Visceral leishmaniasis (VL) is an infectious disease caused by Leishmania spp. The recurrence of the disease occurs, in general, in patients with decreased or loss of T-cell function, whether due to the use of corticosteroids, immunosuppressive disease, or another cause. In some cases, splenectomy may be a therapeutic option. However, the effectiveness of splenectomy is not well defined. This report describes the evolution of a pediatric patient with seven recurrences of VL, who relapsed post-surgery after drug therapy and splenectomy.

Context: Recently, with the advance of neuroimaging modalities, the windows of reperfusion therapy in patients with acute stroke have been reviewed and extended, especially for mechanical thrombectomy. Case report: 81 year old patient, previously hypertensive and dyslipidemic, fully functional (modified Rankin scale = 0), admitted to the emergency room of a tertiary hospital with global aphasia, right hemiparesis, right homonymous hemianopsia and severe hypoesthesia of the right upper limb, scoring 26 on the NIHSS, with report of having contacted family members for the last time 15 hours before admission. She was treated according to the institution’s acute stroke protocol, and underwent non-contrast brain computed tomography (CT), perfusion CT with Rapid CT protocol and cerebral artery + neck angio-CT, which ruled out bleeding and showed an ASPECTS of 8, an estimated ischemic core volume of 17 mL, and an area with hypoperfusion of 118 mL (perfusional mismatch of 101 mL), besides occlusion of the M1 segment of the left middle cerebral artery. Thus, she was submitted to chemical thrombolysis, with a decrease in NIHSS score to 15 and evolving without complications upon hospitalization. Conclusions: In patients with uncertain ictus, the use of advanced neuroimaging modalities, such as perfusion tomography with Rapid CT protocol, may assist in the indication of reperfusion therapies safely.

Case report: Woman, 34 years old, with paresis that started four years ago during pregnancy, predominantly distal in the lower limbs and progression to the upper limbs. No involvement of cranial nerves and sensitivity. Initially considered a diagnosis of Myasthenia Gravis and clinical gain was observed with the use of pyridostigmine. After a few months, the patient’s symptoms recurred with asymmetric flaccid tetraparesis, predominantly in the lower limbs, associated with global areflexia and oral immunosuppressive therapy was initiated, with improvement. Electroneuromyography with normal sensory nerve conduction studies, but reductions in amplitudes in proximal compound muscle action potentials, with markedly reduced persistence in F-wave studies of the four limbs. Diffuse neurogenic changes were observed on exertion and activities such as positive sharp waves, fibrillation, fasciculations and myokymia at rest. Repetitive nerve stimulation at 3Hz without changes. A hypothesis of multifocal motor neuropathy (MMN) was then made. Treatment with intravenous immunoglobulin was performed, with significant recovery of symptoms. Discussion: MMN is a rare disease (prevalence of 0.6 per 100,000 individuals), with a predominance in men and a mean age of onset around 40 years. The differential diagnosis includes motor neuron disease and other demyelinating neuropathies. It is immune-mediated by antianglioside antibodies (anti-GM1), but they are not identified in all patients and may be present in other neuropathies. It is defined by muscle weakness predominantly distal, asymmetrical, predominantly in the upper limbs, slowly progressive, associated with reduced deep reflexes in the affected regions. The main electrophysiological characteristic is the presence of motor nerve conduction blocks (CB) outside the usual sites of compression. Conclusion: The finding that CB presents in patients with MMN suggests that nerve conduction should be extensively studied in every patient with a lowermotor-neuron syndrome to identify patients who might respond favorably to immunomodulating treatment.

Introduction: Posterior reversible leukoencephalopathy syndrome is an acute/subacute clinical-radiological syndrome characterized by headache, changes in consciousness, seizures, focal neurological deficits, visual deficits and that may be preceded by uncontrolled blood pressure in the day before. It does not commonly occur concomitantly with prolonged infectious conditions. The most typical imaging finding is white matter edema in the posterior cerebral hemispheres. Treatment is based on adequate control of blood pressure and epileptic seizures, as well as metabolic and electrolyte control. The prognosis in most cases is excellent with significant improvement and complete reversal over days to weeks. Case report: Female, 37-year-old, after one month of underwent an endoscopic retrograde cholangiopancreatography was hospitalized due to a perirenal abscess, and treatment with antibiotics was initiated. During this treatment, she developed a sudden onset of bilateral amaurosis, continuous horizontal nystagmus, mental confusion, right upper limb weakness and hyperreflexia, in addition to an epileptic seizure and fencing response posture requiring intravenous phenytoin. Brain tomography demonstrated hypodensity in the occipital hemispheres and magnetic resonance imaging identified signal alteration in the white matter diffuse without diffusion restriction compatible with posterior reversible leukoencephalopathy syndrome. She evolved with adequate control of blood pressure and epileptic seizures, progressive improvement in visual acuity and muscle strength, until he returned to normality 10 days after the onset of symptoms. The antiepileptic drug was suspended, and she was discharged with antihypertensive medication. Conclusion: Posterior reversible leukoencephalopathy syndrome is an important differential diagnosis in conditions of sudden deficits and seizures, especially in this infectious context, because it is a reversible clinical condition with a good prognosis.