Relación entre manifestaciones neurológicas y severidad de la COVID-19. Hospital San Vicente de Paúl. Ecuador 2021 / Relationship between neurological manifestations and severity of COVID-19. San Vicente de Paul Hospital. Ecuador 2021

Introducción: El SARS-CoV-2 afecta principalmente al sistema respiratorio, pero el daño producido por este virus también se extiende a otros sistemas, incluido el sistema nervioso, y los mecanismos de infección neurológica pueden ser directos o indirectos. Objetivo: Determinar la relación entre las manifestaciones neurológicas y la severidad de la enfermedad en pacientes sintomáticos positivos a la COVID-19. Hospital San Vicente de Paúl. 2021. Material y Métodos: Estudio observacional de corte transversal, empleando el registro de historias clínicas de los pacientes hospitalizados con la COVID-19 y manifestaciones neurológicas, las cuales se clasificaron en manifestaciones del sistema nervioso central y manifestaciones del sistema nervioso periférico. Resultados: 74,1 por ciento pacientes presentaron manifestaciones neurológicas, el mayor porcentaje se concentró en pacientes que desarrollaron enfermedad grave (15 [60 por ciento], SNC; 91 [77,1 por ciento], SNP; 125 [65,4 por ciento], SNC y SNP). La presencia conjunta de manifestaciones neurológicas centrales y periféricas se asoció significativamente con la COVID-19 crítica (P valor= 0,011; OR: 2,005). El índice de mortalidad alcanzó 2,69 por ciento. Conclusiones: Las manifestaciones neurológicas en pacientes hospitalizados con la COVID-19 son muy frecuentes, y la COVID-19 crítica tiene mayor probabilidad de presentar manifestaciones neurológicas(AU)

Introduction: SARS-CoV-2 mainly affects the respiratory system, but the damage caused by this virus also extends to other systems, including the nervous system, and the mechanisms of neurological infection can be direct or indirect. Objective: To determine the relationship between neurological manifestations and disease severity in symptomatic COVID-19 positive patients at San Vicente de Paul Hospital in 2021. Material and Methods: A cross-sectional observational study was conducted using medical records of patients hospitalized with COVID-19 and neurological manifestations, which were classified into manifestations of the central nervous system and manifestations of the peripheral nervous system. Results: The results show that 74,1 percent of patients presented neurological manifestations; the highest percentage was concentrated in patients who developed severe disease (15 [60 percent], CNS; 91 [77,1 percent], PNS; 125 [65,4 percent], CNS and PNS). The joint presence of central and peripheral neurological manifestations was significantly associated with critical COVID-19 (P value= 0,011; OR: 2,005). The mortality rate reached 2,69 percent. Conclusions: Neurological manifestations in hospitalized COVID-19 patients are very common, and critical COVID-19 is more likely to have neurological manifestations(AU)

Misdiagnosis and diagnostic delay in non-paraneoplastic sensory neuronopathies / Erro e atraso diagnóstico nas neuronopatias sensitivas não paraneoplásicas

ABSTRACT Sensory neuronopathies (SN) are a group of peripheral nerve disorders characterized by multifocal non-length-dependent sensory deficits and sensory ataxia. Its recognition is essential not only for proper management but also to guide the etiological investigation. The uncommon SN clinical picture and its rarity set the conditions for the misdiagnosis and the diagnostic delay, especially in non-paraneoplastic SN. Therefore, our objectives were to characterize the diagnostic odyssey for non-paraneoplastic SN patients, as well as to identify possible associated factors. Methods We consecutively enrolled 48 non-paraneoplastic SN patients followed in a tertiary neuromuscular clinic at the University of Campinas (Brazil). All patients were instructed to retrieve their previous medical records, and we collected the data regarding demographics, disease onset, previous incorrect diagnoses made and the recommended treatments. Results There were 34 women, with a mean age at the diagnosis of 45.9 ± 12.2 years, and 28/48 (58%) of the patients were idiopathic. Negative sensory symptoms were the heralding symptoms in 25/48 (52%); these were asymmetric in 36/48 (75%) and followed a chronic course in 35/48 (73%). On average, it took 5.4 ± 5.3 years for SN to be diagnosed; patients had an average of 3.4 ± 1.5 incorrect diagnoses. A disease onset before the age of 40 was associated to shorter diagnosis delay (3.7 ± 3.4 vs. 7.8 ± 6.7 years, p = 0.01). Conclusions These results suggest that diagnostic delay and misdiagnosis are frequent in non-paraneoplastic SN patients. As in other rare conditions, increased awareness in all the healthcare system levels is paramount to ensure accurate diagnosis and to improve care of these patients.

RESUMO As neuronopatias sensitivas (NS) representam um grupo de doenças caracterizadas por ataxia sensitiva e déficits sensitivos multifocais e não-comprimento dependentes. O seu reconhecimento é fundamental para o tratamento apropriado e para a investigação de doenças associadas. O quadro clínico pouco frequente aliado à baixa prevalência, especialmente das formas não-paraneoplásicas (NSnp), colaboram para o atraso e erro no diagnóstico. Os objetivos desse trabalho são descrever a odisseia diagnóstica dos pacientes com NSnp e tentar identificar possíveis fatores associados. Métodos Foram incluídos consecutivamente 48 pacientes com NSnp acompanhados no ambulatório de doenças neuromusculares da Universidade Estadual de Campinas (Brasil). Dados demográficos e sobre o início da NS (incluindo diagnósticos que lhes foram dados e tratamentos prescritos) foram coletados. Resultados Na coorte descrita havia 34 mulheres e a idade ao diagnóstico era de 45,9 ± 12,2 anos. Os sintomas inaugurais eram sensitivos deficitários em 25/48 (52%) dos pacientes, sendo assimétricos em 36/48 (75%) e de evolução crônica em 35/48 (73%). Para 28/48 (58%) dos pacientes a NS era idiopática. Em média, os pacientes com NSnp tiveram um atraso diagnóstico de 5,4 ± 5,3 anos com uma média de 3,4 ± 1,5 diagnósticos incorretos. Pacientes com início antes dos 40 anos tiveram diagnóstico mais precoce que aqueles com início tardio (3,7 ± 3,4 vs. 7,8 ± 6,7 anos, p = 0,01). Conclusão Os dados ora apresentados sugerem que o erro e o atraso diagnóstico são frequentes e impactam os pacientes com NS. A importância do diagnóstico das NS deve ser constante em todos os níveis do sistema de saúde para o diagnóstico correto e a consequente melhora no cuidado a esses pacientes.

Livedoid vasculopathy associated with peripheral neuropathy: a report of two cases / Vasculopatia livedoide associada a neuropatia periferica: relato de dois casos

Livedoid vasculopathy (LV) is a chronic and recurrent disease consisting of livedo reticularis and symmetric ulcerations, primarily located on the lower extremities, which heal slowly and leave an atrophic white scar ("atrophie blanche"). Neurological involvment is rare and presumed to be secondary to the ischemia from vascular thrombosis of the vasa nervorum. Laboratory evaluation is needed to exclude secondary causes such as hyper-coagulable states, autoimmune disorders and neoplasms. We present two patients with a rare association of peripheral neuropathy and LV, thereby highlighting the importance of a multidisciplinary approach to reach the correct diagnosis. .

Vasculopatia livedoide é uma doença crônica e recorrente caracterizada por livedo reticular e úlceras simétricas nos membros inferiores, que cicatrizam e deixam uma cicatriz branca atrófica ("atrophie blanche"). Envolvimento neurológico é raro e está provavelmente associado a isquemia pela trombose dos vasa nervorum. Avaliação laboratorial é indicada com o intuito de excluir causas secundárias como estados de hipercoagulabilidade, doenças autoimunes e neoplasias. Apresentamos dois pacientes com uma rara associação de vasculopatia livedoide com neuropatia periférica, enfatizando a importância de uma abordagem multidisciplinar na busca do diagnóstico correto.

Análise do equilíbrio bipodal em diabéticos com neuropatia periférica / Analysis of balance in double leg stance position in diabetics with peripheral neuropathy

O objetivo deste trabalho foi analisar o equilíbrio estático em postura bipodal em indivíduos diabéticos. Participaram 7 indivíduos, com idade entre 40 e 64 anos e neuropatia periférica. A primeira etapa consistiu na avaliação dos pés, através do monofilamento de 10 g, gelo, diapasão de 128 Hz, agulha e chumaço de algodão. Os participantes foram estratificados de acordo com o grau de neuropatia. Foi avaliado o equilíbrio através do comportamento do centro de pressão plantar (COP), em postura bipodal com e sem visão. Os dados foram analisados por estatística descritiva, teste t de student pareado e correlação de Spearman. O COP teve maior oscilação na direção médio-lateral (M/L), que se acentuou quando os sujeitos estavam com olhos fechados. Os fisioterapeutas podem contribuir na recuperação e prevenção das alterações sensoriais e motoras nesses pacientes, portanto estudos como este são importantes para ampliar os conhecimentos a respeito da doença e das suas implicações.

The aim of this study was to analyze balance in double leg stance position in individuals with diabetes. Seven people participated, 40 to 64 years old, with peripheral neuropathy. The first stage was the feet evaluation using a monofilament of 10g, ice, 128 Hz turning fork, needle and cotton. The subjects were graded according to neuropathy severity. The behavior of center of plantar pressure (COP) in double leg stance position was verified, with and without vision. Data was analyzed through descriptive statistics, test t of student and Spearman’s correlation. The COP had greater oscillation in the direction medium-lateral (M/L), that it had been increase when the persons were with closed eyes. The physical therapists can contribute in recovery and prevention of sensorial and motor alterations in these patients; therefore studies like this are important to extend the knowledge about this disease and its consequences.

Os efeitos da mobilização neural como abordagem fisioterapêutica na síndrome do túnel do carpo / The effects of neural mobilization as physical therapy approach in carpal tunnel syndrome

A síndrome do túnel do carpo é uma neuropatia compressiva periférica que consiste na compressão do nervo mediano no canal do carpo. Apresenta maior incidência no sexo feminino e está associada ao esforço repetitivo. Os sinais e sintomas mais freqüentes são fraqueza, hipotrofia dos músculos tenares e dos dois primeiros lumbricais, retração do adutor do polegar e dos músculos flexores profundos e superficiais dos dedos, perda da mobilidade no deslizamento longitudinal e transversal do nervo mediano. Esses estão associados a edema, inflamação e retração do tecido conjuntivo neural. O objetivo deste estudo foi mostrar a aplicação da técnica de mobilização neural, como tratamento para a síndrome do túnel do carpo. Tal técnica tem como principal objetivo restaurar o movimento e a elasticidade tecidual do nervo periférico.

The carpal tunnel syndrome is a peripheral compressive neuropathy that consists in median nerve compression in the carpal tunnel. It occurs more often in females and is associated with repetitive strain. The more frequent signals and symptoms are weakness, hypertrophy of the tenhar and the first two lumbrical muscles, retraction of adductor of thumb and the deep and superficial flexor finger muscles, loss of mobility in the longitudinal and transverse sliding of the median nerve. These signals and symptoms are associated with swell, inflammation and retraction of the conjunctive neural tissue. The objective of the study aimed to show the use of neural mobilization technique as treatment for the carpal tunnel syndrome. Such technique has as main objective to restore range of motion and elasticity of the peripheral nerve tissue.

Mitochondrial neuro-gastrointestinal encephalopathy syndrome.

Mitochondrial neurogastrointestinal encephalomyopathy is a rare disorder affecting the pediatric age group with a heterogeneous multisystem involvement. We happen to manage a young child with symptoms of constipation since infancy along with cachexia, seizures and peripheral neuropathy. The child later went into encephalopathy preterminally. This clinical syndrome fitted very well with mitochondrial neurogastrointestinal encephalomyopathy. The child had elevated lactate levels and electron microscopy of the rectal biopsy was suggestive of a mitochondrial disorder To the best of our knowledge there is no case report of this syndrome from India and since this presents with diagnostic difficulties so is being reported.

Peripheral neuropathy in hepatitis C patients in Egypt

The overall prevalence of HCV antibodies in the general population is around 10-15% and is highly prevalent among Egyptian blood donors. The study was carried out on 30 patients, there was [21 male and 9 were female] age ranged from 27-62 ys with proved HCV infection by means of positive antibody assay for the virus and positive PCR for HCN RNA. The current study aimed to evaluate the role of HCV in peripheral neuropathy [PN] and to assess the response of PN to medical treatment PN was assessed clinically by motor and sensory examination. Beside routine clinical and laboratory tests, electrophysiological studies were also done. At presentation, sensory axonal degeneration neuropathy was the most prevalent type of neuropathy in the studied HCV subjects, in addition male HCV -patient are slightly more subjected to the development of HCV- associated peripheral neuropathy furthermore. Peroneal nerve conduction velocity was found to be impaired more than that of median nerve. Interestingly the presence of ascites had no significant effect on the degree of nerve conduction. The underlying mechanism of such peripheral neuropathy is mostly due to axonal degeneration. We therefore conclude that HCV- associated neuropathy had mainly a chronic evolution. PN manifestations can be the initial presenting manifestation of HCV infection

Incidence of neuritis among paucibacillary leprosy patients during treatment and surveillance.

A cohort study was done on 180 patients receiving the standard WHO PB-MDT regimen at the TLM Hospital in Kolkata, during MDT and 2 years of surveillance to determine the incidence of neuritis. Neuritis occurred in only 2 out of the 180 patients, confirming that the current WHO treatment for PB-MDT is attendant with minimal risk of neuritis. No risk factors were found, except pregnancy in a female patient. While addition of clofazimine in the new U-MDT under trial might take care of the occasional neuritis, further clinical research might be useful to identify sub-groups of PB patients at risk of neuritis.

A Case of Hodgkin's Lymphoma Associated with Sensory Neuropathy

Peripheral neuropathies occur in lymphoma patients. Causes of neuropathy include chemotherapy, opportunistic infections, and the lymphoma itself. We report a patient with lymphoma whose chief complaint was a sensory loss in the hands and feet. Electrophysiologic studies and sural nerve biopsy showed sensory polyneuropathies. We hypothesize that this neuropathy is associated with lymphoma-related ganglionopathy, and among the possible causes, we suspect that a systemic cause such as a paraneoplastic syndrome is the most likely pathogenic etiology. However, further follow-up will be necessary to see whether sensory symptoms change with lymphoma treatment.

Hernia lumbar y múltiples trastornos degenerativos vertebrales: enfoque neuromecánico / Lumbar hernia and multiple degenerative vertebral disorder: neuromechanical focusing

El presente trabajo describe el cuadro clínico de un paciente con hernia del núcleo pulposo derecha extruída, con multiples procesos degenerativos vertebrales y trastornos del sistema nervioso periférico. Se da importancia al proceso de evaluación y de razonamiento clínico de la información recopilada a través de los exámenes de imágenes y de evaluaciones kinésicas. Los objetivos principales del tratamiento kinésico fueron lograr la desensibilización del sistema neuro-artro-músculo-esquelético y la estabilización de la cintura lumbo-pelvis-cadera. El protocolo de rehabilitación se realiza basándose en un modelo de tratamiento neuro-mecánico

The diagnosis of leprosy among patients with symptoms of peripheral neuropathy without cutaneous lesions: a follow-up study

Forty-four patients with neuritic leprosy were individually followed for periods ranging from 4 months to almost 4 years for the purpose of ascertaining the presence and/ or absence of leprosy. The neural symptoms presented were sensory impairment (41), parasthesia (28), nerve enlargement (22), nerve tenderness (20), paresia (20), amyotrophy (8). Leprosy was diagnosed in ten out of the total number of patients studied. Leprosy was confirmed by the appearance of reactional neuritis (4), reversal reaction (2), biopsy of the hypoesthesic area (3) and the appearance of non-reactional cutaneous lesion. We reported an experience in the diagnosis of neuritic leprosy and its most frequent clinical presentation with which clinicians have to be acquainted. We can also state that the clinical follow-up was an effective strategy for the diagnosis of the disease when diagnostic facilities are not available or have not confirmed the diagnosis

Compromiso neurologico asociado al sindrome de Sjogren / Nervous system involvement in patient with Sjorgren' syndrome

Objetivo: determinar la prevalencia y las características clínicas e inmunogenéticas del compromiso neurológico en pacientes con síndrome de Sjogren (SS) primario. Métodos: estudio transversal y retrospectivo realizado en una cohorte de pacientes con SS primario, clasificados de acuerdo con los criterios europeos, incluyendo una biopsia de glándulas salivales positiva. Se compararon las características de los pacientes con y sin compromiso neurológico. Resultados: se estudiaron 95 pacientes (93 mujeres, edad promedio: 50 ± 1.4 años, duración de la enfermedad: 6.7 ± 0.6 años, tiempo promedio de seguimiento: 4.1 ± 0.7 años). Once pacientes (11.6 por ciento) presentaron compromiso neurológico, de los cuales ocho (8.4 por ciento) presentaron afección del sistema nervioso periférico (SNP): síndrome del túnel del carpo (STC) en cinco y polineuropatía sensitiva distal en tres. Tres (3.2 por ciento) pacientes presentaron compromiso del sistema nervioso central (SNC): migraña complicada, esclerosis múltiple con vasculitis y neuritis óptica con epilepsia. El compromiso neurológico fue la manifestación inicial en una paciente (STC), y coincidió con el inicio de los síntomas secos en otra con patología del SNC. La afección del SNP se observó en pacientes con mayor compromiso extraglandular, en particular en aquéllos con vasculitis cutánea (OR: 6, IC95 por ciento: 1.3-27, p=0.02) y fenómeno de Raynaud (OR:10.3, IC95 por ciento: 2-55,p = 0.004). Los tres pacientes con afección del SNC presentaron anticuerpos anti-Ro pero no anticardiolipina, y fueron HLA-DQB1*0303 (OR:29, IC95 por ciento: 1.4-597,p=0.009). Conclusión: el compromiso neurológico en el SS primario es poco frecuente aunque puede ser revelador de la enfermedad. Las manifestaciones periféricas son las más comunes y se asocian con vasculopatía. El compromiso del SNC es raro, variado y puede ser severo. La presencia del HLA-DQB1*0303 podría ser un marcador de esta afección. Se necesitan estudios multicéntricos y con mayor número de casos para evaluar esta hipótesis.

Acalasia, alacrima sin insuficiencia suprarrenal, con disfunción neurológica periférica y autonómica (síndrome de Allgrove) / Achalasia, alacrima without adrenal insufficiency, with pheripheral and autonomic neurological dysfunction (Allgrove's syndrome)

Objetivo. Presentar un paciente con síndrome de Allgrove y disfunción neurológica periférica y autonómica. Un caso no informado previamente en la literatura médica nacional. Antecedentes. El síndrome de Allgrove es una entidad patológica poco común caracterizada por acalasia, alacrima (ausencia de lágrimas) e insuficiencia suprarrenal el cual se presenta por lo general en niños. En la literatura se han descrito casos aislados. La serie más grande, consistente en 20 pacientes procedentes de varios países de Europa, fue publicada en 1993. Método. Se describe un caso clínico compatible con síndrome de Allgrove y se realiza un revisión bibliográfica haciendo énfasis en las alteraciones neurológicas las cuales no han sido bien caracterizadas en estos pacientes. Resultados. Se presenta un paciente de 12 años de edad quien fue admitido al hospital por sifagia. Se sospechó el diagnóstico de acalasia por endoscopia, esofagograma y se confirmó por manometría. El examan clínico mostró además alacrima y datos de disfunción neurológica y del intelecto. La prueba de estimulación suprarrenal con ACTH (Cortosin) fue normal. La evaluación neurológica mostró datos de neuropatía periférica de predominio motor y axonal; datos clínicos de neuropatía autonómica; afección de la vía corticoespinal y retraso psicomotor y del coeficiente intelectual. Conclusiones. El síndrome de Allgrove debe incluirse en el diagnóstico diferencial de los infantes con acalasia. La insuficiencia suprarrenal podría aparecer después de realizado el diagnóstico de la enfermedad. La disfunción neurológica parece ser la lesión más prominente de este síndrome

Peripheral nerve abscess in leprosy: report of twenty cases.

During the year 1994-1995, 20 of the 67 leprosy patients attending the dermatology department with any kind of nerve involvement were found to be having nerve abscess. These abscesses occurred in all types of leprosy (except the Indeterminate) and a variety of nerve trunks and cutaneous nerves. In none of the instances the abscess was associated with reaction. All the patients were surgically treated, without any steroid therapy. All cases showed significant improvement whenever there was nerve function deficit. Similarly, pain was relieved in all cases, when it was present.