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Case reports



Volume 49, 2013


bullet 4'2013


Ketamine therapy in a patient with treatment-resistant bipolar depression: a case report -- 49, 2013, № 4, 68-71.
Krastev(1), Sv. Bataklieva(1), Sn. Tacheva(1), A. Temelkov(2), R. Vladimirova(1), V. Stoyanova(1), V. Milanova(1)
(1)Clinic of Psychiatry, “Aleksandrovska” University Hospital -- Sofia, (2)Clinic of Anesthesiology and Intensive Care, “Aleksandrovska” University Hospital -- Sofia
Summary: We present a clinical case of a patient with treatment-resistant bipolar depression in which we conducted a course of ketamine infusions without the concomitant antidepressant treatment to be discontinued. Unlike most of the cited cases, this kind of treatment led to sustained improvement. There were no identified risks of induction of mania and cycling, as well as signs of drug dependence. It was assumed that whereas the initial impact of improvement was due to the ketamine infusions, the long-term effectiveness of the thera­peutic response was linked with the concomitant antidepressant treatment.
Key words: Ketamine, bipolar depression, treatment-resistance
Address for correspondence: Stefan Krastev, M. D., Clinic of Psychiatry, “Aleksandrovska” University Hospital, 1, Sv. G. Sofyiski St., Bg -- 1431 Sofia, e-mail: stkrastev@hotmail.com



Bilateral facial palsy -- diagnostic and therapeutic approach based on one case. - - 49, 2013, № 4, 72-75.
R. Ikonomov and T. Stoyanova

Department of Neurology, MHAT “Sofiamed” -- Sofia
Summary: Bilateral facial palsy is a rare form of facial palsy, which usually represents a serious diagnostic problem. We have presented a clinical case of a 59-year-old woman with consecutive involvement of the muscles of both facial sides, as well as a discussion of the diagnostic options for the patient. We have carried out a number of clinical and paraclinical tests, including full clinical examination, laboratory methods, X-ray examination, computed tomography, magnetic resonance tomography, electromyography, and immunology tests. The patient refused a lumbar puncture. Based on the evaluation of the tests described above and the continuous monitoring of the patient, we have established that this was Lyme disease. The respective etiological treatment was carried out, which lead to a significant improvement of the patient’s condition. Bilateral facial palsy is a condition, which requires a thorough examination of the patient. One of its common causes may be Lyme disease, which requires timely diagnosis and early etiological treatment.
Key words: bilateral facial palsy, Lyme disease
Address for correspondence: Rosen Ikonomov, M. D., Department of Neurology, MHAT ”Sofiamed”, 16, G. M. Dimitrov Blvd., Bg -- 1797 Sofia



Diagnosis, treatment and dispanserization of a patient after cerebellar infarction in ambulatory care - 49, 2013, № 4,76-79.
V. Damyanov (1), K. Prinova (2), E. Yanis(3), E. Mermeklieva(4) and L. Haralanov(5).
(1)Neurology Section, 8th Diagnostic and Consultative Center -- Sofia, (2)Neurology Clinic, Military Medical Academy -- Sofia, (3)Physiotherapy and Rehabilitation Unit, 5th MHAT -- Sofia, (4)Ophthalmology Clinic, Medical University -- Sofia, (5)Neurology Clinic, National Cardiology Hospital -- Sofia
Summary: Dispanserization of people having cerebrovascular disease is carried out by the neurologist at the polyclinic. Medical examinations play an important role with regard to the effectiveness of the dispanserization. Hereby we describe a patient with cerebellar infarction, caused by obturation of the right cerebellar part of the anterior inferior cerebellar artery (AICA). The patient has been diagnosed in the ambulatory care setting, irrespective of his stay and treatment prior to that in a specialized health institution. After the disease has been established, the respective etiological and symptomatic treatment has been carried out with good effect. Conclusions were made with respect to the behavior of patients with cerebrovascular disease in ambulatory care.
Key words: cerebellar infarction, anterior inferior cerebellar artery, nystagmus
Address for correspondence: V. Damyanov, M. D., Neurology Section, 8th Diagnostic and Consultative Center, 77, Hristo Silyanov St., Bg -- Sofia



Radiological finding in a patient with fibrous dysplasia: a case report - 49, 2013, № 4,80-85.
Ts. Tsvetanov.
Department of Oral Surgery, Faculty of Dental Medicine, Medical University -- Plovdiv
Summary: Fibro-osseous lesions of the maxillofacial bones comprise a diverse group of pathologic conditions that include developmental lesions, reactive or dysplastic diseases, and neoplasms. The concept of fibro-osseous lesions has evolved over the last several decades and now includes two major entities: fibrous dysplasia and ossifying fibroma. Fibrous dysplasia is characterized with an increase in the jaw size, as a consequence of abnormal growth of osteoid tissue. We present a case of a woman with fibrous dysplasia, with a prior history of surgical treatment, conducted 41 years ago in the clinic of Oral and Maxillofacial Surgery in the Military Medical Academy -- Sofia. The radiological finding is visible on the orthopantomography scheduled by us. At the present moment, no treatment has been initiated due to lack of complaints by the patient.
Key words: radiological finding, fibrous dysplasia
Address for correspondence: Tsvetan Tsvetanov, Ph.D, Department of Oral Surgery, Faculty of Dental Medicine, Medical University, 3, Hristo Botev Blvd., Bg -- 4000 Plovdiv, tel. +359 898-32-53-32




bullet 2'2013

Meningitis and meningoencephalitis caused by Rickettsia conorii - 49, 2013, № 2, 73-77.
I. Baltadzhiev(1), I. Boev(2), A. Dineva, A.
Gocheva(2), Ts. Kazakova(2) and А. Tsoneva(2)
(1)Department of Infectious Diseases, Parasitology and Tropical Medicine, Medical University of Plovdiv, (2)Clinic of Infectious Diseases and Parasitology, University Hospital “Sv. Georgi” -- Plovdiv
Mediterranean spotted fever (MSF) is a vector-borne rickettsiosis of the Spotted fever group (SFG). The disease is caused by Rickettsia conorii and transmitted by the brown dog tick Rhipicephalus sanguineus. Plovdiv region is the largest endemic area for this infection in Bulgaria. The aim of the study is to draw attention to one of the rarest but most severe manifestations of MSF -- inflammatory process in the central nervous system (CNS), due to rickettsial invasion of the small blood vessel endothelial cells. We report on seven MSF patients, five of which presented with symptoms of meningitis. Two patients developed a more severe, prolonged infection with multiple organ involvement, including meningoencephalitis. Diagnosis was confirmed by indirect immunofluorescence assay. Involvement of CNS was confirmed by cerebrospinal fluid (CSF) examination and CT scan. CSF showed evidence of serous inflammation type -- normal or increased protein level, less than 1 g/l in most of the cases, and mild to moderate cell count increase, consisting predominantly of lymphocytes. MSF encephalitis was distinguished by a comatose state, seizures, and breathing disturbances. Artificial lung ventilation was initiated in one of the patients and was continued for about two months. Development of meningoencephalitis suggests the most serious MSF form, called "malignant" -- a form with multiple organ involvement, with CNS inflammation being the hallmark of it, and which can result in the most serious and deadly complication -- brain edema. Nevertheless, our patients survived. The need for a timely diagnosis and correct treatment, including administration of antibiotics and anti-brain edema agents should be underlined.
Key words: Mediterranean spotted fever, Rickettsia conorii, meningoencephalitis
Address for correspondence: Ivan Baltadzhiev, M. D., Department of Infectious Diseases, Parasitology and Tropical Medicine, Medical University of Plovdiv, 15A Vasil Aprilov Blvd., Bg -- 4002 Plovdiv, e-mail: ivan_balt@yahoo.com




bullet 1'2013

A case with chronic atypical lymphocytic leukemia and trisomy 12 - 49, 2013, № 1, 70-74.
M. Velizarova(1), L. Mitev(2), D. Popova(2), V. Uzunova(2), R. Stanchev(3), I. Gigov(3), Yu. Rainov(3) and K. Tzachev(1)
(1)Department of Clinical Laboratory and Clinical Immunology, University Hospital „Aleksandrovska” -- Sofia, (2)Department of Clinical Laboratiry and Immunology, Military Academy -- Sofia, (3)Clinic of Hematology, Military Academy -- Sofia
Summary: Chronic lymphocytic leukemia (CLL) occurs as two morphologic types: the standard form with small or big lymphocytes and the other cell variant with a dimorphic population of small lymphocytes and prolymphocytes in the peripheral blood. According to the FAB classification, the second type CLL is atypical CLL (aCLL) and is defined as having a prolymphocyte population constituting more than 10% and fewer than 55% of the circulating lymphocytes. Atypical CLL is characterized by high leucocyte count, low thrombocyte count, high CD23 expression, non-mutated VH-genes and poor prognosis. Often there is a trisomy of chromosome 12. We report a case of a 78-year old male patient, presenting with aCLL and trisomy 12. The anomaly was proved by the fluorescent in situ hybridization and a centromere probe for chromosome 12. We recorded significantly higher expressions of CD23 (73%), CD20, СD22, lambda and CD5 compared with typical CLL. In this case report we have discussed the patient’s specific clinical and laboratory findings.
Key words: trisomy 12, atypical chronic lymphocytic leukemia, fluorescence in situ hybridization
Address for correspondence:Milena Velizarova, Department of Clinical Laboratory and Clinical Immunology, University Hospital „Aleksandrovska”, 1, Sv. G. Sofiyski Str., Bg -- 1431 Sofia



Rare case of primary small intestinal anaplastic large cell lymphoma - 49, 2013, № 1, 75
A. Kotsev(1), D. Petrova(1), K. Aleksandrova(2), М. Slavova(2), L. Shemelkova(2), E. Hadzhiev(2), A. Yonkov(3), B. Milev(4) and S. Hristova(5)

(1)Gastroenterology Unit, (2)Clinic of Hematology, (3)Clinic of General, Hepatobiliary and Pancreatic Surgery, (4)Clinic of Diagnostic Imaging, (5)Clinic of General and Clinical Pathology, University Hospital „Aleksandrovska” -- Sofia
Summary: Malignant tumors of the small intestines are rare and generally diagnosed at late stages. We present a case of a patient with а primary small intestinal anaplastic large cell lymphoma (АLCL) of the null phenotype, in stage IV. The morphological alterations were typical for the АLCL, but expression of CD30, as well as expressions of anaplastic lymphoma kinase (ALK), AE1-AE3, S-100 protein, Melanoma Ab, c-kit, CD34, CD20, CD5, CD45, CD45RO, CD3, EMA, CEA, AFP and PLAP were not found. Surgical treatment and chemotherapy were performed, but the disease progressed quickly with a lethal outcome. We suggest that the late stage of the disease and the absence of ALK expression are associated with the failure of the applied therapy.
Key words: small intestines, malignant tumor, anaplastic large cell lymphoma
Аddress for correspondence: Andrey Kotzev, M. D., Gastroenterology Unit, University Hospital „Aleksandrovska”, 1, Sv. G. Sofiyski Blvd., Bg -- 1431 Sofia, е-mail: dr_andrey_kotzev@abv.bg


Last update of the page: 06.01.2014




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