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Duarte VMS, Bonazza DSS, Lino-Dos-Santos-Franco A, Fontes CJF, Damazo AS. Application of a physiotherapeutic protocol associated with photobiomodulation for the treatment of leprosy patients. Lasers Med Sci 2023; 39:12. [PMID: 38133695 DOI: 10.1007/s10103-023-03957-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
Leprosy is a chronic infectious disease characterized by acute inflammatory episodes that affect the skin and peripheral nerves and can develop progressive and irreversible disabilities and deformities. In addition, drug therapy and physiotherapy offer resources and techniques capable of mitigating the consequences of neural lesions, but neural lesions can occur before, during, and even after drug treatment. Thus, new treatments are needed. Photobiomodulation (PBM) might be a promissor therapy since it aims to reduce the inflammatory process and restore motor and sensory functions in the affected area. This study aims to compare the evolution of neural status, pain, and functionality in patients with leprosy and neuritis after a physiotherapeutic protocol and PBM treatment. This was a randomized controlled clinical trial that analyzed a group of patients receiving a physiotherapeutic protocol (PPG) and another receiving physiotherapeutic protocol associated with PBM (PLG) (wavelength 904 nm, potency 70 mW, time per point 9 s). Our results showed when evaluating functional capacity limitations with the SALSA scale, the PLG patients improved from moderate to mild limitations. On the other hand, the PPG remained as moderate limitations. Also, the PLG showed a significant reduction in pain on the VAS scale. The neurological assessment showed that PLG improved palpation of the median, radial, and peroneal nerves. In the strength test, PLG patients improved in the 5th finger abduction and ankle dorsiflexion. Assessing sensitivity, it was identified an improvement in PLG for the ulnar nerve and tibial nerve. All those changes were statistically significant when compared to the PPG patients. Finally, the PLG patients improved disabilities, identified by the neurological assessment of the eyes, hands, and feet. In conclusion, this study demonstrated that combining a physiotherapeutic protocol with PBM treatment effectively improved functional status and reduced pain in leprosy patients.
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Affiliation(s)
| | | | | | | | - Amílcar Sabino Damazo
- Post Graduate Program in Health Science, Federal University of Mato Grosso (UFMT), Cuiabá, Brazil.
- Department of Basic Science in Health, Faculty of Medicine, Federal University of Mato Grosso (UFMT), Cuiabá, Brazil.
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Yildiz G, Perdecioglu GRG, Yuruk D, Can E, Akkaya OT. Comparison of the efficacy of genicular nerve phenol neurolysis and radiofrequency ablation for pain management in patients with knee osteoarthritis. Korean J Pain 2023; 36:450-457. [PMID: 37732409 PMCID: PMC10551393 DOI: 10.3344/kjp.23200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023] Open
Abstract
Background : Genicular nerve neurolysis with phenol and radiofrequency ablation (RFA) are two interventional techniques for treating chronic refractory knee osteoarthritis (KOA) pain. This study aimed to compare the efficacy and adverse effects of both techniques. Methods : Sixty-four patients responding to diagnostic blockade of the superior medial, superior lateral, and inferior medial genicular nerve under ultrasound guidance were randomly divided into two groups: Group P (2 mL phenol for each genicular nerve) and Group R (RFA 80°C for 60 seconds for each genicular nerve). The numeric rating scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used to evaluate the effectiveness of the interventions. Results : RFA and phenol neurolysis of the genicular nerves provided effective analgesia within groups at 1 week, 1 month, and 3 months compared to baseline. There was no significant difference between the groups in terms of NRS and WOMAC scores at all measurement times. At the 3rd month follow-up, 50% or more pain relief was observed in 53.1% of patients in Group P and 50% of patients in Group R. The rate of transient paresthesia was 34.4% in Group P and 6.3% in Group R, and this was significantly higher in Group P. Conclusions : Neurolysis of the genicular nerves with both RFA and phenol is effective in the management of KOA pain. Phenol may be a good alternative to RFA. Further studies are needed on issues such as dose adjustment to prevent transient paresthesia response.
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Affiliation(s)
- Gokhan Yildiz
- Department of Algology, Ankara Etlik City Hospital, Ankara, Turkey
| | | | - Damla Yuruk
- Department of Algology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Ezgi Can
- Department of Algology, Ankara Etlik City Hospital, Ankara, Turkey
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Ramasamy S, Galhotra A, Agrawal S. Adverse reactions after Covid-19 vaccination in persons affected by leprosy: A scoping review. J Family Med Prim Care 2023; 12:1771-1774. [PMID: 38024943 PMCID: PMC10657070 DOI: 10.4103/jfmpc.jfmpc_635_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 12/01/2023] Open
Abstract
Background Leprosy reactions are the main pathway leading to severe nerve damage and disability. These reactions can occur at any time. The coronavirus disease 2019 (Covid-19) pandemic led to a catastrophic loss of human life and has had a devastating impact on persons affected by leprosy. Objective To achieve deep insight into the subject of adverse reactions acquired after Covid vaccinations in persons affected by leprosy through a literature review. Materials and Methods A scoping review was conducted in the studies published between July 2021 and June 2022 using the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) checklist. Results Using the search strategy, a total of 130 articles were found, of which five were relevant to the study. The adverse reactions were acquired mostly in males [9 (81.8%)]; the majority of them belong to borderline tuberculoid [4 (36.4%)], and most of them were released from treatment (multi-drug therapy) [7 (63.6%)]. Conclusion Surveillance and management of adverse events following immunization (AEFI) are essential; even minor AEFI should be reported and documented in a line list.
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Affiliation(s)
| | - Abhiruchi Galhotra
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Schapher M, Bruegel J, Guener F, Volbers B, Eichhorn P, Agaimy A, Berger M, Mardin C, Doerfler A, Hock SW. Toxic retrobulbar neuritis due to recurrent nonsteroidal antiinflammatory drug-exacerbated respiratory disease-based chronic sinusitis in the left sphenoid sinus: a case report. J Med Case Rep 2023; 17:331. [PMID: 37537663 PMCID: PMC10401847 DOI: 10.1186/s13256-023-04060-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Abrupt visual impairment constitutes a medical urgency, necessitating an interdisciplinary diagnostic and therapeutic approach owing to the broad spectrum of potential etiologies, thereby engaging numerous medical specialties. CASE PRESENTATION A 21-year-old Mixed White and Asian female patient, with medical history of nonsteroidal antiinflammatory drug-exacerbated respiratory disease necessitating previous sinus surgery, reported sudden monocular vision loss. Unremarkable ophthalmological examination of the fellow eye and hematological parameters, save for a slight elevation in lymphocytes and eosinophils, were observed. Imaging studies indicated recurrence of bilateral chronic rhinosinusitis with nasal polyps and a mucocele in the left sphenoid sinus, accompanied by bony structural deficits. Emergency revision sinus surgery, guided by navigation, was promptly performed. The patient received treatment with methylprednisolone, ceftriaxone, cyanocobalamin, pyridoxine, thiamine, and acetylsalicylic acid. During the hospital stay, she developed steroid-induced glaucoma, which was subsequently managed successfully. Negative microbiological swabs, along with pathohistological evidence of increased tissue eosinophilia and the patient's clinical history, led to the diagnosis of toxic retrobulbar neuritis secondary to recurrent nonsteroidal antiinflammatory drug-exacerbated respiratory disease-associated chronic rhinosinusitis of the left sphenoid sinus. CONCLUSIONS In cases of acute unilateral vision loss, optic neuritis is a highly probable differential diagnosis and may be induced by pathologies of the paranasal sinuses. Nonsteroidal antiinflammatory drug-exacerbated respiratory disease, a subtype of chronic rhinosinusitis, is associated with type 2 inflammation, which is increasingly recognized for its role in the pathogenesis of bronchial asthma, eosinophilic esophagitis, and atopic eczema. Clinicians should consider chronic rhinosinusitis as a potential differential diagnosis in unilateral visual loss and be cognizant of the rising significance of type 2 inflammations, which are relevant to a variety of diseases.
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Affiliation(s)
- Mirco Schapher
- Department of Otorhinolaryngology-Head and Neck Surgery, Erlangen University Hospital, University of Erlangen-Nuremberg, Waldstraße 1, 91054, Erlangen, Germany
| | - Jacob Bruegel
- Department of Otorhinolaryngology-Head and Neck Surgery, Erlangen University Hospital, University of Erlangen-Nuremberg, Waldstraße 1, 91054, Erlangen, Germany
| | - Fabian Guener
- Department of Neurology, Erlangen University Hospital, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bastian Volbers
- Department of Neurology, Erlangen University Hospital, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Philip Eichhorn
- Department of Pathology, Erlangen University Hospital, University of Erlangen-Nuremberg, Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - Abbas Agaimy
- Department of Pathology, Erlangen University Hospital, University of Erlangen-Nuremberg, Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - Magdalena Berger
- Department of Ophthalmology, Erlangen University Hospital, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christian Mardin
- Department of Ophthalmology, Erlangen University Hospital, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, Erlangen University Hospital, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan W Hock
- Department of Neuroradiology, Erlangen University Hospital, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Chhabra A, Deshmukh SD, Lutz AM, Fritz J, Andreisek G, Sneag DB, Subhawong T, Singer AD, Wong PK, Thakur U, Pandey T, Chalian M, Mogharrabi B, Guirguis M, Xi Y, Ahlawat S. Neuropathy Score Reporting and Data System: A Reporting Guideline for MRI of Peripheral Neuropathy With a Multicenter Validation Study. AJR Am J Roentgenol 2022. [PMID: 35234483 DOI: 10.2214/AJR.22.27422] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: A standardized guideline and scoring system would improve evaluation and reporting of peripheral neuropathies on MRI. Objective: The objective of this study was to create and validate a neuropathy classification and grading system, which we named the Neuropathy Score Reporting and Data System (NS-RADS). Methods: This retrospective study included 100 patients with nerve imaging studies and known clinical diagnoses. Experts crafted NS-RADS using mutually agreed-upon qualitative criteria for the classification and grading of peripheral neuropathies. Different classes were created to account for the spectrum of underlying pathologies: unremarkable (U), injury (I), neoplasia (N), entrapment (E), diffuse neuropathy (D), not otherwise specified (NOS), and postintervention state (PI). Subclasses were established to describe the severity or extent of the lesions. Validation testing was performed by 11 readers from multiple institutions with experience levels ranging from 3 to 18 years after residency. After initial reader training, cases were presented to readers, who were blinded to final clinical diagnoses. Interobserver agreement was assessed using correlation coefficients and the Conger kappa, and accuracy testing was performed. Results: Final clinical diagnoses included normal (n = 5), nerve injury (n = 25), entrapment (n = 15), neoplasia (n = 33), diffuse neuropathy (n = 18), and persistent neuropathy after intervention (n = 4). The miscategorization rate for NS-RADS classes was 1.8%. Final diagnoses were correctly identified by readers in 71-88% of cases. Excellent interreader agreement was found on the NS-RADS pathology categorization (κ = 0.96; 95% CI, 0.93-0.98) as well as muscle pathology categorization (κ = 0.76; 95% CI, 0.68-0.82]. The accuracy for determining milder versus more severe categories per radiologist ranged from 88% to 97% for nerve lesions and from 86% to 94% for muscle abnormalities. Conclusion: The proposed NS-RADS classification is accurate and reliable across different reader experience levels and a spectrum of peripheral neuropathy conditions. Clinical Impact: NS-RADS can be used as a standardized guideline for reporting peripheral neuropathies and improved multidisciplinary communications.
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Bernardes-Filho F, Lima FR, Voltan G, de Paula NA, Frade MAC. Leprosy case series in the emergency room: A warning sign for a challenging diagnosis. Braz J Infect Dis 2021; 25:101634. [PMID: 34648742 PMCID: PMC9392170 DOI: 10.1016/j.bjid.2021.101634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/24/2021] [Accepted: 09/20/2021] [Indexed: 12/02/2022] Open
Abstract
Leprosy can be considered a dissimulated disease, mainly when presented as atypical cases leading to mistaken diagnosis at the emergency setting. Herein we report six patients referred to the emergence room with hypotheses of acute myocardial infarction and arterial and venous thrombosis, although with chronic neurological symptoms; the seventh patient was referred with a wrong suspicion of infected skin ulcer. Positive findings included hypo-anesthetic skin lesions and thickened nerves; 100% were negative for IgM anti-phenolic glycolipid-I, while 71.4%, 100% and 42.8% were positive for IgA, IgM and IgG Mce1A. RLEP-PCR was positive in all patients. Ultrasound of peripheral nerves showed asymmetric and focal multiple mononeuropathy for all patients. Unfortunately, in many patients leprosy is often misdiagnosed as other medical conditions for long periods thus delaying initiation of specific treatment. This paper is intended to increase physicians’ awareness to recognize leprosy cases presented as both classical and unusual forms, including in emergency department.
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Affiliation(s)
- Fred Bernardes-Filho
- Dermatology Division, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; Emergency Department, Hospital Imaculada Conceição da Sociedade Portuguesa de Beneficência, Ribeirão Preto, SP, Brazil; Center of National Reference in Sanitary Dermatology focusing on Leprosy of Ribeirão Preto Clinical Hospital, Ribeirão Preto, SP, Brazil.
| | - Filipe Rocha Lima
- Dermatology Division, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; Center of National Reference in Sanitary Dermatology focusing on Leprosy of Ribeirão Preto Clinical Hospital, Ribeirão Preto, SP, Brazil.
| | - Glauber Voltan
- Dermatology Division, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; Center of National Reference in Sanitary Dermatology focusing on Leprosy of Ribeirão Preto Clinical Hospital, Ribeirão Preto, SP, Brazil.
| | - Natália Aparecida de Paula
- Dermatology Division, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; Center of National Reference in Sanitary Dermatology focusing on Leprosy of Ribeirão Preto Clinical Hospital, Ribeirão Preto, SP, Brazil.
| | - Marco Andrey Cipriani Frade
- Dermatology Division, Department of Medical Clinics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil; Center of National Reference in Sanitary Dermatology focusing on Leprosy of Ribeirão Preto Clinical Hospital, Ribeirão Preto, SP, Brazil.
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Abstract
Neuropathy and related disabilities are the major medical consequences of leprosy, which remains a global medical concern. Despite major advances in understanding the mechanisms of M. leprae entry into peripheral nerves, most aspects of the pathogenesis of leprosy neuropathy remain poorly understood. Sensory loss is characteristic of leprosy, but neuropathic pain is sometimes observed. Effective anti-microbial therapy is available, but neuropathy remains a problem especially if diagnosis and treatment are delayed. Currently there is intense interest in post-exposure prophylaxis with single-dose rifampin in endemic areas, as well as with enhanced prophylactic regimens in some situations. Some degree of nerve involvement is seen in all cases and neuritis may occur in the absence of leprosy reactions, but acute neuritis commonly accompanies both Type 1 and Type 2 leprosy reactions and may be difficult to manage. A variety of established as well as new methods for the early diagnosis and assessment of leprosy neuropathy are reviewed. Corticosteroids offer the primary treatment for neuritis and for subclinical neuropathy in leprosy, but success is limited if nerve function impairment is present at the time of diagnosis. A candidate vaccine has shown apparent benefit in preventing nerve injury in the armadillo model. The development of new therapeutics for leprosy neuropathy is greatly needed.
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Affiliation(s)
- Gigi J Ebenezer
- Neurology/Cutaneous Nerve Laboratory, Johns Hopkins University, The John G Rangos Bldg, room: 440, 855 North Wolfe Street, Baltimore, MD, 21205, USA.
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Giesel LM, Hökerberg YHM, Pitta IJR, Andrade LR, Moraes DB, da Costa Nery JA, Sarno EN, Jardim MR. Clinical prediction rules for the diagnosis of neuritis in leprosy. BMC Infect Dis 2021; 21:858. [PMID: 34425777 DOI: 10.1186/s12879-021-06545-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background Diagnosing neuritis in leprosy patients with neuropathic pain or chronic neuropathy remains challenging since no specific laboratory or neurophysiological marker is available.
Methods In a cross-sectional study developed at a leprosy outpatient clinic in Rio de Janeiro, RJ, Brazil, 54 individuals complaining of neural pain (single or multiple sites) were classified into two groups (“neuropathic pain” or “neuritis”) by a neurological specialist in leprosy based on anamnesis together with clinical and electrophysiological examinations. A neurologist, blind to the pain diagnoses, interviewed and examined the participants using a standardized form that included clinical predictors, pain features, and neurological symptoms. The association between the clinical predictors and pain classifications was evaluated via the Pearson Chi-Square or Fisher’s exact test (p < 0.05). Results Six clinical algorithms were generated to evaluate sensitivity and specificity, with 95% confidence intervals, for clinical predictors statistically associated with neuritis. The most conclusive clinical algorithm was: pain onset at any time during the previous 90 days, or in association with the initiation of neurological symptoms during the prior 30-day period, necessarily associated with the worsening of pain upon movement and nerve palpation, with 94% of specificity and 35% of sensitivity. Conclusion This algorithm could help physicians confirm neuritis in leprosy patients with neural pain, particularly in primary health care units with no access to neurologists or electrophysiological tests.
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Pearce B. Nonoperative treatment of recalcitrant neuritis of the infrapatellar saphenous nerve: a case series. J Med Case Rep 2021; 15:378. [PMID: 34261538 PMCID: PMC8281630 DOI: 10.1186/s13256-021-02912-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 05/17/2021] [Indexed: 12/03/2022] Open
Abstract
Background Neuritis of the infrapatellar branch of the saphenous nerve can result from iatrogenic injury, entrapment, bursitis, or patellar dislocation. Currently, there is an unmet clinical need for treating refractory neuritis nonsurgically. Case presentation Three patients presented with persistent anterior knee pain caused by neuritis of the infrapatellar branch of the saphenous nerve that had got excellent but only temporary relief from steroid and local anesthetic nerve block. The neuropathic pain diagnostic Douleur Neuropathique 4 questionnaire and painDETECT questionnaire confirmed presence of neuropathic pain. After injection with 25 mg amniotic and umbilical cord particulate, the patient’s pain decreased from 7.3 before injection to 0.3 at 6 weeks postinjection. In addition, neuropathic symptoms significantly improved at 2 weeks and were not present by 6 weeks. By 63 weeks, two of the patients reported continued complete pain relief, while one patient underwent total knee replacement due to an allergy of a previously implanted unicondylar implant. Conclusions This case series suggests that amniotic and umbilical cord particulate may be a viable alternative to reduce pain in patients with neuropathic pain.
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Affiliation(s)
- Beth Pearce
- Orthopaedic Associates of St. Augustine, One Orthopaedic Pl, St. Augustine, Jacksonville, FL, 32086, USA.
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Umashankar A, Prakash P, Prabhu P. Sudden Sensorineural Hearing Loss Post Coronavirus Disease: A Systematic Review of Case Reports. Indian J Otolaryngol Head Neck Surg 2021; 74:3028-3035. [PMID: 34277383 PMCID: PMC8271291 DOI: 10.1007/s12070-021-02756-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/04/2021] [Indexed: 02/08/2023] Open
Abstract
The coronavirus disease of 2019 is a global pandemic disease severely affecting the upper respiratory tract that can be fatal in some instances. The virus most commonly affects the respiratory system. However, in certain cases it affects the other systems, including cardiovascular, renal, gastrointestinal, neurological, and auditory. Concerning the hearing and balance system, the microcirculation supply to the inner ear is hampered thus causing audiovestibular symptoms. Several case studies have reported sudden sensorineural hearing loss post-coronavirus disease and its detrimental impact on overall hearing. As both sudden sensorineural hearing loss and coronavirus disease deals with an emergency situation, there is a need to document case studies on how these individuals have been assessed and treated. The article has systematically reviewed these case reports involving a search strategy in databases like PubMed, PubMed Central, science direct, J-GATE, Google Scholar, and a manual Google Search.
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Affiliation(s)
- Abishek Umashankar
- All India Institute of Speech and Hearing, Mysore, Karnataka 570006 India
| | - Praveen Prakash
- All India Institute of Speech and Hearing, Mysore, Karnataka 570006 India
| | - Prashanth Prabhu
- All India Institute of Speech and Hearing, Mysore, Karnataka 570006 India
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Morrison M, Korda A, Zamaro E, Wagner F, Caversaccio MD, Sauter TC, Kalla R, Mantokoudis G. Paradigm shift in acute dizziness: is caloric testing obsolete? J Neurol 2021; 269:853-860. [PMID: 34191079 PMCID: PMC8782777 DOI: 10.1007/s00415-021-10667-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/03/2022]
Abstract
Objective Cold and warm water ear irrigation, also known as bithermal caloric testing, has been considered for over 100 years the ‘Gold Standard’ for the detection of peripheral vestibular hypofunction. Its discovery was awarded a Nobel Prize. We aimed to investigate the diagnostic accuracy of Caloric Testing when compared to the video head impulse test (vHIT) in differentiating between vestibular neuritis and vestibular strokes in acute dizziness. Design Prospective cross-sectional study (convenience sample). Setting All patients presenting with signs of an acute vestibular syndrome at the emergency department of a tertiary referral center. Participants One thousand, six hundred seventy-seven patients were screened between February 2015 and May 2020 for Acute Vestibular Syndrome (AVS), of which 152 met the inclusion criteria and were enrolled. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if they were younger than 18 years, if symptoms lasted < 24 h or if the index ED visit was > 72 h after symptom onset. Of the 152 included patients 85 completed testing. We assessed 58 vestibular neuritis and 27 stroke patients. Main outcome measures All patients underwent calorics and vHIT followed by a delayed MRI which served as a gold standard for vestibular stroke confirmation. Results The overall sensitivity and specificity for detecting stroke with a caloric asymmetry cut-off of 30.9% was 75% and 86.8%, respectively [negative likelihood ratio (NLR) 0.29] compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT. Conclusions Caloric testing proved to be less accurate than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Contrary to classic teaching, asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We, therefore, recommend to abandon caloric testing in current practice and to replace it with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10667-7.
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Affiliation(s)
- Miranda Morrison
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Roger Kalla
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland.
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Abstract
Case summary An 8-year-old neutered female domestic longhair cat was presented for investigation of a 48 h history of lethargy and pelvic limb ataxia. MRI of the spinal cord and vertebral column (C1 to sacrum) and brain was unremarkable. Lumbar cerebrospinal fluid analysis revealed pleocytosis and increased protein concentration. Thoracic radiographs and abdominal ultrasound were unremarkable. Anti-inflammatory doses of prednisolone were administered. Clinical deterioration occurred over the following 2 days, with the development of lower motor neuron deficits in both thoracic limbs. On repetition of the MRI, bilateral enlargement, T2-weighted hyperintensity, and marked contrast enhancement of the C7, C8 and T1 nerve roots, spinal nerves and brachial plexuses were observed. Infectious disease testing was negative. An immune-mediated inflammatory process was suspected and immunosuppressive doses of prednisolone were commenced. The clinical signs improved transiently, but marked deterioration occurred after 2 weeks. The patient was euthanased and a post-mortem examination was performed. A lymphocytic inflammatory infiltrate was detected in the C7, C8 and T1 nerve roots and dorsal root ganglia, and neoplastic plasma cells were identified in multiple organs. A diagnosis of non-cutaneous extramedullary plasmacytoma with multiorgan involvement and paraneoplastic ganglioradiculoneuritis was reached. Relevance and novel information Paraneoplastic ganglioradiculoneuritis in association with a plasma cell neoplasia has not been previously reported in the cat and should be considered as a differential diagnosis for cats with clinical or imaging evidence of an inflammatory process affecting the nerve roots, spinal nerves or brachial plexuses.
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Affiliation(s)
| | | | | | - Lorenzo Mari
- Wear Referrals Veterinary Hospital, Bradbury, UK
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Moon AS, DeBell HA, Peng J, McKissack H, Chinnakkannu K, Moraes L, Brahmbhatt A, Alexander B, Shah A. Macroscopic changes in sural nerve after gastrocnemius recession: a cadaver study. Foot (Edinb) 2020; 44:101682. [PMID: 32663773 DOI: 10.1016/j.foot.2020.101682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/18/2019] [Accepted: 03/22/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Gastrocnemius recession is a common foot and ankle procedure and various techniques that have been utilized are mainly delineated by the anatomic position of the gastrocnemius transection; the 2 common ones are the Baumann and Strayer procedure. Both can adversely affect the sural nerve. The objective of this study was to evaluate the macroscopic changes in the sural nerve following gastrocnemius recession, and to compare the efficacy of the two procedures, regarding the improvement of maximal ankle dorsiflexion. METHODS Ten fresh-frozen, above knee cadaveric legs were assigned to one of two gastrocnemius recession techniques: Baumann (n = 5) or Strayer (n = 5). A goniometer was used to measure degree of ankle dorsiflexion before and after the surgery. The sural nerve was meticulously dissected and marked with two suture knots, 2 cm apart. The ankle was passively dorsiflexed from 90° to maximal dorsiflexion in 5° degree increments, and the distance between two suture knots was measured at each increment. The distance between the two cut ends of gastrocnemius muscle was measured with the ankle at 90° and at maximal dorsiflexion. RESULTS Overall, a mean increase in length between the suture knots on the sural nerve was 0.2 cm, from 90° to maximum ankle dorsiflexion (130°); both the Baumann and Strayer techniques resulted in 0.2 cm increase. The mean improvement in maximal ankle dorsiflexion in the Baumann and Strayer group was 22.6° and 22°, respectively. The mean change in distance between the two cut ends of the gastrocnemius muscle in the Baumann and Strayer group was 1.0 cm and 0.9 cm, respectively. CONCLUSION Increased dorsiflexion of the ankle following Strayer or Baumann gastrocnemius recession resulted in similar macroscopic change in the sural nerve, which may contribute to the development of sural neuritis. Further clinical studies are warranted to assess clinical implications of these findings.
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Affiliation(s)
- Andrew S Moon
- Tufts University School of Medicine, Boston, MA, USA; University of Alabama at Birmingham, AL, USA.
| | | | | | | | | | | | - Ashish Brahmbhatt
- Tufts University School of Medicine, Boston, MA, USA; University of Alabama at Birmingham, AL, USA; Edward Via College of Osteopathic Medicine, Auburn, AL, USA.
| | | | - Ashish Shah
- University of Alabama at Birmingham, AL, USA.
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Escolano-Serrano J, Monera-Lucas CE, Moreno-Escudero IM, Romero-Valero D, Fernández-Martínez C, Martínez-Toldos JJ. Optical neuropathy due to inhaled cocaine, causality or chance. Arch Soc Esp Oftalmol (Engl Ed) 2020; 95:411-414. [PMID: 32499061 DOI: 10.1016/j.oftal.2020.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 06/11/2023]
Abstract
A 44-year-old man, active cocaine consumer, who referred decrease in visual acuity in the right eye in 24 hours of evolution, being 0,05 in that eye and 1 in the left eye. The examination showed a relative afferent pupil defect and a swelling head of optic nerve. The systemic studies performed were normal, except the nuclear magnetic resonance of the brain that showed a thickening of the maxillary and frontal sinus mucosa, compatible with sinusitis. Hospital admission and the start of intravenous corticosteroid treatment were decided, with a favourable evolution, a visual acuity of 1.0 in both eyes and an anatomical improvement of the optic nerve head. Due to the medical history of the patient and the assessment of other plausible alternative diagnoses, we established the diagnosis of optical neuropathy due to inhaled cocaine abuse.
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Affiliation(s)
- J Escolano-Serrano
- Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, España.
| | - C E Monera-Lucas
- Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, España
| | - I M Moreno-Escudero
- Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, España
| | - D Romero-Valero
- Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, España
| | - C Fernández-Martínez
- Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, España
| | - J J Martínez-Toldos
- Servicio de Oftalmología, Hospital General Universitario de Elche, Alicante, España
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15
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Muke I, Sprenger A, Bobylev I, Wiemer V, Barham M, Neiss WF, Lehmann HC. Ultrastructural characterization of mitochondrial damage in experimental autoimmune neuritis. J Neuroimmunol 2020; 343:577218. [PMID: 32251941 DOI: 10.1016/j.jneuroim.2020.577218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/11/2022]
Abstract
Data are sparse about mitochondrial damage in GBS and in its most frequently employed animal model, experimental autoimmune neuritis (EAN). We here characterized changes in mitochondrial content and morphology at different time points during EAN by use of ultrastructural imaging and immunofluorescent labelling. Histological examination revealed that demyelinated axons and their adjacent Schwann cells showed reduced mitochondrial content and remaining mitochondria appeared swollen with greater diameter in Schwann cells and unmyelinated axons. Our findings indicate that in EAN, particularly mitochondria in Schwann cells are damaged. Further studies are warranted to address whether these changes are amenable to novel, mitoprotective treatments.
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Affiliation(s)
- Ines Muke
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Germany
| | - Alina Sprenger
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Germany
| | - Ilja Bobylev
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Germany
| | - Valerie Wiemer
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Germany
| | - Mohammed Barham
- Department of Anatomy I, Faculty of Medicine, University of Cologne, Germany
| | | | - Helmar Christoph Lehmann
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, Germany; Center for Molecular Medicine Cologne (CMMC), University of Cologne, Germany.
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16
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Molero-Senosiain M, Domingo-Gordo B, Fernández Cabrera C, Hernández-García E, Gómez de Liaño R. Neuro-ophthalmological manifestations as complication of an infection with Mycoplasma pneumoniae and subsequent development of disseminated acute encephalitis. ACTA ACUST UNITED AC 2020; 95:254-8. [PMID: 32147128 DOI: 10.1016/j.oftal.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 11/21/2022]
Abstract
El objetivo es describir dos cuadros clínicos neuroftalmológicos en niños por infección sistémica por Mycoplasma pneumoniae (M. pneumoniae). Se presentan los casos de dos niñas de 14 y 12 años que acudieron a urgencias: la primera con oftalmoplejía internuclear y la segunda con pérdida de visión y cefalea. No presentaban otra focalidad neurológica. En la imagen de resonancia magnética se evidenciaron placas hiperintensas en ambas, sugerentes de cuadro desmielinizante. Al mes, los síntomas neuroftalmológicos se resolvieron y las resonancias magnéticas de control fueron normales. El diagnóstico fue encefalitis diseminada aguda secundaria a M. pneumoniae. El diagnóstico se hace por PCR (gold standard) y/o IgM en serología. Es importante pensar en esta posible etiología ante casos sugerentes de enfermedad desmielinizante. Existe controversia sobre el papel de los antibióticos y si se contemplan los corticoides. Como conclusión, M. pneumoniae debe ser diagnóstico diferencial en afectaciones neuroftalmológicas agudas en niños.
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17
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Shushan S, Shemesh S, Ungar OJ, Cavel O, Handzel O, Tamir SO, Oron Y. Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio among Patients with Vestibular Neuritis. ORL J Otorhinolaryngol Relat Spec 2019; 81:304-308. [PMID: 31499507 DOI: 10.1159/000502152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/15/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare the level of the inflammatory markers (IM) neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) among healthy subjects and those presenting with vestibular neuritis (VN). METHODS A cross-sectional retrospective study was conducted in a tertiary hospital setting. The medical records of patients (20-60 years old) who were hospitalized between the years 2005 and 2014 with the diagnosis of VN were retrieved. Inclusion criteria were: (1) acute vertigo lasting for at least 24 h, (2) absence of auditory complaints, (3) presence of horizontal unidirectional nystagmus during physical examination, (4) absence of neurological symptoms or signs. The levels of the IM were compared with levels reported among two large cohorts of healthy subjects, within the same age range. RESULTS A statistically significant difference was found between the levels of NLR in VN subjects compared with controls, with higher levels of NLR in VN subjects (p < 0.001), while no significant difference was found between both groups concerning the levels of PLR. CONCLUSION Higher levels of IM were found among VN patients, with significantly higher levels of NLR, but not PLR. This may suggest a possible inflammatory etiology of VN.
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Affiliation(s)
- Sagit Shushan
- Department of Otolaryngology-Head & Neck Surgery, The Edith Wolfson Medical Center, Tel Aviv University Sackler Faculty of Medicine, Holon, Israel
| | - Shay Shemesh
- Department of Otolaryngology-Head & Neck Surgery, Samson Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Omer J Ungar
- Department of Otolaryngology-Head & Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Oren Cavel
- Department of Otolaryngology-Head & Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Ophir Handzel
- Department of Otolaryngology-Head & Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Sharon Ovnat Tamir
- Department of Otolaryngology-Head & Neck Surgery, Samson Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Yahav Oron
- Department of Otolaryngology-Head & Neck Surgery and Maxillofacial Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel,
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Park C, Ikram A, Abdul-Jabar HB, Radford WJ. Sciatic nerve neuritis of no cause in primary total hip replacement: A case series. J Clin Orthop Trauma 2019; 10:121-123. [PMID: 30705545 PMCID: PMC6349595 DOI: 10.1016/j.jcot.2017.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/17/2017] [Indexed: 11/16/2022] Open
Abstract
Neuritis of the sciatic nerve is a rare complication of total hip replacements. It is characterized by symptoms of neuropathic pain with or without motor and or sensory symptoms. Causes include direct intra-operative trauma or mechanical lengthening of the nerve. Cases of sciatic nerve neuritis without an organic cause however, are rarer still. We present two cases of sciatic nerve neuritis post total hip replacement with no identified organic cause. Whereas the reversal of the underlying cause has shown improvement in symptoms, in cases without an organic cause our experience advocates close observation and conservative management with spontaneous resolution of symptoms.
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Affiliation(s)
- Chang Park
- Corresponding author at: Stanmore Royal National Orthopaedic Hospital,Stanmore, HA7 4LP, London, United Kingdom.
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19
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Dietsche J, Brühschwein A, Rosati M, Knubben-Schweizer G, Feist M. [Possibilities of diagnostics in unilateral fibular-nerve-paresis in a calf]. SCHWEIZ ARCH TIERH 2018; 160:539-545. [PMID: 30206050 DOI: 10.17236/sat00175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The present case report describes the workup of unilateral fibular-nerve-paresis in a female neonatal Fleckvieh calf. The calf was admitted to the Clinic for Ruminants with Ambulatory and Herd Health Services, Ludwig- Maximilians-University Munich as part of an investigation into a herd problem. The herd problem was presented as movement disorder in neonatal calves with an incidence of 10%. A physical, hematological, and musculoskeletal, as well as neurological examination was performed, and a diagnosis of a left-sided paresis of the fibular-nerve (N. fibularis) was made. Further special examinations including sonography, magnetic resonance tomography and muscle, lymph node, and nerve biopsies of the affected limb of the calf were also carried out. Advanced imaging examinations suggested the presence of inflammatory changes caudal to the left stifle joint in the region of the fibular nerve. Histopathological examination of the nerve biopsy confirmed the presence of a fibular-nerve-neuritis. Inflammatory changes in the ischiocrural-muscles were most likely injection-induced, consistent with the history of the veterinary practitioner and the examination results.
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Affiliation(s)
- J Dietsche
- Klinik für Wiederkäuer mit Ambulanz und Bestandsbetreuung, Ludwig-Maximilians-Universität München
| | - A Brühschwein
- Chirurgische und Gynäkologische Kleintierklinik der Ludwig-Maximilians-Universität München
| | - M Rosati
- Institut für Tierpathologie, Abteilung für klinische und vergleichende Neuropathologie, Tierärztliche Fakultät, Ludwig-Maximilians-Universität München
| | - G Knubben-Schweizer
- Klinik für Wiederkäuer mit Ambulanz und Bestandsbetreuung, Ludwig-Maximilians-Universität München
| | - M Feist
- Klinik für Wiederkäuer mit Ambulanz und Bestandsbetreuung, Ludwig-Maximilians-Universität München
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20
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Lindland ES, Solheim AM, Andreassen S, Quist-Paulsen E, Eikeland R, Ljøstad U, Mygland Å, Elsais A, Nygaard GO, Lorentzen ÅR, Harbo HF, Beyer MK. Imaging in Lyme neuroborreliosis. Insights Imaging 2018; 9:833-44. [PMID: 30187265 DOI: 10.1007/s13244-018-0646-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/25/2018] [Accepted: 07/04/2018] [Indexed: 12/13/2022] Open
Abstract
Abstract Lyme neuroborreliosis (LNB) is a tick-borne spirochetal infection with a broad spectrum of imaging pathology. For individuals who live in or have travelled to areas where ticks reside, LNB should be considered among differential diagnoses when clinical manifestations from the nervous system occur. Radiculitis, meningitis and facial palsy are commonly encountered, while peripheral neuropathy, myelitis, meningoencephalitis and cerebral vasculitis are rarer manifestations of LNB. Cerebrospinal fluid (CSF) analysis and serology are key investigations in patient workup. The primary role of imaging is to rule out other reasons for the neurological symptoms. It is therefore important to know the diversity of possible imaging findings from the infection itself. There may be no imaging abnormality, or findings suggestive of neuritis, meningitis, myelitis, encephalitis or vasculitis. White matter lesions are not a prominent feature of LNB. Insight into LNB clinical presentation, laboratory test methods and spectrum of imaging pathology will aid in the multidisciplinary interaction that often is imperative to achieve an efficient patient workup and arrive at a correct diagnosis. This article can educate those engaged in imaging of the nervous system and serve as a comprehensive tool in clinical cases. Key Points • Diagnostic criteria for LNB emphasise exclusion of an alternative cause to the clinical symptoms. • MRI makes a crucial contribution in the diagnosis and follow-up of LNB. • MRI may have normal findings, or show neuritis, meningitis, myelitis, encephalitis or vasculitis. • White matter lesions are not a prominent feature of LNB.
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21
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Appelbaum J, Wells D, Hiatt JB, Steinbach G, Stewart FM, Thomas H, Nghiem P, Kapur RP, Thompson JA, Bhatia S. Fatal enteric plexus neuropathy after one dose of ipilimumab plus nivolumab: a case report. J Immunother Cancer 2018; 6:82. [PMID: 30170630 DOI: 10.1186/s40425-018-0396-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/14/2018] [Indexed: 12/31/2022] Open
Abstract
Background Immune checkpoint inhibitors (ICIs) are the treatment of choice for several cancers and can be associated with remarkable clinical benefit, but can also cause serious immune-related adverse events (irAEs). Management of rare and severe irAEs is challenged by an incomplete knowledge of their natural history and pathogenetic mechanisms. We report a case of fatal acute-onset gastro-intestinal (GI) hypomotility from myenteric plexus neuropathy following a single dose of ipilimumab plus nivolumab given for treatment of Merkel cell carcinoma (MCC). Case presentation A 66-year-old man with recurrent metastatic MCC involving several organs (liver, bones and disseminated retroperitoneal lymphadenopathy) developed profound pharyngeal dysphagia and ileus that started 7 days after receiving a single administration of combination immune checkpoint blockade consisting of nivolumab (3 mg/kg) and low-dose ipilimumab (1 mg/kg). A swallowing study showed oropharyngeal dysfunction and aspiration. Imaging studies were consistent with diffuse intestinal paresis. An extensive work-up did not reveal obvious causes of these symptoms, and enteric plexopathy was suspected. Empiric immune suppressive therapy was initiated urgently. Despite an escalating immunosuppressive regimen that included high dose steroids, tacrolimus and therapeutic plasma exchange, no improvement in GI motility was seen and the patient suffered repeated episodes of aspiration. Seven weeks after the onset of GI hypomotility, the patient succumbed to sepsis from intestinal perforations. At autopsy, histologic specimens obtained from the entire GI tract (pharynx to rectum) showed near complete loss of ganglion cells within the myenteric and submucosal plexuses. An associated inflammatory infiltrate was not seen, suggesting a ‘burned out’ phase of illness. C4d complement deposition was found at the ganglionic sites, suggesting antibody-mediated pathogenesis. Remarkably, at sites of previously suspected Merkel cell metastases, no residual viable Merkel cell carcinoma was identified. Conclusions GI-tract paresis due to myenteric neuritis is a rarely reported toxicity of ICIs. Because the window of reversibility is likely to be very brief, quick and decisive interventions are warranted. Subtle functional and anatomic perturbations of the myenteric nervous system from the use of ICIs may be more prevalent than realized and should be suspected and addressed in both clinical and investigational settings.
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Abstract
BACKGROUND Many patients with neuropathic pain present without signs of nerve injury on routine clinical examination. Some of these patients may have inflamed peripheral nerves (neuritis). In this study, we have examined whether neuritis causes changes within the dorsal horn that may contribute to a central pain mechanism. Comparisons have been made to a model of axonal transport disruption induced using vinblastine, since neuritis disrupts such processes. RESULTS At the peak of cutaneous hypersensitivities, recordings from wide dynamic range neurons revealed increases in wind-up following neuritis but not vinblastine treatment. Ongoing activity from these neurons was unchanged. Vinblastine treatment caused a reduction in the responses of wide dynamic range neurons to noxious mechanical stimulation of the receptive field. The response of neurons to innocuous mechanical stimulation was also reduced in wide dynamic range neurons that were at a depth ≥550 µm following vinblastine treatment. An examination of the superficial dorsal horn revealed an increase in c-Fos-positive neurons in both groups following electrical stimulation of the sciatic nerve. The area of dorsal horn expressing substance P was also decreased following vinblastine treatment. CONCLUSION These findings indicate that a minor nerve insult, such as neuritis, can lead to changes within the dorsal horn that are consistent with a central neuropathic pain mechanism.
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Affiliation(s)
- Ieva Satkeviciute
- 1 Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, UK
| | - Andrew Dilley
- 1 Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, UK
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Abstract
Neuropathic pain of the orofacial region can cause much distress in individuals presenting with this condition. It may be easily mistaken for dental pain, and hence many individuals may undergo unnecessary dental work. Knowledge of the types of neuropathic orofacial pain may assist in timely diagnosis and improvement of a patient's quality of life.
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Serrano-Coll H, Muñoz M, Camilo Beltrán J, Duthie MS, Cardona-Castro N. Anti-natural octyl disaccharide-leprosy IDRI diagnostic (NDO-LID) antibodies as indicators of leprosy reactions and neuritis. Trans R Soc Trop Med Hyg 2018. [PMID: 28633333 DOI: 10.1093/trstmh/trx026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Leprosy is a complex infectious and neurological disease caused by Mycobacterium leprae. Nerve damage is related to immunological hypersensitivity responses known as leprosy reactions (LRs). Diagnostic tools to predict LRs are not available. We hypothesized that natural octyl disaccharide-leprosy IDRI diagnostic (NDO-LID) would be helpful as an indicator of LRs and neuritis. Methods To assess the utility of NDO-LID in indicating reactions, ELISA were used to detect specific antibodies in serum samples from 80 Colombian leprosy patients (40 with and 40 without history of LRs). Responses were detected using a range of detection reagents detecting IgG, IgM or both isotypes. Results Patients with a history of LRs had an increased seropositivity rate for anti-NDO-LID antibodies compared to patients without (anti-NDO-LID protein A [p=0.02], IgG anti-NDO-LID [p=0.01] and IgM anti-NDO-LID [p=0.01]). Further analyses of patients with a history of LRs indicated that both seropositivity rate and magnitude of responses were elevated among patients with neuritis versus those without neuritis (anti-NDO-LID protein A [p=0.03], IgG anti-NDO-LID [p=0.001] and IgM anti-NDO-LID [p=0.06]). Conclusions Our data indicate that testing for serum anti-NDO-LID antibodies can be a useful screen to identify patients at risk of developing LRs and neuritis.
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Affiliation(s)
- Héctor Serrano-Coll
- Instituto Colombiano de Medicina Tropical - Universidad CES, Medellín, Colombia
| | - Mónica Muñoz
- Instituto Colombiano de Medicina Tropical - Universidad CES, Medellín, Colombia
| | - Juan Camilo Beltrán
- Instituto Colombiano de Medicina Tropical - Universidad CES, Medellín, Colombia
| | | | - Nora Cardona-Castro
- Instituto Colombiano de Medicina Tropical - Universidad CES, Medellín, Colombia
- Facultad de Medicina Universidad CES
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25
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Lemaître S, Zmuda M, Jacomet PV, Lévy-Gabriel C, Dendale R, Berges O, Fréneaux P, Mariani P, Desjardins L, Galatoire O, Cassoux N. Small Choroidal Melanoma Revealed by a Large Extrascleral Extension. Ocul Oncol Pathol 2017; 3:240-246. [PMID: 29071276 DOI: 10.1159/000455870] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 01/04/2017] [Indexed: 11/19/2022] Open
Abstract
AIMS Orbital extraocular extension of choroidal melanoma is very rare with small melanomas. We report the case of a patient whose small choroidal melanoma was initially overlooked and was revealed by a large extrascleral extension. METHODS A 48-year-old Caucasian woman presented with sudden total visual loss in the right eye. Multicolor imaging of the fundus showed right optic disc edema and an orange and green lesion near the optic disc. The diagnosis of unilateral optic neuritis was made. Magnetic resonance imaging showed an extraocular mass adjacent to the optic nerve; on ultrasound, this mass was acoustically hollow and a small intraocular component was visible. RESULTS Choroidal melanoma with a large extrascleral extension was diagnosed (T4eN0M0, stage IIIC according to the AJCC 7th TNM classification, 2010). The size of the extraocular nodule was 13 × 5 mm. Treatment consisted of enucleation followed by adjuvant external beam orbital radiotherapy. Tumor analysis showed a mixed cell type melanoma with monosomy 3. The patient developed liver metastasis 10 months after local treatment. CONCLUSION Extraocular extension of choroidal melanoma can occur with small lesions. Prognosis is generally poor according to AJCC TNM. This case is a reminder that fundus examination may reveal the nature of the mass in some patients with orbital tumors.
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Affiliation(s)
- Stéphanie Lemaître
- Institut Curie, Paris, France.,Université Paris Descartes, Paris, France
| | - Mathieu Zmuda
- Fondation ophtalmologique Adolphe de Rothschild, Paris, France
| | | | | | - Rémi Dendale
- Institut Curie, ICPO (Protontherapy Center), Orsay, France
| | - Olivier Berges
- Fondation ophtalmologique Adolphe de Rothschild, Paris, France
| | | | | | | | | | - Nathalie Cassoux
- Institut Curie, Paris, France.,Université Paris Descartes, Paris, France
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26
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Abstract
Bone morphogenetic protein-2 (BMP-2), a potent osteoinductive cytokine from the transforming growth factor beta (TGF-β) family, is currently the most commonly used protein-based bone graft substitute. Although clinical use of BMP-2 has significantly increased in recent years, its prominence has also highlighted various adverse events, including induction of inflammation. This review will elucidate the relationship between BMP-2 and inflammation, with an emphasis on peripheral nerve inflammation and its sequelae. As well, we review the potential additive roles of nerve released factors with BMP2 in the context of bone formation.
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Affiliation(s)
- Vi Nguyen
- Department of Pathology, Johns Hopkins University, 21205, United States
| | - Carolyn A Meyers
- Department of Pathology, Johns Hopkins University, 21205, United States
| | - Noah Yan
- Department of Pathology, Johns Hopkins University, 21205, United States
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan, 48109, United States
| | - Benjamin Levi
- Department of Surgery, University of Michigan, 48109, United States
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, 21205, United States
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Jarius S, Ringelstein M, Haas J, Serysheva II, Komorowski L, Fechner K, Wandinger KP, Albrecht P, Hefter H, Moser A, Neuen-Jacob E, Hartung HP, Wildemann B, Aktas O. Inositol 1,4,5-trisphosphate receptor type 1 autoantibodies in paraneoplastic and non-paraneoplastic peripheral neuropathy. J Neuroinflammation 2016; 13:278. [PMID: 27776522 PMCID: PMC5078930 DOI: 10.1186/s12974-016-0737-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 09/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently, we described a novel autoantibody, anti-Sj/ITPR1-IgG, that targets the inositol 1,4,5-trisphosphate receptor type 1 (ITPR1) in patients with cerebellar ataxia. However, ITPR1 is expressed not only by Purkinje cells but also in the anterior horn of the spinal cord, in the substantia gelatinosa and in the motor, sensory (including the dorsal root ganglia) and autonomic peripheral nervous system, suggesting that the clinical spectrum associated with autoimmunity to ITPR1 may be broader than initially thought. Here we report on serum autoantibodies to ITPR1 (up to 1:15,000) in three patients with (radiculo)polyneuropathy, which in two cases was associated with cancer (ITPR1-expressing adenocarcinoma of the lung, multiple myeloma), suggesting a paraneoplastic aetiology. METHODS Serological and other immunological studies, and retrospective analysis of patient records. RESULTS The clinical findings comprised motor, sensory (including severe pain) and autonomic symptoms. While one patient presented with subacute symptoms mimicking Guillain-Barré syndrome (GBS), the symptoms progressed slowly in two other patients. Electrophysiology revealed delayed F waves; a decrease in motor and sensory action potentials and conduction velocities; delayed motor latencies; signs of denervation, indicating sensorimotor radiculopolyneuropathy of the mixed type; and no conduction blocks. ITPR1-IgG belonged to the complement-activating IgG1 subclass in the severely affected patient but exclusively to the IgG2 subclass in the two more mildly affected patients. Cerebrospinal fluid ITPR1-IgG was found to be of predominantly extrathecal origin. A 3H-thymidine-based proliferation assay confirmed the presence of ITPR1-reactive lymphocytes among peripheral blood mononuclear cells (PBMCs). Immunophenotypic profiling of PBMCs protein demonstrated predominant proliferation of B cells, CD4 T cells and CD8 memory T cells following stimulation with purified ITPR1 protein. Patient ITPR1-IgG bound both to peripheral nervous tissue and to lung tumour tissue. A nerve biopsy showed lymphocyte infiltration (including cytotoxic CD8 cells), oedema, marked axonal loss and myelin-positive macrophages, indicating florid inflammation. ITPR1-IgG serum titres declined following tumour removal, paralleled by clinical stabilization. CONCLUSIONS Our findings expand the spectrum of clinical syndromes associated with ITPR1-IgG and suggest that autoimmunity to ITPR1 may underlie peripheral nervous system diseases (including GBS) in some patients and may be of paraneoplastic origin in a subset of cases.
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Affiliation(s)
- Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany.
| | - Marius Ringelstein
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Jürgen Haas
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Irina I Serysheva
- Department of Biochemistry and Molecular Biology, The University of Texas Medical School at Houston, 6431 Fannin Street, Houston, TX, 77030, USA
| | - Lars Komorowski
- Institute of Experimental Immunology, affiliated to Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Kai Fechner
- Institute of Experimental Immunology, affiliated to Euroimmun AG, Seekamp 31, 23560, Lübeck, Germany
| | - Klaus-Peter Wandinger
- Department of Neurology, University of Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Philipp Albrecht
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Harald Hefter
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Andreas Moser
- Department of Neurology, University of Schleswig Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Eva Neuen-Jacob
- Department of Neuropathology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Brigitte Wildemann
- Molecular Neuroimmunology Group, Department of Neurology, University Hospital Heidelberg, Otto Meyerhof Center, Im Neuenheimer Feld 350, 69120, Heidelberg, Germany
| | - Orhan Aktas
- Department of Neurology, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Krogias C, Ayzenberg I, Schroeder C, Grüter T, Gold R, Yoon MS. Transorbital sonography in CIDP patients: No evidence for optic nerve hypertrophy. J Neurol Sci 2016; 362:206-8. [PMID: 26944149 DOI: 10.1016/j.jns.2016.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/07/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022]
Abstract
Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired, chronic progressive or relapsing immune mediated disorder of the peripheral nervous system. Thickening of cranial nerves as a sign of central nerve involvement is increasingly reported in the last years. Our aim was to assess systematically for the first time the frequency of optic nerve hypertrophy in patients with CIDP by means of transorbital sonography (TOS). Thirty-four optic nerves of 17 patients with CIDP (age=60.8±13.3y, range=39-82y; 7 female) were examined by TOS. The diameter of Optic nerve (OND) as well as the intern and extern diameters of the sheath (ONDSi, ONSDe) was measured 3mm behind the optic disc. Findings were compared to the data of 15 healthy controls. CIDP-patients showed a mean OND of 2.8±0.4mm, an ONSDi of 4.7±0.7mm, and an ONSDe of 6.3±0.9mm. No papilledema was detectable. There was no significant difference to the healthy control group. Our study revealed no evidence for a frequent optic nerve involvement in CIDP. Reported cases seem to represent exceptions. Transorbital sonography could be a useful tool in these rare cases with optic nerve hypertrophy.
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Affiliation(s)
- Christos Krogias
- Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany.
| | - Ilya Ayzenberg
- Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
| | | | - Thomas Grüter
- Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
| | - Ralf Gold
- Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
| | - Min-Suk Yoon
- Dept. of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany
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Habashy A, Sumarriva G, Treuting RJ. Neurectomy Outcomes in Patients With Morton Neuroma: Comparison of Plantar vs Dorsal Approaches. Ochsner J 2016; 16:471-474. [PMID: 27999504 PMCID: PMC5158152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Morton neuroma is a compressive neuropathy of the plantar digital nerve. Several surgical approaches have been used to treat painful Morton neuroma, with each approach having distinct advantages and disadvantages. For this study, we used validated outcome assessment tools to retrospectively compare patient satisfaction with 2 approaches. METHODS The medical records and survey responses of 37 patients with 42 neuromas were evaluated with respect to outcomes and patient satisfaction after neurectomies performed through either a plantar or dorsal surgical approach by one Ochsner Clinic Foundation attending physician. Outcomes were evaluated using the 36-Item Short Form Health Survey (SF-36) and the Foot Function Index (FFI) self-assessments. RESULTS Twenty patients underwent neurectomy through a dorsal approach, and 17 patients underwent neurectomy through a plantar approach. We found no statistically significant differences between the dorsal and plantar approach groups with respect to outcomes and patient satisfaction as measured by the SF-36 or the FFI. CONCLUSION This study supports the use of either the plantar or dorsal approach for the resection of Morton neuroma and suggests that a plantar approach for neurectomy can produce satisfactory results.
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Affiliation(s)
- Alexander Habashy
- Department of Orthopedic Surgery, Ochsner Clinic Foundation, New Orleans, LA
| | - Gonzalo Sumarriva
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Robert J. Treuting
- Department of Orthopedic Surgery, Ochsner Clinic Foundation, New Orleans, LA
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Yoo JH, Oh JH, Kang SH, Kim JB. Management of traumatic neuralgia in a patient with the extracted teeth and alveoloplasty: a case report. J Dent Anesth Pain Med 2015; 15:241-245. [PMID: 28879286 PMCID: PMC5564161 DOI: 10.17245/jdapm.2015.15.4.241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 11/24/2015] [Accepted: 12/10/2015] [Indexed: 11/29/2022] Open
Abstract
A majority of patients who sustain injuries to the peripheral sensory nerves of the face and jaws experience a slow but gradual return of sensation that is functional and tolerable, if not the same as before the injuries. However, long-term effects of such injuries are aggravating for many patients, and a few patients experience significant suffering. In some of these patients, posttraumatic symptoms become pathological and are painful. The predominant painful components are (1) numbing anesthesia dolorosa pain, (2) triggered neuralgiaform pain, (3) burning and aching causalgiaform pain, and (4) phantom pain. This is a case report of conservative management of traumatic neuralgia and neuritis as part of posttraumatic pain syndromes in geriatric patients who have undergone the teeth extraction and alveoloplasty.
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Affiliation(s)
- Jae-Ha Yoo
- Department of Dentistry, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea
| | - Ji-Hyeon Oh
- Department of Dentistry, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea
| | - Se-Ha Kang
- Department of Dentistry, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea
| | - Jong-Bae Kim
- Department of Dentistry, Dong San Medical Center, Keimyung University, Daegu, Korea
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Abstract
High valgus and extension loads imparted to the athlete's elbow during repetitive overhead throwing can lead to acute and chronic pathology. Over time, normal soft tissue and bony stabilizing structures of the elbow undergo progressive structural changes and can succumb to injury. Modern diagnostic modalities, including plain radiographs, computed tomography, and magnetic resonance imaging, in addition to arthroscopy, can aid in diagnosis. Although nonoperative management is often successful, surgical intervention may be necessary before allowing return to play.
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Affiliation(s)
- Vamsi K Kancherla
- Department of Orthopaedic Surgery, St. Luke's University Hospital, 801 Ostrum Street, PPHP2, Bethlehem, PA 18015, USA
| | - Nicholas M Caggiano
- Department of Orthopaedic Surgery, St. Luke's University Hospital, 801 Ostrum Street, PPHP2, Bethlehem, PA 18015, USA
| | - Kristofer S Matullo
- Department of Orthopaedic Surgery, St. Luke's University Hospital, 801 Ostrum Street, PPHP2, Bethlehem, PA 18015, USA.
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Santos-Bueso E, Sáenz-Francés F, Méndez-Hernández C, Martínez-de-la-Casa JM, García-Feijoo J, Gegúndez-Fernández JA, García-Sánchez J. [Papillitis due to Epstein-Barr virus infection in an adult patient]. ACTA ACUST UNITED AC 2013; 89:245-9. [PMID: 24269432 DOI: 10.1016/j.oftal.2013.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 05/06/2013] [Accepted: 05/27/2013] [Indexed: 10/26/2022]
Abstract
CASE REPORT A 70-year- old woman who consulted due to poor vision in her right eye for 2 weeks. The examination showed a visual acuity (VA) of 0.6 and 1.0, with normal anterior pole and intraocular pressure and a relative afferent pupillary defect. Some papillitis was observed in the fundus of her right eye. The high levels of acute phase reactants led to an initial diagnosis of arteritic anterior ischemic optic neuropathy (AAION) and treatment with corticosteroids was started. DISCUSSION According to the age of the patient, the fundus and the high levels of acute phase reactants, the initial diagnosis was AAION. However, the atypical papillitis features, with good AV and non-specific perimetry, together with a suitable medical history, and a profile of viral characteristics, with laboratory confirmation, led to the diagnosis of a primary papillitis infection due to Epstein-Barr virus, a very rare case due to the advanced age of the patient.
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Affiliation(s)
- E Santos-Bueso
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.
| | - F Sáenz-Francés
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - C Méndez-Hernández
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - J M Martínez-de-la-Casa
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - J García-Feijoo
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - J A Gegúndez-Fernández
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - J García-Sánchez
- Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
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