Combined Central and Peripheral Demyelination in a Case With Sjogren Syndrome

INTRODUCTION

Combined central and peripheral demyelination (CCPD) is a rare entity in which central and peripheral nervous system demyelination coexist. Herein, we present a patient with coexistence of Sjögren syndrome (SS) and CCPD.

CASE REPORT

A 58-year-old female patient was admitted to our neurology clinic with paraparesis, difficulty walking, imbalance, and paresthesia. Neurological examination showed paraparesis, absence of lower extremity deep tendon reflex, sensory deficit at the T8 level, loss of deep sensory position, and vibration. Spinal magnetic resonance imaging revealed multiple focal T2-hyperintense and contrast-enhancing cord lesions. Fat-suppressed imaging disclosed T2 hyperintensity in lumbar nerve roots, diffuse linear enhancement of the cauda equina, and diffuse increased enhancement in lumbar nerve roots. Electrodiagnostic findings fulfilled the diagnostic criteria for chronic inflammatory demyelinating polyneuropathy. Extensive laboratory workup excluded all possible pathologies. The Schirmer test detected positive in both eyes and minor salivary gland biopsy resulted in grade 3. These results were consistent with SS. The patient received intravenous methylprednisolone, azathioprine hydroxychloroquine. Approximately 2 years later, her complaints had completely disappeared, except for mild sensory complaints.

CONCLUSION

It is unclear whether the association of central nervous system and peripheral nervous system demyelination and SS is a coincidence or a consequence. Our patient shows that patients with SS can have CCPD, and a significant clinical response can be obtained with early treatment. We hope that this unique case sheds light on the pathophysiology of CCPD.

Brachial Diparesis due to Motor Neuronopathy as One of the Predominant Presenting Signs of Occult Small Cell Lung Carcinoma

Sensory neuronopathy is a well-established presentation in paraneoplastic neurological syndromes that is mostly associated with small cell lung cancer and anti-Hu antibodies. Motor neuronopathy, on the other hand, is an extremely rare observation in this syndrome. A 56-year-old man presented with asymmetric brachial diparesis and sensory ataxia. Electrophysiological studies revealed sensory ganglionopathy and progressive anterior horn degeneration in cervical segments. Small cell lung carcinoma with associated anti-Hu antibodies was later diagnosed. The patient did not improve despite the administration of steroids and chemotherapy. Paraneoplastic syndromes may exceptionally present with a bilateral arm weakness. Cases accompanied by sensory ganglionopathy should therefore be promptly investigated for any underlying malignancy.

Atypical Aicardi-Goutieres syndrome: is the WRN locus a modifier?

We describe a 28-year-old Turkish man with consanguineous parents who presented with an aged appearance with prematurely gray hair and scleroderma-like skin, spastic paraplegia, and apparent disability. The proband and each of his parents were heterozygous for a mutation in WRN, which could not explain his symptoms. Exome sequencing of the proband's blood DNA showed a homozygous c.626-1G > C mutation in intron 5 of the SAMHD1 gene, which encodes a triphosphohydrolase involved in the regulation of intracellular dNTP pools and which is mutated in Aicardi-Goutieres syndrome. The RNA studies confirmed aberrant splicing of exon 6, and family studies showed that both parents are heterozygous for this mutation. We conclude that mutations in SAMHD1 - in addition to causing an early-onset form of encephalopathy in Aicardi-Goutieres syndrome - may present with modest signs of accelerated aging similar to Werner syndrome. The extent to which heterozygosity at the WRN locus may modify the effect of biallelic SAMHD1 mutations is unknown. It is conceivable that synergistic effects of these two mutations might be responsible for the unusual phenotype.

Effects of exercise and electrical stimulation on lumbar stabilization in asymptomatic subjects: a comparative study

BACKGROUND AND OBJECTIVES

Segmental stabilization training and electrical stimulation are used as a treatment for patients with low back pain. There is limited information on the efficacy of two interventions in the literature. In this study, the efficacy of the two interventions on the multifidus muscle activation and fatigue, segmental stabilization training and electrical stimulation, were examined and compared.

MATERIAL AND METHODS

Our sample consists of 30 asymptomatic individuals, randomly assigned to one of three groups: the group that was given segmental stabilization training, the group that was given electrical stimulation and the control group that received no treatment. The muscle activity and fatigability of the multifidus were recorded by the surface electromyography before and after the intervention.

RESULTS

No difference is detected for any of the multifidus muscle activation and fatigue characteristics either within or between groups.

CONCLUSION

Both techniques did not improve multifidus activation capacity. An effort at submaximal and maximal level affects and increases the activity of multifidus.

Measurement of motor root conduction time at the early stage of Guillain-Barre syndrome

BACKGROUND AND PURPOSE

As they are mainly performed at distal nerve parts, routine electrophysiological examinations can fail to detect the abnormalities at the early stage of Guillain-Barre syndrome (GBS) because of predominant involvement of proximal nerve segments. Measurements focused on proximal conduction can provide additional findings. We investigated the diagnostic significance of motor root conduction time (MRCT) at the early stage of GBS.

METHODS

Study was performed in 30 healthy volunteers and within the first week of 12 patients with GBS. MRCT was calculated as the latency differences between motor nerve conduction time (MNCT) obtained by cervical magnetic stimulation and total peripheral motor conduction time obtained by electrical stimulation of ulnar nerve. Also MNCT/MRCT ratio was calculated in each subject.

RESULTS

  There were statistically significant differences between groups for MRCT (P < 0.0001) and MNCT/MRCT ratio (P < 0.0001). Although the F-wave latency at ulnar nerve was abnormal only in 33%, MRCT was significantly prolonged in 83% of patients. In three patients, prolongation of MRCT was the only abnormality at the first electrodiagnostic examination.

CONCLUSIONS

Motor root conduction time as a non-invasive method can provide additional and confirmative information at the early stage of GBS in which routine nerve conduction studies may fail to detect the focal demyelination.

Assessment of the short-term effect of antispastic positioning on spasticity

BACKGROUND

This study was performed in order to investigate the effect of antispastic positioning on spasticity by using different assessment methods.

METHODS

A total of 16 patients (11 males [68.75%] and five females [31.25%]), diagnosed as spastic diplegic and referred to the School of Physical Therapy and Rehabilitation, Paediatric Rehabilitation Unit for treatment, were included in this study. The mean age of patients was 6.43 +/- 1.99 years (range, 4-13 years). Passive dorsi-flexion movement was measured by using goniometer and intensity of spasticity was determined by using Modified Ashworth Scale (MAS) and electromyography. For the objective measurement of severity of spasticity, Hoffman reflex (H) and Hoffman reflex/motor response (H/M) ratios were used. Children were placed in an antispastic position for 20 min. The patient was placed in a sitting position, by a physiotherapist, with hips abducted at a 45 degrees angle and externally rotated, knees extended, and ankles placed in a neutral position.

RESULTS

The decrease in H responses, H/M ratios, MAS values and the increase in goniometric measurement values were found statistically significant after antispastic positioning (P < 0.05).

CONCLUSION

Our study supports that antispastic positioning can be used with neurodevelopmental treatment approaches when it is required. Antispastic positioning may help exercises to be performed more easily, and also has importance in a home exercise program to prevent muscle contractures and joint limitation in children with long-term spastic diplegia.

Erythropoietin against cisplatin-induced peripheral neurotoxicity in rats

Cisplatin (CDDP) is a potent anticancer drug, and neurotoxicity is one of its most important dose-limiting toxicities. In this study we investigated the role of recombinant human erythropoietin (rhuEPO) for protection against CDDP-induced neurotoxicity. All experiments were conducted on female Wistar-albino rats. Animals were randomly assigned to three groups. Group A received only CDDP, group B received CDDP plus rhuEPO, and group C received only rhuEPO. Electroneurography (ENG) was done in the beginning and at the end of 7 wk, then the rats were sacrificed and the sciatic nerve was removed for histopathological examination. The mean initial latency was 2.7438 ms in group A, 2.4875 ms in group B, and 2.62 ms in group C. After 7 wk of treatment, the latency was 2.4938, 2.6313, and 2.3900 ms, respectively. The difference in latencies was not statistically significant. The amplitude of compound muscle action potential (CMAP) was 12.8125 mV, 14.3875 mV, and 14.5600 mV before the treatment and 8.4875, 12.8250, and, 13.0800 mV after treatment, respectively. Amplitude of CMAP was significantly greater in rhuEPO-treated groups (groups B and C) compared to cisplatin only Group A. The mean area of CMAP was 12.2625, 12.3500, and, 12.2800 mV s before the treatment and 5.7125, 10.6463, and 9.1600 mV s after the treatment, respectively. The area of CMAP was significantly larger in rhuEPO-treated groups. In histopathological studies thick, thin, and total number of nerve fibers were 4053, 5050, and 9103, in group A, 5100, 8231, and 13331, in group B, and 5264, 6010, and 11274, in group C respectively. In the microscopic examination active myelinization process was observed in rhuEPO-treated groups. We concluded that at the given dose and schedule CDDP-induced motor neuropathy and rhuEPO prevented this neuropathy by sparing the number of normal nerve fibers and by protecting the amplitude and area of CMAP. We concluded that rhuEPO may also play a role in active myelinization and it is an active agent in protection against CDDP-induced peripheral neuropathy, warranting further clinical studies.

Impact of Epineurial Excision of the Distal Recipient Nerve in Terminolateral Neurorrhaphy

Different surgical modifications were studied to improve success in terminolateral neurorrhaphy. The authors evaluated the efficacy of distal epineurial excision of the recipient nerve stump. Forty male Wistar rats were evaluated in four groups. The right hind limbs of the animals were used as experimental limbs and the left hind limbs as control limbs. The peroneal nerve was transected at a level 1 cm above the bifurcation of the tibial nerve. The proximal stump of the peroneal nerve was covered with gluteus maximus muscle fibers in all groups. In Group 1, the distal peroneal nerve was not processed and was left in the operative field. In Group 2, the distal peroneal nerve stump was sutured to an epineurial window on the tibial nerve by epineurial neurorrhaphy. In Group 3, the distal stump of the peroneal nerve was buried in the tibial nerve without epineurial resection, and in Group 4 with a 1-mm epineurial excision. Walking track analyses, electromyographic studies, and histomorphometric analyses were performed after a 3-month follow-up period. Statistical analysis was done with ANOVA and Tukey tests. No important donor-nerve injury was detected. Axonal regeneration and functional results were better in Group 4 compared to Groups 2 and 3. An increased donor and recipient nerve contact surface area with the excision of the epineurium from the distal peroneal nerve stump (Group 4) might provide superior results with longer follow-up periods.

Paroxysmal autonomic alterations mimicking epilepsy: a case report

A 22-year-old male patient presented with paroxysmal hyperhidrosis, mydriasis, hypertension, and tachycardia. Cranial and cervical MRI revealed focal atrophy in the high order zone of the central autonomic network and syringomyelia. His physical and neurological examinations were unremarkable. Physiological testing included EEG, SPECT, serum/urine tests and autonomic testing. A poor response was achieved with the medical and interventional procedures employed. As the central autonomic network is an integral component of the internal regulation system of the brain, any lesion, no matter where in the network, may lead to paroxysmal autonomic alterations mimicking epilepsy (Published with videosequences).

Protective effect of amifostine against cisplatin-induced motor neuropathy in rat

Cisplatin (CDDP) is a potent anticancer drug. Neurotoxicity is one of the most important dose-limiting toxicity of CDDP. We investigated the role of amifostine in the protection against CDDP-induced neurotoxicity especially on the motor nerves. All experiments were conducted on female Wistar albino rats. Animals were randomly assigned to two groups, each including six rats. Group A received CDDP plus amifostine and Group B received CDDP only. Electroneurography (ENG) was carried out in the beginning and at the end of 7 wk; then, the rats were sacrificed and the sciatic nerve was removed for histopathological examination. The mean initial latency was 2.4667 msn for group A and 2.44833 msn for group B. After 7 wk of treatment, the latency was 2.9167 for group A and 2.6333 for group B. The difference in latencies was not statistically significant. The amplitude was 11.7853 mV and 13.533 mV for groups A and B, respectively. After 7 wk of treatment, the amplitude was 9.400 mV and 9.000 mV, respectively. The decrease of amplitude in compound muscle action potential (CMAP) was 20% in the amifostine group and the decrease was 33% in the untreated group. The mean area of the CMAP in group A was 9.400 mVsn initially and 9.666 mVsn at the end of the treatment; there was a 0.3% increase despite CDDP treatment. In group B, the mean area of the CMAP was 13.816 mVsn initially and 11.857 mVsn at the end of the treatment; this corresponded to a statistically significant 14% decrease as a result of CDDP treatment. The ENG and histopathological studies showed that at the given dose and schedule CDDP-induced motor neuropathy and amifostine reduced this neuropathy both by protection of the amplitude and area of the CMAP in ENG studies and by sparing a larger number of nerve fibers.

Involvement of the central nervous system in Miller Fisher syndrome: a case report

Miller Fisher syndrome (MFS) is characterised by ophthalmoplegia, ataxia and areflexia. Reports on cerebellar ataxia and supranuclear oculomotor derangement in MFS suggested an additional involvement of the central nervous system (CNS), resembling Bickerstaff's brainstem encephalitis (BBE). In the present report, a patient with a monophasic acute illness, early recovery and specific clinical-laboratory findings suggested both intrinsic brainstem and peripheral nerve disease (MFS and BBE). In pons and medulla oblangata, blurred to discrete T2-lesions were revealed by cranial MRI, while involvement of peripheral nerves was detected with EMG. The CSF showed no increase in protein or cell content, such as occurs in brainstem encephalitis.

Evoked potentials in children with Wilson's disease

We assessed multimodal evoked potentials (EPs) in 13 children with newly diagnosed neurologically symptomatic Wilson's disease (WD) and in their first degree symptom-free relatives, consisting of seven presymptomatic and 15 asymptomatic siblings and 22 asymptomatic parents. EP abnormalities of at least one modality and one side stimulation were observed in 38.5% of patients, 42.9% of presymptomatic siblings, 21.4% of asymptomatic siblings and 18.2% of parents. Patients tended to have more prolonged central latencies of EPs. However, the left I-V interpeak brainstem auditory EP latency difference was the only one to reach at the statistical significance (P = 0.001). Abnormal VEP P100 latency was detected more frequently in presymptomatic siblings than those in asymptomatic ones (42.9% vs 7.1%, P = 0.049). In all relatives, other diagnostic tests including electroencephalography, electromyography and head magnetic resonance imaging (MRI) for subclinical nervous system involvement and Kayser-Fleischer rings examination yielded normal results. In pre/asymptomatic siblings, genetic and biochemical studies may aid to initiate treatment prior to the development of permanent tissue damage. Our results indicate that abnormal EPs may signal unique pathological finding in some subjects. Importantly, these abnormalities occur earlier than Kayser-Fleischer rings and MRI lesions. In early stages of WD, EP recordings may, therefore, be used to help decide on treatment initiation and treatment efficacy evaluation. Moreover, EP recordings can readily be added to family screening studies.

Physiotherapy approaches in the treatment of ataxic multiple sclerosis: a pilot study

OBJECTIVE

This study was planned to investigate the efficacy of neuromuscular rehabilitation and Johnstone Pressure Splints in the patients who had ataxic multiple sclerosis.

METHODS

Twenty-six outpatients with multiple sclerosis were the subjects of the study. The control group (n = 13) was given neuromuscular rehabilitation, whereas the study group (n = 13) was treated with Johnstone Pressure Splints in addition.

RESULTS

In pre- and posttreatment data, significant differences were found in sensation, anterior balance, gait parameters, and Expanded Disability Status Scale (p < 0.05). An important difference was observed in walking-on-two-lines data within the groups (p < 0.05). There also was a statistically significant difference in pendular movements and dysdiadakokinesia (p < 0.05). When the posttreatment values were compared, there was no significant difference between sensation, anterior balance, gait parameters, equilibrium and nonequilibrium coordination tests, Expanded Disability Status Scale, cortical onset latency, and central conduction time of somatosensory evoked potentials and motor evoked potentials (p > 0.05). Comparison of values revealed an important difference in cortical onset-P37 peak amplitude of somatosensory evoked potentials (right limbs) in favor of the study group (p < 0.05).

CONCLUSIONS

According to our study, it was determined that physiotherapy approaches were effective to decrease the ataxia. We conclude that the combination of suitable physiotherapy techniques is effective multiple sclerosis rehabilitation.

A new model for tethered cord syndrome: a biochemical, electrophysiological, and electron microscopic study

In order to investigate the pathophysiology of the tethered cord syndrome, a few experimental models have been developed and used previously. In this study, the authors present a new experimental model to investigate the biochemical, electrophysiological, and histopathological changes in the tethered spinal cord syndrome. A model was produced in guinea pigs using an application of cyanoacrylate to fixate the filum terminale and the surrounding tissue to the dorsal aspect of the sacrum following 5-gram stretching of the spinal cord. The experiments were performed on 40 animals divided into two groups. The responses to tethering were evaluated with hypoxanthine and lipid peroxidation, somatosensory and motor evoked potentials, and transmission electron microscope examination. The hypoxanthine and lipid peroxidation levels significantly increased, indicating an ischemic injury (p < 0.01). The average hypoxanthine level in the control group was 478.8 +/- 68.8 nmol/g wet tissue, while it was 651.2 +/- 71.5 nmol/g in the tethered cord group. The lipid peroxidation level in group I was 64.0 +/- 5.7 nmol/g wet tissue, whereas it was 84.0 +/- 4.7 nmol/g in group II. In the tethered cord group, the latencies of the somatosensory and motor evoked potentials significantly increased, and the amplitudes decreased. These changes indicated a defective conduction in the motor and sensorial nerve fibers. In the transmission electron microscopic examinations, besides the reversible changes like edema and destruction in the gray-white matter junction, irreversible changes like scarcity of neurofilaments and destruction in axons and damage in myelin sheaths were observed. We consider that this work can be used as an experimental model for tethered cord syndrome.

PCR detected hepatitis C virus genome in the brain of a case with progressive encephalomyelitis with rigidity

A case of progressive encephalomyelitis with rigidity (PEWR) associated with hepatitis C virus (HCV) is reported. A 58 year-old woman presented with a clinical picture of progressive quadriparesis, sensory loss, sphincter dysfunction, painful muscle spasms in the upper and lower limbs and continuous muscle unit activity in electromyography. She developed hepatitis, pancreatitis and HCV-RNA was detected in the plasma by reverse transcription-polymerase chain reaction (RT-PCR). Postmortem histopathological examination showed encephalomyelitis with perivascular lymphocyte cuffing, infiltration and neuronal loss mainly affecting the brainstem and cervical spinal cord. The RT-PCR analysis of the postmortem brain, brainstem, liver, pancreas, plasma and CSF samples revealed the presence of HCV genome in all specimens except CSF. Clinical features, postmortem histopathology and PCR results and the possible etiopathogenesis of PEWR are briefly discussed.

Efficacy of high dose amino acid solution on spinal cord injury induced by focal Nd:YAG laser irradiation

In this experimental study, a neodymium:yttrium-aluminium-garnet (Nd:YAG) laser was used to induce highly reproducible focal spinal cord lesions in anaesthetized guinea pigs. The efficacy of high dose amino acid solution (HDAAS) on this injury is investigated. Experiments were performed on 36 animals divided into three groups; sham operated controls, laser irradiated surgical controls, and amino acid groups. Acute responses to injury were evaluated with somatosensory (SSEP) and motor evoked potentials (MEP) and functional recovery was assessed for 8 weeks using the inclined plane technique. In the laser irradiated surgical control group, MEP disappeared one hour after the laser injury, but SSEP revealed changes of amplitude and latency. In this group, the average value of the inclined plane at 24 hours after the laser application was 45.3 +/- 1.4 degrees. In the amino acid group, at the sixth hour of injury, MEP and SSEP changes improved with infusion of HDAAS for 4 hours. This improvement was statistically significant (for latency of SSEP U = 140 p < 0.05). Inclined plane value at 24 hours after the laser application was 65.5 +/- 1.2 degrees in this group. This study showed that application of Nd:YAG laser irradiation on the spinal cord induced spinal cord injury which presented as paraparesis, HDAAS may provide significant therapeutic protection in secondary damage following this injury and may have a potential role in the treatment of acute spinal cord injury.

Brainstem auditory evoked potentials and blink reflexes in patients with pontocerebellar angle tumors

Brainstem auditory evoked potentials (BAEP) and blink reflexes (BR) were obtained from 13 patients with pontocerebellar angle (PCA) tumors whose pathological diagnosis was as follows: 7 acoustic neurinoma, 3 meningioma, 1 neurinoma, 1 brain stem epidermoid tumor, 1 arteriovenous malformation. The most prominent abnormality was noted in BAEP generated by stimulating the ear ipsilateral to the lesion and ipsilateral R1 reflexes obtained from ipsilateral stimulation of the supraorbital nerve.

A new experimental model: for further investigation of the secondary changes following spinal cord injury

To investigate the pathophysiology of spinal trauma, several experimental models have been used. In this study, the authors present a new experimental model for further investigation of secondary damage following spinal injury. Nd:YAG laser irradiation was applied to the spinal cord of guinea pigs to produce an injury. A 30 Watt (20 Joule) laser produced paraparesis. The injury was evaluated with evoked potentials, lipid peroxidation values, and histopathological examination.

Late visual recovery after intravenous methylprednisolone treatment of Purtscher's retinopathy

A 25-year-old man involved in a minor traffic accident subsequently had a Purtscher's-type retinopathy and lost visual acuity (20/800). After treatment with intravenous methylprednisolone at a dose of 1 g/day, his visual acuity improved to 20/70 three days later and to 20/50 one week later. The exudates and hemorrhages gradually disappeared. However, a localized central scotoma and afferent pupillary defect still persisted. We review previous reports on the retinal pathophysiology of Purtscher retinopathy and discuss the potential benefit of treatment with high-dose intravenous corticosteroids.

Evoked potentials in Guillain-Barré syndrome

A prospective evaluation was made in a total of 19 patients with Guillain-Barré syndrome (GBS) by neurologic examination, visual evoked potentials (VEP), brain-stem auditory evoked potentials (BAEP) and somatosensory evoked potentials (SEP) during the acute phase of the disease, three weeks later, and then again three months after the onset of symptoms. The results of electrophysiologic studies of the patients were compared with those of 19 healthy children. There were no statistically significant differences found in the mean VEP and BAEP values between the patient and control groups. However, the VEP and BAEP values were abnormal during the first and second stages of the disease in only a few patients. There was a statistically significant prolongation of the response in tibial and median SEP during the first and second stages of the disease when compared with the third stage and the control group. The Erb-Cervical 7 (C7) interwave latency was elevated in the median SEP. It was concluded that the prolongation of the response in SEP was diagnostically important in the acute phase of GBS. There was no correlation found between SEP and clinical progression.

Neurophysiological studies of patients with classical phenylketonuria: evaluation of results of IQ scores, EEG and evoked potentials

Neurophysiological studies were conducted in 42 patients with classical phenylketonuria. The results of the intelligence quotient scores, electroencephalogram, visual evoked potentials and brain-stem auditory evoked potentials were evaluated. When compared with the controls, the subjects demonstrated a significant prolongation in VEP P1 and BAEP I-V interpeak latencies and an increase in VEP N1P1 amplitudes. No relationship was found between these pathological responses and metabolic control. However, the observation of normal intelligence quotient scores in 14 out of 18 patients who displayed a pathological prolongation in P1 latencies led us to the conclusion that evoked potentials may have a significant role in the determination of neurophysiological defects and that even cases with good metabolic control may have some obscure neurophysiological dysfunction which should be evaluated more carefully.

Occidental type cerebromuscular dystrophy: a report of eleven cases

Occidental type cerebromuscular dystrophy (OCMD) forms a substantial distinct group within congenital muscular dystrophy (CMD). These patients invariably present with amyotrophy, multiple joint contractures, facial muscle involvement, normal or nearly normal intelligence, leukodystrophic appearance on CT scan, and dystrophic changes in muscle.

Fukuyama type congenital muscular dystrophy in a Turkish child

Congenital muscular dystrophy (CMD) is a heterogeneous group of disorders which is associated with more or less degrees of cerebral involvement. There are four separate entities within CMD nosology. Among these Fukuyama's CMD (FCMD) is highly prevalent in Japan, whereas the classic form with normal or subnormal intelligence, also known as the occidental type, covers the vast majority of cases in the West. We report a case of FCMD seen in a Turkish child.