Bilateral diaphragmatic paralysis and Lyme neuroborreliosis. Ten-years of follow-up / Parálisis diafragmática bilateral y neuroborreliosis de Lyme. Diez años de seguimiento

Abstract Borrelia burgdorferi infection (Lyme disease) is one of the few identifiable causes of neuralgic amyotrophy (AN). Bilateral diaphragmatic paralysis is considered rare in borreliosis, and the pattern of long-term recovery of diaphragm function is also uncertain. Transdiaphragmatic pressure is the gold standard for diagnosing bilateral diaphragmatic paralysis, a study that has been reported on a few occasions. We pres ent a case of AN associated with borrelia infection and bilateral diaphragmatic paralysis that provides a detailed follow-up of the spirometric evolution, the maximum static pressures in the mouth, and the transdiaphragmatic pressure from the onset of symptoms and in the long term. This case allows us to know one of the possible evolutionary profiles of diaphragmatic dysfunction in AN due to borreliosis.

Resumen La infección por Borrelia burgdorferi (enfermedad de Lyme) es una de las pocas causas identificables de amiotrofia neurálgica. La parálisis diafragmática bilateral es considerada rara en la borreliosis y el patrón de recuperación a largo plazo de la función del diafragma también es incierto. La presión transdiafragmática es el patrón de oro para el diagnóstico de parálisis diafragmática bilateral, un estudio que ha sido informado en pocas ocasiones. Se presenta un caso de amiotrofia neurálgica asociado a infección por Borrelia y parálisis diafrag mática bilateral, que aporta un seguimiento detallado de la evolución espirométrica, de las presiones estáticas máximas en la boca y de la presión transdiafragmática desde el inicio de los síntomas y a largo plazo. Este caso permite conocer uno de los posibles perfiles evolutivos de la disfunción diafragmática en la amiotrofia neurálgica por borreliosis.

Síndrome de Parsonage Turner: um relato de caso / Parsonage-Turner Syndrome: a case report

A Síndrome de Parsonage-Turner (SPT) é uma doença rara que acomete a musculatura da cintura escapular, acarretando hipotrofia muscular e grande limitação funcional. A etiologia ainda é indeterminada; acredita-se que existam fatores autoimunes e infecciosos envolvidos. No presente caso foi aventada possível relação com a vacina da influenza. Os sintomas da SPT incluem dor abrupta de um lado da cintura escapular, sendo característico o despertar noturno. É uma condição de difícil diagnóstico, podendo ser confundida inicialmente com espondilose cervical, capsulite adesiva, radiculopatia cervical e bursite. Na investigação diagnóstica, foram realizados exames laboratoriais e ressonâncias magnéticas e eletroneuromiografia que auxiliou na definição diagnóstica. O tratamento envolve a abordagem da dor neuropática e reabilitação visando a recuperacao da força e da função muscular. O objetivo dessa descrição é revisar o assunto através de um relato de caso típico mas que, no entanto, não foi inicialmente considerado, servindo de alerta para que diante de quadros de dor aguda em membros superiors seja ponderado o diagnóstico de Parsonage Turner. Dessa forma o assunto se torna mais habitual no ofício médico, facilitando o diagnóstico precoce e oferecendo o prognóstico ao paciente, evitando exames e medicações desnecessárias.

Parsonage-Turner Syndrome (SPT) is a rare disease that affects the musculature of the shoulder girdle, resulting in muscle hypotrophy and functional limitation. The etiology is still undertermined: It is believed that exist autoimune disorders and infections involved. In this case a possible relationship with the influenza vacinne was suggest. The symptoms of SPT include acute onset pain in one side of the shoulder girdle and frequently awakens pacients from sleep, fact that occurred in this report. This disease has difficult diagnostic and can be confused initially with cervical spondylosis, adhesive capsulitis, cervical radiculopathy and bursitis. In the diagnostic investigation, laboratory exams, magnetic resonances and electroneuromyography were performed, of the latter deserves mention for assisting in the definitive diagnosis and determining the extent of the lesion. There is still no protocol for specific treatment, but it should be focused on reducing neuropathic pain and recovering muscle strength and function. The purpose of this description is to review the subject through a typical case report, which, however, was not initially considered, serving as a warning so that in the face of acute pain in upper limbs, the diagnosis of Parsonage Turner should be considered. Thus, the subject becomes more usual in the medical craft making the clinical evaluation more careful so that the diagnosis is early and offers a better prognosis to the patient, avoiding unnecessary exams and medications.

Daño neurológico perioperatorio. Identificación de factores de riesgo, prevención y estudios relacionados / Perioperative nerve injury. Risk factor identification, prevention and work-up

BACKGROUND: Regional anesthesia techniques can have adverse effects, like peripheral nerve injuries. This can affect the practitioner on the choice of techniques when offering multimodal analgesia. CASE REPORT: We present the case of an arthroscopic rotator cuff repair on a patient with no comorbidities who presented peripheral nerve injury during post-op. Initially thought to have occurred as a consequence of the anesthetic technique, further study of the patient revealed the injuries to have been produced by the arthroscopic surgery. CONCLUSION: There are multiple factors that influence the possibility of peripheral nerve injury associated with nerve blocks. They can be grouped as related to the patient, the anesthetic technique or the surgical technique, the latter being the most relevant. If a patient manifests signs of peripheral nerve injury high-resolution magnetic resonance of the neural tissue must be performed immediately. Sensory nerve conduction study and electromyography must be performed 4 weeks after by an expert neurologist.

INTRODUCCIÓN: La anestesia regional puede producir como efecto adverso lesiones de nervios periféricos, lo que puede hacer desistir al anestesiólogo de realizar técnicas que mejoran la analgesia multimodal. CASO CLÍNICO: Se presenta el caso de un paciente sin comorbilidades que se operó de reparación artroscópica del manguito rotador y presentó daño neurológico postoperatorio. Inicialmente se sospechó que el daño había sido producido durante la técnica anestésica, sin embargo, el estudio adecuado demostró que el daño se relacionaba con la técnica quirúrgica. CONCLUSIÓN: Existen factores que influyen en la posibilidad de daño neurológico asociado a bloqueos de nervios periféricos que pueden ser propios del paciente, de la técnica anestésica o quirúrgicos, siendo estos últimos los más relevantes. En un paciente con clínica compatible debe realizarse resonancia magnética del tejido neural de alta resolución de forma inmediata; estudio de conducción neural sensitiva y electromiografía a las 4 semanas de evolución por un neurólogo experto.

Síndrome de Parsonage-Turner en paciente sometido a cirugía de revascularización miocárdica. caso clínico / Parsonage-Turner syndrome: report of one case

We report a 59-year-old male who, three weeks after a coronary revascularization surgery, reported a sudden intense burning pain in his left upper limb. Two weeks later, he reports a paresis with difficulty to extend his left wrist and fingers. The electromyography showed a severe axonal damage of the radial nerve with distal denervation signs. This clinical picture probably corresponds to a neuralgic amyotrophy, an inflammatory disorder of the brachial plexus known by a number of terms, including Parsonage-Turner syndrome.

Neuralgic Amyotrophy Associated with Cytomegalovirus Infection: A Case Report

Neuralgic amyotrophy (NA) is a peripheral neuropathy, primarily involving the brachial plexus. There is a relation between antecedent infection and NA. A few cases of NA after infections such as Epstein-Barr virus, herpes zoster virus, parvovirus, human immunodeficiency virus, Borrelia, and other infections have been reported. This case report describes a 26-year-old man with motor impairment after neuropathic pain with preceding mild flu-like symptoms whose laboratory studies revealed evidence of cytomegalovirus (CMV) infection. He was diagnosed with NA associated with CMV infection. In conclusion, CMV is a rare but possible pathogen of NA.

Brachioradial pruritus in a patient with cervical disc herniation and Parsonage-Turner syndrome

Abstract Brachioradial pruritus is a chronic sensory neuropathy of unknown etiology which affects the skin of the shoulders, arms and forearms on the insertion of the brachioradialis muscle. We describe the case of a 60-yearold woman recently diagnosed with multiple myeloma who refers paresis, severe pruritus and itching lesions on the right arm with 6 months of evolution. Investigation led to a diagnosis of Brachioradial pruritus consequent to the presence of cervical disc herniation and Parsonage-Turner syndrome. The patient started gabapentin 900mg/day with good control of itching. Corticosteroids and antihistamines are often ineffective in the treatment of BP. Gabapentin has been used with encouraging results. All patients with Brachioradial pruritus should be evaluated for cervical spine injuries.

Neuralgic Amyotrophy Manifesting as Mimicking Posterior Interosseous Nerve Palsy

The upper trunk of the brachial plexus is the most common area affected by neuralgic amyotrophy (NA), and paresis of the shoulder girdle muscle is the most prevalent manifestation. Posterior interosseous nerve palsy is a rare presentation in patients with NA. It results in dropped finger on the affected side and may be misdiagnosed as entrapment syndrome or compressive neuropathy. We report an unusual case of NA manifested as PIN palsy and suggest that knowledge of clinical NA phenotypes is crucial for early diagnosis of peripheral nerve palsies.

Extended Neuralgic Amyotrophy Syndrome: voice therapy in one case of vocal fold paralysis / Amiotrofia Nevrálgica Estendida: fonoterapia em um caso de paralisia de prega vocal

Neuralgic Amyotrophy (NA) is a rare disturb of the peripheral nervous system that can include extreme pain, multifocal paresis and atrophy of the muscles of the upper limbs. When the nerves located outside of the brachial plexus are involved, the term Neuralgic Amyotrophy Extended (ANE) is used. Diagnosis of NA is clinical and has a series of inclusion and compatibility criteria established by the European CMT Consortium. On this study the clinical history, multidimensional vocal assessment data and the vocal techniques used in five-weeks voice therapy for one patient, professional voice, with ANE are presented. In this case, sudden and recurrent paralysis of his right vocal fold was the only manifestation of the disease. At the end of the fifth week the patient's voice was normal, the spoken and sung vocal ranges were same as before the current episode of ANE and scores of his vocal self-assessment were appropriate.

A Amiotrofia Nevrálgica (AN) é um distúrbio raro do sistema nervoso periférico que pode incluir dor extrema, paresia multifocal e atrofia dos músculos dos membros superiores. Quando há o envolvimento de nervos localizados fora do plexo braquial, o termo Amiotrofia Nevrálgica Estendida (ANE) é utilizado. O diagnóstico da AN é clínico e possui uma série de critérios de inclusão, bem como critérios de compatibilidade estabelecidos pelo European CMT Consortium. Neste estudo são apresentados a história clínica, os dados da avaliação vocal multidimensional e as técnicas vocais utilizadas na terapia vocal de cinco semanas de um paciente, profissional da voz, com ANE. A paralisia súbita e recorrente da prega vocal direita foi a única manifestação da doença. Ao término da quinta semana, a voz do paciente estava adaptada, as extensões de voz falada e cantada eram as mesmas de antes da lesão e os escores de sua autoavaliação vocal estavam adequados.

Magnetic Resonance Neurographic Findings in Classic Idiopathic Neuralgic Amyotrophy in Subacute Stage: A Report of Four Cases

Neuralgic amyotrophy (NA) is characterized by acute onset of severe pain, followed by muscular weakness and wasting of the shoulder girdle. While the diagnosis of NA mainly relies on the clinical history and examination, some investigations including electrophysiologic study and radiologic study may help to confirm the diagnosis. Magnetic resonance neurography (MRN), a new technique for the evaluation of peripheral nerve disorders, can be helpful in the diagnosis of NA. MRN presents additional benefits in comparison to conventional magnetic resonance imaging in the diagnosis of idiopathic NA (INA). In this report, we present the first four cases of classic INA diagnosed with MRN in subacute stage. MRN imaging modality should be considered in patients clinically suspected of INA.

Brachial Plexus Neuritis Associated With Streptococcus agalactiae Infection: A Case Report

Brachial plexus neuritis is reportedly caused by various factors; however, it has not been described in association with Streptococcus agalactiae. This is a case report of a patient diagnosed with brachial plexus neuritis associated with pyogenic arthritis of the shoulder. A 57-year-old man visited the hospital complaining of sudden weakness and painful swelling of the left arm. The diagnosis was pyogenic arthritis of the left shoulder, and the patient was treated with open irrigation and debridement accompanied by intravenous antibiotic therapy. S. agalactiae was isolated from a wound culture, and an electrodiagnostic study showed brachial plexopathy involving the left upper and middle trunk. Nine weeks after onset, muscle strength improved in most of the affected muscles, and an electrodiagnostic study showed signs of reinnervation. In conclusion, S. agalactiae infection can lead to various complications including brachial plexus neuritis.

Síndrome de parsonage-turner: relato de caso em paciente HIV soropositivo / Parsonage-turner syndrome: case report of a HIV seropositive patient

A síndrome de Parsonage-Turner é uma doença rara que acomete a musculatura da cintura escapular levando à hipotrofia muscular e grande déficit motor. A etiologia é indeterminada; acredita-se que existam fatores infecciosos e autoimunes envolvidos. O diagnóstico é de exceção, e os principais diagnósticos diferenciais são hérnias discais cervicais, lesões do manguito rotador e doenças reumáticas. Na investigação diagnóstica realizamos exames laboratoriais, radiografias e ressonância magnética dos ombros e da coluna cervical com destaque para a eletroneuromiografia auxiliando no diagnóstico definitivo. Por se tratar de uma doença raramente associada à soropositividade do vírus HIV e pela importância do diagnóstico precoce para o melhor tratamento destes pacientes é que relatamos este caso.

The Parsonage-Turner Syndrome is a rare disease that affects the muscles of the scapular girdle, leading to muscular atrophy and a large motor deficit. The etiology is unknown, but it is believed that infectious and autoimmune factors are involved. The diagnosis is made by exclusion, and the main differential diagnoses are cervical disc hernias, rotator cuff injuries and rheumatic diseases. During diagnostic research, we conducted laboratory tests, radiographs and MRI of the shoulder and cervical spine, with particular reference to electroneuromyography to help generate a definitive diagnosis. This case report is presented because it shows a disease that is rarely associated with HIV seropositivity and the importance of early diagnosis for better treatment of these patients.

Therapeutic Experience in a Patient with Complex Regional Pain Syndrome Related to Brachial Plexitis: A case report

We report our therapeutic experience in a patient with complex regional pain syndrome (CRPS) related to brachial plexitis. A 16-year-old female suffered from excruciating burning pain and allodynia abruptly developed on left shoulder. Cervical MRI was normal. Electrodiagnostic findings were compatible with acute brachial plexopathy. Hand swelling, dystrophic color change, desquamation, and anhidrosis were displayed. Three-phase bone scan revealed increased radio-uptake on left upper extremity. The course of the disease was slowly progressive with wax and wane pattern. Pain became gradually intractable to all therapeutic modalities and medications. She gradually improved with long-term multimodal pain management. After 2 years of disease-free period, CRPS recurred and the extent was more severe than the first attack. We tried oral mexiletine, risedronate, high dose multi-vitamin, and leukotriene modulator which were effective in reducing pain and allodynia. Hand swelling gradually subsided and functional regain was obtained.