increase in the number of bariatric surgeries (BS), and with it, we have seen an increase in neurological complications secondary to multivitamin deficiencies, which are reversible if its control is adequate and it is treated early.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe two cases treated in our hospital. The first was that of a 49-year-old female patient who underwent vertical banded gastroplasty in 1999, reconverted to gastric bypass due to weight gain in 2007. She stopped attending consultations and did not follow established nutritional guidelines, after which she visited in 2013 due to vomiting and striking weight loss, and months later neurology, due to generalised weakness and a decreased level of consciousness. Treatment with thiamine and nutrition by nasogastric tube was initiated because she was unable to consume orally. She presented cachexia, bradypsychia, disorientation, amyotrophy, paresis in all four limbs and oedema. She required orotracheal intubation due to convulsions and respiratory insufficiency. She had a multivitamin deficiency (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), but did not show low levels of thiamine, probably due to the initiation of treatment with vitamin B<span class="elsevierStyleInf">1</span> before the sample was collected. The electroencephalogram showed severe diffuse involvement, and the resonance suggested encephalopathy of metabolic origin. After adjusting treatment with vitamins from group B and trace elements, she presented progressive clinical improvement, but would require prolonged rehabilitation treatment.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In October 2015, a 24-year-old female patient was admitted due to progressive weakness, paresthesias and vomiting. She had undergone a gastric bypass in another centre months earlier, and she had a diagnosis of major depression. She started with blurred vision and weakness, until she as unable to walk. She presented somnolence, disatria, complex ophthalmoparesis with nystagmus, mydriasis, bilateral facial paresis and paresis and hypoesthesia in all four limbs (more intense in legs). We suspected a Miller-Fisher variant of Guillain-Barré syndrome (due to predominant weakness in the lower limbs and ophthalmological alterations), but the electromyogram revealed a severe axonal sensory-motor polyneuropathy, and the resonance showed a Wernicke encephalopathy with myelopathy. She was treated with thiamin, mutivitamin and parenteral nutrition. The vitamin B<span class="elsevierStyleInf">1</span> deficiency could not be demonstrated either (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). She also presented a progressive recovery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Wernicke encephalopathy has been classically associated with alcoholism, but cases have recently been described associated with other diseases or circumstances, such as malnutrition or malabsorption syndromes, parenteral nutrition, prolonged fasting, gastrointestinal neoplasms, dialysis, infection by the human immunodeficiency virus and BS (even purely restrictive surgeries).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Thiamine deficiency usually occurs a few weeks after BS but can occur up to years later. It occurs in the context of excessively rapid weight loss, vomiting and lack of adherence to nutritional guidelines. It can present with polyneuropathy, which can be confused with Guillain-Barré syndrome.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The deficiency of other micronutrients is also associated with neurological symptoms. A deficiency in: Vitamin B<span class="elsevierStyleInf">12</span> can generate a subacute syndrome with corticospinal tract dysfunction and posterior columns and a peripheral neuropathy; copper can provoke symptoms similar to a deficiency of B12, with myeloneuropathy; vitamin E can cause spinocerebellar syndrome together with predominantly sensitive peripheral neuropathy; vitamin B<span class="elsevierStyleInf">6</span> is not usually associated with peripheral neuropathy (although it can occur in cases of isoniazid use as a treatment for tuberculosis).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">These tables are complex and often respond to the combination of several deficiencies. The term APGARS (acute post-gastric reduction surgery) neuropathy was coined in 2002, referring to cases of postoperative polyneuropathy in bariatric surgery, characterised by vomiting, hyporeflexia and muscle weakness.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical practice guidelines<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> emphasise the importance of prevention (through multivitamin supplements), follow-up and early treatment of those patients who undergo surgery. They explain the ‘warning’ symptoms too look out for, such as excessively rapid weight loss, onset of nausea or vomiting and neuropathic symptoms (paresthesias, weakness, etc.).</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, patients who have undergone any type of bariatric surgery procedure, both recently and not so recently, are susceptible to neurological complications due to micronutrient deficiency. We must educate our patients to ensure a strict adherence to established nutritional guidelines and to be alert to any symptoms that may suggests neuropathy, since the reversibility of such a clinical profile depends on its early treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Isasa Rodríguez L, Fernández López MC, Maldonado Castro GF. Neuropatía relacionada con la cirugía bariátrica. Med Clin (Barc). 2019;153:e17–e18.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical case 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical case 2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference values \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.22↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3–1<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5–20<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Copper \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">926 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">477↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">750–1.500<span class="elsevierStyleHsp" style=""></span>μg/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Zinc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">631↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">500↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">750–1.500<span class="elsevierStyleHsp" style=""></span>μg/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin B<span class="elsevierStyleInf">1</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">There are no values prior to replacement with thiamin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin B<span class="elsevierStyleInf">6</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.2↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.4↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23–172.5<span class="elsevierStyleHsp" style=""></span>nmol/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vitamin B<span class="elsevierStyleInf">12</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">143↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1279 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">191–663<span class="elsevierStyleHsp" style=""></span>pg/ml \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Folates \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><2↓ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6–18.7<span class="elsevierStyleHsp" style=""></span>ng/ml \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2103641.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analytical results after diagnosis of neuropathy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A fatal case of Wernicke's encephalopathy after sleeve gastrectomy for morbid obesity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.K. 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Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient – 2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.I. Mechanick" 1 => "A. Youdim" 2 => "D.B. Jones" 3 => "W.T. Garvey" 4 => "D.L. Hurley" 5 => "M.M. 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Journal Information
Vol. 153. Issue 4.
Pages e17-e18 (August 2019)
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Vol. 153. Issue 4.
Pages e17-e18 (August 2019)
Letter to the Editor
Acute neuropathy after gastric reduction surgery
Neuropatía relacionada con la cirugía bariátrica
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Leire Isasa Rodríguez
, María del Carmen Fernández López, Gonzalo Fernando Maldonado Castro
Corresponding author
Servicio de Endocrinología y Nutrición, Hospital Universitario Álava, Vitoria-Gasteiz, Álava, Spain
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