Taste Disorder and Tongue Numbness After Lithium Overdose

PURPOSE

Drug-induced taste disturbances are prevalent in clinical practice, with dysgeusia being a frequent manifestation. This study aims to present a case of taste disorders and tongue numbness induced by a lithium overdose.

CASE REPORT

A 33-year-old woman with bipolar II disorder attempted suicide by ingesting multiple drugs, including lithium and benzodiazepines. She exhibited weakness but was conscious after admission. Laboratory analyses indicated elevated serum lithium and urine benzodiazepine levels. Admitted to a psychiatric ward, her symptoms included diarrhea, poor appetite, and postprandial nausea. Two weeks later, she reported altered taste sensations and tongue numbness following the overdose. Her ongoing medication included venlafaxine, valproate sodium, and clozapine. Symptoms improved over time without specific treatment, aligning with increased appetite and weight gain.

CONCLUSION

Drug-induced taste disturbances have a substantial impact on patients' quality of life and medication adherence. This case brings attention to taste disorders induced by lithium and suggests potential mechanisms that could contribute to taste alterations. It underscores the importance of conducting thorough assessments in patients experiencing gustatory symptoms, particularly during the ongoing pandemic.

Rhinocerebral mucormycosis in immunocompetent patients: a case report and review of literature

INTRODUCTION

Mucormycosis of the head and neck region is a rare but aggressive fungal infection that usually involves immunocompromised patients. More infrequently, this infection can also occur in people with no otherwise known underlying immunological deficit. This rarity usually causes a delay in diagnosis and may severely decrease the chance of survival in these patients. In this study, we present an extreme case of mucormycosis in an immunocompetent patient. By conducting a thorough review of the literature, we aim to increase our knowledge on this matter. Our goal is to improve diagnosis and start treatment at an earlier stage.

CASE PRESENTATION AND METHODS

Our patient was a 31-year-old man who presented with bilateral face numbness, neck pain, headache, and a necrotic palatal lesion 45 days after a dental root canal procedure. There was extensive involvement of facial and skull base bony and soft tissues. Through two debridement sessions and intravenous antifungal treatment, the patient was discharged with near-complete disease resolution. We identified 48 cases in the literature that matched our study criteria. We searched the current literature for proven cases of mucormycosis in the head and neck region who didn't have any underlying disease. We extracted their data and added the data of our patient. Then, we re-analyzed them using descriptive analysis, chi-square, and binary logistic regression to better understand the different factors for survival and disease burden in these patients.

RESULTS

49 patients were analyzed in this study. The mean age was 46.93 ± 15.75 (min 16 and max78 years old). The most prevalent subsite to be involved was the sino-nasal mucosa, followed by the surrounding soft tissues and the orbit. While both orbit and intracranial tissue involvement differed significantly between surviving and deceased patients, only intracranial tissue involvement could be used to predict survival. The overall survival rate was 91.8%.

CONCLUSION

Although very rare, mucormycosis can occur in immunocompetent patients. Physicians should consider mucormycosis when faced with refractory conditions and unusual symptoms such as exposed bones, facial numbness, headaches, and intractable pain. Complementary imaging (CT scan with or without MRI) and histopathological examination are critical for timely diagnosis or exclusion of this potentially fatal yet treatable disease.

Machine learning applied in patient-reported outcome research-exploring symptoms in adjuvant treatment of breast cancer

BACKGROUND

Patient-reported outcome (PRO) data may help us better understand the life of breast cancer patients. We have previously collected PRO data in a national Danish breast cancer study in patients undergoing adjuvant chemotherapy. The aim of the present post-hoc explorative study is to apply Machine Learning (ML) algorithms using permutation importance to explore how specific PRO symptoms influence nonadherence to six cycles of planned adjuvant chemotherapy in breast cancer patients.

METHODS

We here investigate ePRO-data from the 347 patients. The ePRO presented 42 PROCTCAE questions on 25 symptoms. Patients completed the ePRO before each cycle of chemotherapy. Number of patients with completion of the scheduled six cycles of chemotherapy were registered. Two ML models were applied. One aimed at discovering the individual relative importance of the different questions in the dataset while the second aimed at discovering the relationships between the questions. Permutation importance was used.

RESULTS

Out of 347 patients 238 patients remained in the final dataset, 15 patients dropped out. Two symptoms: aching joints and numbness/tingling, were the most important for dropout in the final dataset, each with an importance value of about 0.04. Model's average ROC-AUC-score being 0.706. In the second model a low performance score made the results very unreliable.

CONCLUSION

In conclusion, this explorative data analysis using ML methodologies in an ePRO dataset from a population of women with breast cancer treated with adjuvant chemotherapy unravels that the symptoms aching joints and numbness/tingling could be important for drop out of planned adjuvant chemotherapy.

Vitamin B12 Deficiency Anemia and Polyneuropathy Due to Chronic Radiation Enteritis

A 62-year-old Japanese woman developed numbness of the extremities and megaloblastic anemia. She had undergone total abdominal hysterectomy, whole-pelvis radiation therapy and chemotherapy for gynecological cancer 10 years before. Chronic abdominal pain, diarrhea and intermittent small-bowel obstruction had afflicted her for a long time. We diagnosed her with vitamin B12 deficiency anemia and polyneuropathy due to chronic radiation enteritis causing malabsorption. Vitamin B12 injections improved her numbness and anemia. The early diagnosis and treatment of deficiency of vitamin B12 are important. Physicians should regularly measure vitamin B12 levels and supplement vitamin B12 as needed in patients with chronic radiation enteritis.

Antineutrophil cytoplasmic antibody-positive familial Mediterranean fever and hyperthyroidism: A case report

RATIONALE

Familial Mediterranean fever (FMF) is a genetic autoinflammatory disorder characterized by serositis and recurrent fever. Previous reports identified patients with antineutrophil cytoplasmic antibody (ANCA)-positive FMF, but vasculitis symptoms were not reported.

PATIENT CONCERNS

We report the case of a 44-year-old man with numbness. He had a history of 3 episodes of pleurisy and was being treated with propylthiouracil for hyperthyroidism. Because he was ANCA-positive, we suspected drug-induced ANCA-associated vasculitis and propylthiouracil was discontinued. However, his numbness was not ameliorated, and he again developed high fever with pleurisy.

DIAGNOSIS

Diagnosis of FMF was finally made, and genetic analysis revealed compound heterozygous mutations in exon 2 of the familial Mediterranean fever gene (L110P/E148Q).

INTERVENTIONS

The patient was treated with 0.5 mg/day of colchicine.

OUTCOMES

His numbness improved, and fever has not recurred.

LESSONS

Appearance of ANCA and development of vasculitis should be considered in a clinical course of FMF with hyperthyroidism.

Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome) Complicated by Perforation of the Small Intestine and Cholecystitis

We report a case of eosinophilic granulomatosis with polyangiitis (EGPA; formerly known as Churg-Strauss syndrome) complicated by perforation of the small intestine and necrotizing cholecystitis. A 69-year-old man with a history of bronchial asthma was admitted with mononeuritis multiplex. The laboratory findings included remarkable eosinophilia. He was treated with corticosteroids and his laboratory indices showed improvement; however, his functional deficits remained. His neuropathy gradually improved after the addition of intravenous immunoglobulin (IVIG). He was subsequently treated with oral prednisolone (40 mg/day) as maintenance therapy. Within a month after finishing IVIG, he developed perforation of the small intestine and necrotizing cholecystitis. Intestinal perforation has often been reported as a gastrointestinal complication of EGPA. In contrast, cholecystitis is a rare complication. We report this case because the manifestation of more than one complication is extremely rare. Gastrointestinal symptoms may be a complication of EGPA itself and/or immunosuppressive treatment.

Ultrasound Guided Intercostobrachial Nerve Blockade in Patients with Persistent Pain after Breast Cancer Surgery: A Pilot Study

BACKGROUND

Persistent pain after breast cancer surgery (PPBCS) affects 25 - 60% of breast cancer survivors and damage to the intercostobrachial nerve (ICBN) has been implicated as the cause of this predominantly neuropathic pain. Local anesthetic blockade of the ICBN could provide clues to pathophysiological mechanisms as well as aiding diagnosis and treatment of PPBCS but has never been attempted.

OBJECTIVES

To assess the feasibility of ICBN blockade and assess its effects on pain and sensory function in patients with PPBCS.

STUDY DESIGN

This prospective pilot study was performed in 2 parts: Part 1 determined the sonoanatomy of the ICBN and part 2 examined effects of the ultrasound-guided ICBN blockade in patients with PPBCS.

SETTING

Section for Surgical Pathophysiology at Rigshospitalet, Copenhagen, Denmark.

METHODS

Part 1: Sixteen unoperated, pain free breast cancer patients underwent systematic ultrasonography to establish the sonoanatomy of the ICBN. Part 2: Six patients with PPBCS who had pain in the axilla and upper arm were recruited for the study. Summed pain intensity (SPI) scores and sensory function were measured before and 30 minutes after the block was administered. SPI is a combined pain score of numerical rating scale (NRS) at rest, movement, and 100kPa pressure applied to the maximum point of pain using pressure algometry (max = 30). Sensory function was measured using quantitative sensory testing, which consisted of sensory mapping, thermal thresholds, suprathreshold heat pain perception as well as heat and pressure pain thresholds. The ICBN block was performed under ultrasound guidance and 10 mL 0.5% bupivacaine was injected.

OUTCOME ASSESSMENT

The ability to perform the ICBN block and its analgesic and sensory effects.

RESULTS

Only the second intercostal space could be seen on ultrasound which was adequate to perform the ICBN block. The mean difference in SPI was -9 NRS points (95%CI: -14.1 to -3.9), P = 0.006. All patients had pre-existing areas of hypoesthesia which decreased in size in 4/6 patients after the block.

LIMITATIONS

The main limitation of this pilot study is its small sample size, but despite this, a statistically significant effect was observed.

CONCLUSION

We have successfully managed to block the ICBN using ultrasound guidance and demonstrated an analgesic effect in patients in PPBCS calling for placebo-controlled studies.

[EFFICIENCY OF COCARNIT IN COMPLEX THERAPY OF PATIENTS WITH SYSTEM DISEASES OF CONNECTING FABRIC WITH DEFEAT OF MYOCARDIUM AND DISPLAYS OF CARDIAC INSUFFICIENCY]

In clinical trial included 41 patient with clinic-instrumental dates, which said about myocardium dysfunction and system diseases of connecting fabric and displays of CCI I-III of functional class (FC). Including of complex metabolic drug Cocarnit in standard therapy of systemdiseases of connecting fabric was instrumental in more expressed clinical improvement of patientsclinical dates in 15 days of supervision: a weakness diminished on 66.67%, shortbreathing at the insignificant physical loading--on 23.81%, at the ordinary physical loading--on 47.62%, at the megascopic physical loading--on 19.05%, pain in area of heart--on 42.85%, there are interruptions in-process heart--on 28.57%, oedematousness of shins--on 57.14%, sense of numbness, burning, sensitiveness to cold of extremities--on 57.14%. Quantity of patients with III FC diminished on 5 (23.81%), in a control group--on 2 (10%). It implementation of test with the 6-minute walking more expressed increase of the overcame distance is set for the patients of basicgroup--on 15.46% as compared to a control group--on 7.01%. Cocarnit patients estimatedpositively; side effects with subsequent abolition of drug, were not. Laboratory indexes (AlAT, AsAT, bilirubin, kreatinine, haemoglobin) at the end of trial did not change considerably, that confirmed good bearableness of drug.

Long-Term Effect of Acetyl-L-Carnitine for Antiretroviral Toxic Neuropathy

BACKGROUND

Nucleoside analogue reverse transcriptase inhibitors (NRTIs) used for the treatment of HIV can a cause distal symmetrical peripheral polyneuropathy by disruption of mitochondrial metabolism. Treatment with acetyl-L-carnitine (ALCAR) has shown short-term symptomatic and histological improvement. Long-term effects have not been investigated.

PURPOSE

To assess the subjective and objective degree of antiretroviral toxic neuropathy (ATN) during treatment with ALCAR.

METHOD

A cohort of 21 patients with ATN who commenced treatment with ALCAR between March 1999 and October 2001 was reviewed after a mean of 4.3 years using standardized questionnaires and neurological examination.

RESULTS

Of the 21 patients, 2 had died and 3 were lost to follow-up. 16 patients were assessed. 10 were still on potentially neurotoxic drugs. 13 were still taking ALCAR. 9 were pain free. The most common symptom was numbness (mild, moderate, and severe in 12, 3, and 0 patients, respectively), followed by paraesthesia (8, 2, 2), pain (4, 3, 0), and burning (5, 2, 0). There was mildly reduced sensation in the toes of 8 patients. 13 patients reported that ALCAR had improved their symptoms very much or moderately, 2 reported no change, and 1 reported a moderate worsening.

CONCLUSION

ALCAR led to long-term symptomatic improvement in most patients without the need to discontinue neurotoxic drugs. Although in this study there was no control group, this agent appears to be an effective pathogenesis-based treatment for ATN.

Clomipramine reverses hypoalgesia/hypoesthesia and improved depressive-like behaviors induced by inescapable shock in rats

An increased vulnerability to pain complaints, along with a simultaneous increase in experimental pain thresholds, shows the paradoxical phenomenon of pain perception in depressive patients. Clomipramine, a tricyclic antidepressant, could also ameliorate syndromes in chronic pain patients. However, few studies have focused on the effect of antidepressants on experimental pain thresholds. By using a rat model, the learned helplessness paradigm, the present study explored the effect of clomipramine on behavioral deficits and experimental pain thresholds to different stimuli in "helpless" rats. Helpless rats were administered clomipramine (10mg/kg, i.p, b.i.d.) for 5 consecutive days. The depressive-like and anxiety-like behaviors were detected by shuttle box, open field and elevated plus maze test before and after inescapable shock and after medication. The sensitivity to the thermal and mechanical stimuli was also measured by the von Frey hair and Hargreaves test at the indicated time points. Helpless rats displayed shorter total travel distance and fewer rearing times in the open field test and decreased percentage of time spent in the open arms in the elevated plus maze test. In addition, they exhibited significant hypoalgesia/hypoesthesia to mechanical and thermal stimuli. Clomipramine alleviate depressive-like and anxiety-like behaviors and increased the sensitivity to von Frey filament stimuli with no effect on the sensitivity to radiant heat stimuli in helpless rats. These suggested that clomipramine could reverse mechanical but not thermal hypoalgesia/hypoesthesia and simultaneously improved behavioral deficits.

[Basic knowledge about Kampo for neurologists]

Kampo is a traditional form of medicine in Japan. The individual formulas of the Kampo medicines consist mainly of plant-derived crude drugs. Recently, extract products that maintain specific levels of quality have been commonly used for dosage formulation instead of decoction. Although severe side effects, including pseudoaldosteronism, interstitial pneumonitis, liver damage and mesenteric phlebosclerosis may occasionally arise in some patients, herbal formulations are generally safe compared with potent western medicines. Since the complicated interaction of a Kampo formulation is difficult to analyze pharmacologically, the use of each Kampo formula has been based on the empirical rules described in classical writings by clinicians. Currently, formula selection is not always based on the pathological recognition from the Oriental medicine perspective, because these ancient theories are not necessarily amenable to current clinical practice. Nevertheless, formula selection would be more appropriate, and the therapeutic efficacy would increase if the physicians understood the basic concepts of ki, ketsu, sui, yin-yang, hypofunction and hyperfunction, heat and cold, superficies and interior, the five parenchymatous viscera and the six stages of disease. Regardless of the primary diseases, many Kampo formulas are considered to be indicated for patients complaining of headache, dizziness and numbness, which are common symptoms in everyday practice in neurology.

Phentolamine mesylate for accelerating recovery from lip and tongue anesthesia

Phentolamine mesylate, at dosages from 0.4 to 0.8 mg in adults and adolescents and at dosages from 0.2 to 0.4 mg in children aged 4 to 11 years, has been proven to be safe and effective for the reversal of soft tissue anesthesia (lip and tongue numbness) and the associated functional deficits resulting from a local dental anesthetic injection containing a vasoconstrictor. Its ability to block a-adrenergic receptors on blood vessels induces vasodilation and enhances the redistribution of the local anesthetic away from the injection site. The low dosages administered for dental local anesthetic reversal in all likelihood accounts for the lack of significant cardiovascular effects that are associated with the medical use of the drug for hypertensive conditions associated with catecholamine excess.

Local anesthesia reversal

PM (OraVerse) enables the dentist or dental hygienist (where permitted) to significantly decrease the duration of residual STA in patients where such numbness may prove to be potentially injurious (children, geriatric, and special needs patients), or a negative influence on their quality of life (speaking, eating, negative body image). (Note: As of August 3, 2009, dental hygienists are permitted to administer PM in the following states: Alaska, Arkansas, Hawaii, Idaho, Iowa, Louisiana, Montana, Nevada, New York, North Dakota, Oklahoma, Rhode Island, Tennessee, Utah, and Wisconsin.)

Idiopathic trigeminal neuropathies: a presentation of 15 cases

PURPOSE

The aim of this study is to present a clinical series of patients with trigeminal neuropathy and their treatment.

PATIENTS AND METHODS

We present a retrospective study of 15 cases of idiopathic trigeminal neuropathies, with unilateral involvement of 1 or more divisions of the trigeminal nerve. The clinical, radiologic, and laboratory data of the patients, in addition to the treatment and clinical evolution, were reviewed. The patients were followed up for a mean of 34.4 months (range, 12-120 months).

RESULTS

The study consisted of 11 women and 4 men. The numbness was predominantly located in the innervated mental area and extended in some cases to the first and second trigeminal divisions. Seven patients had slight continuous discomfort in association with the numbness, one of whom had added bouts of typical neurogenic pain. Of the 15 cases, 8 (53%) had acute idiopathic trigeminal neuropathies and fully recovered within 3 months and 7 (47%) were chronic cases, without full recovery after 3 months. Mild pain was felt by 57% of the chronic patients and 37% of the acute patients; treatment with amitriptyline achieved complete or partial improvement in over half of these patients.

CONCLUSION

Of the idiopathic trigeminal neuropathies, half were acute and half were chronic. Mild pain presented more frequently in the chronic patients and was relieved with amitriptyline.

[Observation on therapeutic effect of digital acupoint pressure for treatment of the nerve root type of cervical spondylosis]

OBJECTIVE

To observe the therapeutic effect of digital acupoint pressure for treatment of the nerve root type of cervical spondylosis.

METHODS

Four hundred cases were randomly divided into a digital acupoint pressure group (DAP group) and a medicine group, 200 cases in each group. Acupoints of Quepen (ST 12), Jianjing (GB 21) and Tianzong (ST 11) etc. were used for digital pressing in the DAP group; and Chinese herb medicine of Gentongping was routinely taken in the medicine group. After three treatment courses, the symptoms of pain and numbness, the signs of pressure measurement by compression of head, brachial plexus drawer test and arm myodynamia, as well as the total cumulative scores of daily living capability, were compared.

RESULTS

After treatment, the total cumulative scores of numbness, pressure measurement by compression of head, brachial plexus drawer test, arm myodynamia and daily living capability in both groups were obviously better than those of before treatment (all P<0.01); but there was a significant difference on the total cumulative score of the symptoms and signs between the two groups. The cured rate of 78.0% and total effective rate of 99.0% in the DAP group were better than those of 61.0% and 87.0% in the medicine group, respectively (both P<0.01).

CONCLUSION

Digital acupoint pressure plays an active role in improving the symptoms and signs on patients with nerve root type of cervical spondylosis, which is better than Chinese herb medicine of Gentongping.

Rho kinase inhibitor improves motor dysfunction and hypoalgesia in a rat model of lumbar spinal canal stenosis

STUDY DESIGN

Immunohistochemical and behavioral study using a rat cauda equina compression model.

OBJECTIVE

To investigate, after cauda equina compression by spinal canal stenosis (SCS), Rho activation in the spinal cord and cauda equina, and the effect of intrathecal administration of a Rho kinase inhibitor on hypoalgesia and motor dysfunction.

SUMMARY OF BACKGROUND DATA

Compression of the cauda equina caused by SCS is a common clinical disorder associated with sensory disturbance and intermittent claudication. Cauda equina compression is thought to reduce blood flow and result in nerve degeneration caused by various cytokines. Rho, a member of the small GTPases, is a signal transmitter. It promotes Wallerian degeneration, decreases blood flow in the spinal cord and brain, and increases expression of several cytokines. Currently, Rho kinase inhibitor is used clinically to treat progressive nerve damage due to cerebrovascular disorders. However, its effect for SCS has not been evaluated.

METHODS

Forty-two 6-week-old male Sprague-Dawley rats (200-250 g) were used. For the SCS model (n = 27), a small piece of silicon was placed under the lamina of the fourth lumbar vertebra. In the sham-operated group, laminectomies were performed at L5 only (n = 15). We examined mechanical sensitivity and motor function using von Frey hairs and a treadmill, and immunohistochemically localized Rho in the spinal ventral neurons, axons, and Schwann cells in the cauda equina. We also examined the effects of intrathecally administered Rho kinase inhibitor for hypoalgesia or motor dysfunction caused by SCS.

RESULTS

We observed motor dysfunction and hypoalgesia and activated Rho-immunoreactive cells in spinal ventral neuroreported to induce neurite and axonal outgrowth in the spinal cord and brain after nervous system injury. In addition, 1 report showed that Rho kinase was involved in Wallerian degeneration that was rescued by Rho kinase inhibitor. Furthermore, it is thought that Rho is involved in TNF-alpha and interleukin (IL) production in the central nervous system, and the production was inhibited by administering Rho kinase inhibitor in the central nervous system. Regardns, axons, and Schwann cells in the cauda equina. Intrathecal administration of Rho kinase inhibitor improved mechanical hypoalgesia and motor dysfunction caused by SCS.

CONCLUSION

Activated Rho may play an important role in nerve damage in the cauda equina in SCS. Rho kinase inhibitor may be a useful tool in determining the pathomechanism of cauda equina syndrome caused by SCS.

[Blue discoloration of hands, numbness of feet, indolent cervical lymph node swelling in a 73-year-old man]

A 73-years old patient came to our outpatient clinic because of a blue discoloration of his hands. Furthermore there was a systemic inflammatory reaction, burning pain and numbness of his feet due to a polyneuropathy, and an indolent enlargement of the cervical lymph nodes. In 1996 and 2001 cervical lymph node resections were done because of localized angiofollicular lymphnode hyperplasia (Castleman's disease). The laboratory values confirmed a systemic inflammatory reaction, a hypothyreosis and a monoclonal gammopathy. A CT-scan showed enlarged cervical, intrathoracic and abdominal lymphnodes and a splenomegaly. So all the criterias for a POEMS syndrome (special form of multiple myeloma) were met with polyneuropathy, organomegaly, endocrinopathy, monoclonal protein and skin changes. The generalized lymphadenopathy corresponded histologically to the prior mentioned Castleman's disease. The patient responded well to systemic glucocorticoid treatment and today he is asymptomatic.

Use of nerve growth factor to treat congenital neurotrophic corneal ulceration

PURPOSE

This study was designed to assess the efficacy of nerve growth factor in the treatment of neurotrophic corneal ulceration in a child with bilateral congenital corneal anesthesia secondary to trigeminal insufficiency.

METHODS

A 5-month-old child presented to the casualty department with a 2-week history of red eyes and right corneal ulceration. Slit-lamp examination showed a central defect in the right corneal epithelium with underlying stromal opacification, only mild conjunctival inflammation with slight decreased tear production, and otherwise apparently normal eyes. Initially this was investigated as an infected ulcer and treated for several weeks as herpetic ulceration with no beneficial effect. Further clinical examination demonstrated bilateral decreased corneal sensation along with decreased facial sensation in keeping with congenital trigeminal nerve insufficiency. Investigation with magnetic resonance imaging showed no obvious abnormality. Conservative treatment with lubricants resulted in progressive right corneal stromal loss, and no healing occurred in the left corneal ulcer. Bilateral large lateral tarsorrhaphies were performed. Despite this, the left corneal ulcer demonstrated no improvement and increasing stromal opacification was noted. Topical nerve growth factor (NGF) was then used to treat the left cornea and resulted in epithelial healing within 1 week. Treatment was continued for a further 10 days after epithelial healing. Despite conventional treatment on 3 separate occasions, further epithelial breakdown occurred. Topical NGF treatment resulted in a rapid improvement and healing of the epithelial defect.'At present, the patient is receiving a 6-month continuous treatment plan of NGF.

RESULTS

Persistent epithelial defects (PED) secondary to neurotrophic ulceration have responded to topical NGF on 3 separate occasions during a 2-year period. The corneal epithelium now remains intact, and the cornea has no vascularization; however, mild anterior stromal opacification has gradually increased despite prolonged NGF treatment.

CONCLUSION

NGF seems to represent a safe and efficacious treatment option to restore the integrity of corneal epithelium in which there is congenital corneal anesthesia because of trigeminal insufficiency. However, this treatment alone is insufficient to prevent progressive anterior stromal opacification.

Neuropathie toxique induite par l’isoniazide : pensez à la prévention

INTRODUCTION

Antituberculous treatment is effective but has numerous side effects. Among these isoniazid induced neuropathy is easily preventable.

CASE REPORT

A female patient of 42 years, infected with HIV, presented with general deterioration associated with an interstitial pulmonary infiltrate and mediastinal lymphadenopathy. Tuberculosis was not confirmed bacteriologically but she responded to antituberculous treatment. Three months later she developed distal leg pains extending proximally. There was superficial sensory impairment up to the groins and loss of the ankle reflexes. The dose of isoniazid was reduced from 5 to 2.5 mg/kg/day on account of slow acetylator status and treatment with pyridoxine 250 mg/day commenced. The clinical signs resolved in a few weeks.

CONCLUSIONS

Isoniazid neuropathy develops in the presence of risk factors (HIV, alcoholism, diabetes, renal failure, malnutrition, pregnancy and lactation, neurotoxic medication) and manifests itself initially by burning feet. Pyridoxine is preventative in low dosage and curative in high dosage. The development of symptoms should lead to measurement of acetylator status, and a reduction of the isoniazid dose to 3 mg/kg/day or even less in slow acetylators.

Analgesic effects of the selective group II (mGlu2/3) metabotropic glutamate receptor agonists LY379268 and LY389795 in persistent and inflammatory pain models after acute and repeated dosing

Group II (mGluR2/3) metabotropic glutamate receptors have been implicated in the mechanisms of persistent pain states. In the present study, the effects of the selective group II metabotropic glutamate receptor agonists LY379268 and LY389795 were evaluated in the formalin test, carrageenan-induced thermal hyperalgesia and mechanical allodynia, and capsaicin-induced mechanical allodynia in rats. The agonists LY379268 and LY389795 produced dose-dependent decreases in formalin-induced behaviors that were antagonized by the mGlu2/3 receptor antagonist LY341495. The group II antagonist LY341495 produced parallel shifts in the LY379268 dose-response curve, consistent with a competitive antagonism. LY379268 decreased formalin-induced behaviors after intracisternal but not intrathecal administration, suggesting primarily a supraspinal site of action. Both LY379268 and LY389795 produced a dose-related reversal of carrageenan-induced thermal hyperalgesia and capsaicin-induced mechanical allodynia, but had no effect on carrageenan-induced mechanical allodynia. Both agonists also increased response latencies in the hot plate test, but were without effect in the tail-flick test. However, both agonists produced motor impairment on the inverted screen at doses that were analgesic. Moreover, tolerance to the analgesic effects of LY379268 developed after 4 days of once-daily repeated administration in the formalin, carrageenan, capsaicin and hot plate tests. The present findings indicate that group II (mGluR2/3) metabotropic glutamate receptors may be involved in the mechanisms of hyperalgesia and allodynia, however tolerance rapidly develops to these effects.

Systemic ATP infusion improves spontaneous pain and tactile allodynia, but not tactile hypesthesia, in patients with postherpetic neuralgia

PURPOSE

Activation of purinoceptors may improve neuropathic pain. Accordingly, the effects of systemic ATP infusion were assessed in patients with postherpetic neuralgia (PHN).

METHODS

Eight patients with PHN lasting over 3 months were enrolled. Initially, patients received the vehicle (20% dextrose) or ATP (at a dose of 1 mg x kg(-1) in 20% dextrose) infused intravenously for 60 min on two separate occasions in a single-blinded manner. The levels of spontaneous continuous pain, paroxysmal pain, and tactile allodynia were assessed by a visual analogue scale (VAS), and tactile hypesthesia was assessed by Semmes-Weinstein monofilament before and after infusion. Subsequently, the eight patients received an ATP infusion (1 mg.kg(-1) in 20% dextrose) once a week for 5-12 weeks in an open-label manner, and changes in the above parameters were assessed.

RESULTS

In the initial study, VAS for spontaneous continuous pain and tactile allodynia decreased significantly with ATP infusion but not with placebo infusion. After repeated ATP infusions for 5-12 weeks, the median VAS for spontaneous continuous pain, paroxysmal pain, and tactile allodynia decreased significantly from 32.1 to 13.0, from 46.9 to 17.5, and from 49.5 to 15.6 respectively. However tactile hypesthesia did not improve significantly.

CONCLUSION

This study demonstrated that repetitive intravenous ATP infusion could improve spontaneous continuous pain and paroxysmal pain, as well as improving tactile allodynia, but did not influence tactile hypesthesia.

[Primary assessment of treatment effect of thymosin alpha1 on chemotherapy-induced neurotoxicity]

BACKGROUND & OBJECTIVE

Clinical trails showed that thymosin alpha1 offers protection from toxicities (nausea, vomiting, fatigue) of chemotherapy. This study was designed to investigate the protection of thymosin alpha1 to nervous system.

METHODS

Twenty-two patients with advanced lung cancer, or advanced breast cancer were treated with vinorelbine (25 mg/m(2), d(1), d(8)) combined with cisplatin (80 mg/m(2), d(1)), or gemcitabine (1.25 g/m(2), d(1), d(8)) combined with cisplatin (80 mg/m(2), d(1)),or paclitaxel (80 mg/m(2), d(1), d(8), d(15)) combined with carboplatin (AUC=6 d(1)),or paclitaxel (80 mg/m(2), d(1), d(8), d(15)) combined with epirubicin (80 mg/m(2), d(1)). They all experienced grade 2 to 4 of neurotoxicities according to common toxicity criteria of National Cancer Institute after chemotherapy. The same chemotherapy regimens were combined with thymosin alpha1 (1.6 mg/d for 4 days before chemotherapy, and 1.6 mg twice weekly for 1-3 weeks after chemotherapy began) in the next cycle. Clinical neurologic evaluation was performed at baseline every week.

RESULTS

In 10 patients (45.4%), neurotoxicities reduced from grade 2-4 before chemotherapy to less than grade 2 after chemotherapy.

CONCLUSION

Thymosin alpha1 may prevent patients from chemotherapy-induced neurotoxicities.

Complex regional pain syndrome-like symptoms during herpes zoster

Complex Regional Pain Syndrome (CRPS) associated with herpes zoster (HZ) was first reported by Sudeck in 1901 (Sudeck, 1901) and is recognized clinically. However, only 13 cases have been published in the literature, and nothing is known about the incidence, prevalence, or natural history (Chester, 1992; Foster et al., 1989; Grosslight et al., 1986; Ketz and Schliack,1968; Kishimoto et al., 1995; Querol and Cisneros, 2001; Sudeck, 1901; Visitsunthorn and Prete, 1981). The aim of the present study was to determine the prevalence of CRPS-like symptoms in a prospectively gathered cohort of subjects with HZ and to follow the natural history of their pain and sensory disturbance during the first 6 months after onset of HZ. Subjects were evaluated at four time points after HZ: 2-6 weeks, 6-8 weeks, 3 months, and 6 months. Only subjects aged 50 or older with pain VAS ratings of >/=20/100 at 2-6 weeks were eligible. The first (screening) visit included a neurological and physical examination that was updated at each subsequent visit. Assessments included ratings of pain intensity, allodynia severity, and rash severity. The neurological exam included determination of presence or absence of the following CRPS-like symptoms: (1) increased sweating, (2) color changes, (3) skin temperature changes, (4) weakness of the affected area based on physical exam, (5) edema, and (6) extension of CRPS-like symptoms outside the affected dermatome. For subjects with HZ in dermatomes that can include the limbs (C4-T2 and L1-S2), extremity involvement was considered present if allodynia or rash extended beyond the neck of the humerus (upper extremity), the inguinal ligament (anterior lower extremity), or gluteal sulcus (posterior lower extremity). Involvement of the extremity was considered proximal if neither HZ rash nor allodynia extended past the elbow (upper extremity) or knee (lower extremity). Of the first 75 subjects recruited, 25 had HZ outbreaks in dermatomes that extended into the extremities (C4-T2 and L1-S2). In this group, 8 subjects had no extremity involvement, 8 had proximal extremity involvement, and 9 had distal extremity involvement. Subjects with distal extremity HZ reported more pain across the four visits (p < 0.05). At 3 months, more subjects with distal extremity involvement met criteria for PHN (8 out of 9, 89%), while only 4 out of 8 (50%) with proximal involvement and 2 out of 8 (25%) of subjects without extremity involvement met criteria for PHN (Chi-square test: p < 0.05). Only 25 out of the remaining 50 (50%) subjects with outbreaks in dermatomes that do not include the extremities met criteria for PHN at 3 months (Chi-square test: p < 0.05). Six months after onset of HZ, 6 out of 9 subjects with distal extremity involvement met PHN criteria compared with 2 out of 8 (25%) with proximal involvement and 2 out of 8 (25%) without extremity involvement (Chi-square test: p = 0.12). Fifteen out of 50 (30%) subjects with outbreaks in dermatomes that do not include the extremities met criteria for PHN (Chi-square test: p < 0.05). No subject had all six CRPS-like symptoms. Of the 17 subjects with extremity involvement, 9 subjects had '0-2 CRPS-like symptoms' and 8 had '3-5 CRPS-like symptoms'. None of the eight subjects without extremity involvement had any CRPS-like symptoms. Of the 50 subjects with HZ outside the extremity, only one had abdominal weakness. Pain ratings were higher in subjects with '3-5 CRPS-like symptoms'. More subjects with '3-5 CRPS-like symptoms' met criteria for PHN at 3 months (7 out of 8, 88%), compared to 5 out of 9 (55%) of subjects with '0-2 CRPS-like symptoms' (p = 0.07). At 6 months, 2 out of 9 (22%) of subjects with '0-2 CRPS-like symptoms' met criteria for PHN, compared with 6 out of 8 (75%) of subjects with '3-5 CRPS-like symptoms' (Chi-square test: p < 0.03). Two case-reports are presented. In summary, the occurrence of CRPS-like symptoms is common in subjects with HZ outbreaks affecting the extremity, particularly if the distal extremity is involved. It is uncertain if the pathophysiology underlying the CRPS-like symptoms observed in this study is similar to that of CRPS from other causes, or if it is relatively specific to HZ. Development of PHN is common in subjects who have experienced CRPS-like symptoms. More aggressive preventive treatments may be justified in this high-risk subset of HZ subjects to prevent development of PHN. Prospective randomized controlled studies are needed to determine which subjects are most likely to benefit and when treatment should begin.

Efficacy of serotonin receptor blocker for symptomatic lumbar disc herniation

Serotonin is one of the chemical mediators associated with nerve root inflammation and sciatic symptoms in lumbar disc herniation. The efficacy of serotonin 5-HT(2A) receptor blocker was examined in 44 patients with symptomatic lumbar disc herniation. A selective 5-HT(2A) receptor blocker (sarpogrelate hydroxychloride) was administered orally at a dose of 300 mg per day for 2 weeks. Visual analog scales of low back pain, sciatic pain, and numbness were significantly improved after the administration of the serotonin 5-HT(2A) receptor blocker. Clinical results were good (> 50% pain relief) in 23 patients, fair (25%-50% pain relief) in five patients, and poor (< 25% of pain relief) in 16 patients. Nineteen patients eventually required surgery because of muscle weakness or cauda equina symptoms. The effect of 5-HT(2A) blocker was good in 64% of patients who had uncontained disc herniation, whereas all patients with contained disc herniation had fair or poor results. Patients with uncontained disc herniation responded more favorably to the 5-HT(2A) blocker treatment than patients with contained disc herniation. A 5-HT(2A) blocker has the potential to block the cascade of acute nerve root inflammation and to alleviate symptoms in lumbar disc herniation.

Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus

PURPOSE

To determine the prognostic value of nasociliary skin lesions (Hutchinson's sign) for ocular inflammation and corneal sensory denervation in acute herpes zoster ophthalmicus.

METHODS

A longitudinal observational study with a 2-month follow-up was performed involving 83 non-immunocompromised adults with acute herpes zoster ophthalmicus, with a skin rash duration of less than 7 days, referred by their general practitioner. All skin lesions at the tip, the side and the root of the nose, representing the dermatomes of the external nasal and infratrochlear branches of the nasociliary nerve, were documented by taking photographs and marking anatomical drawings. Ocular inflammatory signs were observed by slit-lamp biomicroscopy, and corneal sensitivity was measured with the Cochet-Bonnet esthesiometer at 2-month follow-up.

RESULTS

Hutchinson's sign was a powerful predictor of ocular inflammation and corneal denervation in herpes zoster ophthalmicus [relative risks: 3.35 (CI 95%: 1.82-6.15) and 4.02 (CI 95%:1.55-10.42), respectively]. The manifestation of herpes zoster skin lesions at the dermatomes of both nasociliary branches was invariably associated with the development of ocular inflammation.

CONCLUSION

Clinicians should be alert for early skin lesions within the complete nasociliary dermatome, because they are a reliable prognostic sign of sight-threatening ocular complications in acute herpes zoster ophthalmicus.

Alternate numbness in the upper extremities as the initial symptom of basilar migraine: an electrophysiological evaluation using EEG power topography

A case of basilar migraine (BM) with alternate numbness as the initial symptom is described. The patient's chief complaint was alternate numbness in the right and left upper extremities. After angiography the patient fell into a drowsy state, followed by excitation, and finally confusion. The EEG power topography showed slow alpha, theta and delta power in the right occipital area, and alternatively in the right and left parietal area. These findings suggest that the cause of BM is not only based on a vasoconstriction mechanism, but also cortical spreading depression. BM should be suspected as a cause of sensory symptoms.

Treatment of chronic allodynia in spinally injured rats: effects of intrathecal selective opioid receptor agonists

We examined the effects of intrathecal (i.t.) selective opioid receptor agonists in alleviating mechanical and cold allodynia in spinally injured rats. Both DAMGO ([D-Ala2,N-Me-Phe4,Gly5-ol]-enkephalin, a mu-opioid receptor agonist) and DPDPE ([D-Phe2,D-Phe5]-enkephalin, a delta-opioid receptor agonist) dose-dependently relieved the chronic allodynia-like behavior at doses selective for their respective receptors. The anti-allodynic effect of DAMGO and DPDPE was reversed by the selective mu- and delta-opioid receptor antagonists CTOP (D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr-NH2) and naltrindole, respectively. In contrast, the selective kappa-opioid receptor agonist U50488H did not alleviate the allodynia-like behavior, but rather enhanced it. The anti-nociceptive and anti-allodynic effect of i.t. DAMGO was blocked by U50488H. Thus, activation of spinal mu- and delta-, but not kappa-opioid receptors produced anti-allodynic effect in this model of central pain. Drugs which act selectively on opioid receptor subtypes may be useful in managing chronic central pain of spinal cord origin.

Towards restoring sensibility in anaesthetic extremities of leprosy patients

In leprosy patients, the problems arising due to anaesthesia in the extremities have been outlined. The available modalities, some of them still experimental, for overcoming the handicap have been discussed.

Treatment of erythropoietic protoporphyria with hydroxyethylrutosides

BACKGROUND

Assuming that flavonoids have anti-oxidative properties and may protect against abnormal skin reactions in erythropoietic protoporphyria (EPP), we investigated whether systemic treatment with hydroxyethylrutosides (2.7 g/day) could decrease skin sensitivity to blue light in a 37-year-old female patient who suffered from EPP.

DESIGN AND RESULTS

Before treatment, skin exposure during 5 min to a xenon high-pressure gas discharge lamp with filter was sufficient to produce intense erythema, irritation and later swelling. After 1, 2 and 3 months of treatment, the exposure times, necessary to produce similar effects, gradually increased. This improvement coincided with an increased tolerability to sunlight. No adverse effects were observed.

CONCLUSION

These results encourage the set-up of a more systematic, placebo-controlled study of the protective effects of hydroxyethylrutosides in EPP.

Pure sensory seizures

A 62-year-old woman, who frequently had numbness seizures in the right half of her body, is reported. Weakness and consciousness disturbance did not occur during the seizure, and an abnormal electroencephalogram was not observed during the seizure or between seizures. The seizure was completely inhibited by a single-blind administration of phenytoin. It also disappeared on administration of carbamazepine, suggesting that the numbness seizures in this patient were of an epileptic nature.

[Use of dexamethasone in the treatment of spinal cord injuries in the early post-traumatic period]

The clinical usefulness of dexamethasone administered early after injury to the spinal cord is assessed comparing the results of treatment in 269 cases receiving dexamethasone and in 256 controls not receiving corticosteroids. In cases of complete as well as incomplete severing of the cord treated with dexamethasone, the results were better, both qualitatively and quantitatively. However, some increase was noted in the incidence of complications, such as gastrointestinal bleeding and delayed wound healing. Good results demonstrated in this analysis suggest the necessity of widespread administration of corticosteroids within the first hours after cord injury.

Methods for producing a reproducible crush in the sciatic and tibial nerve of the rat and rapid and precise testing of return of sensory function. Beneficial effects of melanocortins

A procedure for placing a crush lesion in the sciatic and tibial nerve of the rat based on anatomical landmarks is described. These crush lesions are used to study the process of regeneration of peripheral nervous tissue and the beneficial effects of melanocortins on speed and quality of nerve regeneration. A new precise and rapid method for testing the return of sensory function by a locally applied electric stimulus is discussed.

Intradiscal collagenase for treatment of lumbar disc herniations. A comparison of clinical results and computed tomography follow-up

In a series of 34 patients with herniated lumbar discs, treated by intradiscal injection of highly purified collagenase, the post-treatment course has been followed-up clinically and by repeated computed tomographies (CT). Good or excellent results have been achieved in 17 patients. An only slight improvement of pain was noted in 2 patients. Fifteen patients had to be operated on due to not improved or worsened clinical symptoms. The most striking result of our CT follow-up was a tendency of the disc herniation to increase initially after collagenase injection. About two thirds of the patients had such an increase at the one week after injection control. After 6 weeks this rate had decreased to only about one quarter, but in the meantime 13 patients had to be operated. Only after 6 months most hernias of the up till then not operated patients were smaller and none were larger than before treatment. There was also a transient density decrease of the treated disc, most pronounced one week after collagenase injection. At controls 6 months later density had reached again pre-treatment levels. It is likely that the volume increase tendency of the disc material after collagenase injection is responsible for a worsening of the clinical symptoms, which not seldomly occurs during the initial post-treatment period, and in some patients makes an operation necessary.

Treatment with acetazolamide of brain-stem and spinal paroxysmal disturbances in multiple sclerosis

Nine cases of multiple sclerosis with paroxysmal disorders were treated with acetazolamide. In most cases a brain-stem origin of the seizures was suggested by their particular pattern: crossed syndromes (facial spasm associated with contralateral weakness of the arm and leg, paroxysmal paraesthesiae in one side of the face and weakness of the contralateral leg), paroxysmal dysarthria, and ataxia. One patient with a Brown-Sequard syndrome complained of paroxysmal paraesthesiae in the lower limbs, for which a spinal origin was admitted. In all patients the paroxysmal disorders were promptly suppressed or markedly reduced by acetazolamide.