ABSTRACT
Introduction: Diabetic peripheral neuropathy (DPN) is the most common neuropathic syndrome seen in patients with diabetes. Roughly 30% of the diabetes patient population1 experience painful DPN symptoms including bilateral stabbing or burning pain in addition to numbness in the feet and lower legs. Traditionally painful DPN symptoms have been treated with conventional medical management (CMM) including glycemic control, general risk factor management, as well as pharmaceutical agents. These treatment approaches are often unsuccessful in the long-term1. Spinal cord stimulation (SCS) has been demonstrated as an effective treatment for painful DPN of the lower extremities with multiple publications dating back to 1996 showing benefits of SCS for pain relief and improved Quality of Life (QoL) in DPN patients (Figure 1)2-18. Method(s): A systematic literature review of the robust body of evidence for SCS in the treatment of painful DPN was conducted. Publications were selected for inclusion by two independent reviewers using defined selection criteria. Additional relevant publications from outside the search dates were included. Result(s): SCS was first documented as an effective treatment for DPN in three single-arm studies published between 1996 and 20122,4,5, one of which was followed-up to thirty-six months18, and another to seven-years3. These studies paved the way for two RCTs published in 20146,7, one of which was followed-up to five-years in two publications8,10, and another7 was followed-up with analyses on QoL9 and an evaluation of the effects of burst SCS17. Two meta-analyses were published in 2020 and 202111,12. A post-hoc analysis of a multi-center single-arm study on high frequency (10kHz) SCS to treat DPN was published in 202013 and followed by an RCT published in 202114 with additional 1-year follow-up15,16. Collectively these studies demonstrate that SCS is an effective therapy for patients with painful DPN by reducing pain and increasing QoL for DPN patients (Figure 1). Conclusion(s): This review of a large body of evidence shows a decades-long history of the effectiveness of SCS for symptom relief in patients suffering from painful DPN. Future research on the effectiveness of new waveforms and novel methods of energy delivery to the spinal cord are needed. The study of outcomes in addition to pain relief is also needed, which may better illustrate the breadth of effects of SCS therapy on the underlying disease factors. Increasing awareness of the current evidence is essential to increasing therapy adoption by expanding payer support and influencing referring health care provider behavior. Disclosure: Eric Grigsby, MD: AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Medtronic: Consulting Fee: Self, SPR Therapeutics: Consultant: Self, Tenex Health: Consultant: Self, Voyager Therapeutics: Consultant: Self, Xalud: Consulting Fee: Self, AE Mann Foundation: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Bioness Inc.: N/A: Self, Medallion Therapeutics: N/A: Self, SPR Therapeutics: N/A: Self, Abbott / St. Jude Medical: N/A: Self, Tenex: N/A: Self, Vertos: N/A: Self, Xalud: N/A: Self, AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medtronic, Inc.: N/A: Self, Collegium Pharmaceutical, Inc.: Trustee: Self, Flowonix Medical: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Trustee: Self, Spinal Restoration, Inc.: Trustee: Self, Jazz Pharmaceuticals: N/A: Self, Alfred Mann Foundation: N/A: Self, Boston Scientific: N/A: Self, CNS Therapeutics: N/A: Self, Collegium Pharmaceutical, Inc.: N/A: Self, Flowonix Medical: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: N/A: Self, Myoscience: N/A: Self, NeurAxon Inc.: N/A: Self, Spinal Restoration, Inc.: N/A: Self, St. Jude Medical, Inc.: N/A: Self, Abbott Laboratories: Consultant: Self, Alfred Mann Foundation: Consulting Fee: Self, Cervel Neurotech, Inc.: Consultant: Self, CNS Therapeutics: Consultant: Self, Covidien: Consultant: Self, Cumberland Pharmaceuticals, Inc.: Consultant: Self, Flowonix Medical: Consultant: Self, Jazz Pharmaceuticals: Consultant: Self, Mainstay Medical: Consultant: Self, Medtronic, Inc.: Consultant: Self, Myoscience: Consultant: Self, NeuroPhage Pharmaceuticals: Consultant: Self, Nevro Corp: Consultant: Self, Palyon: Consultant: Self, Spinal Modulation: Consultant: Self, SPR Therapeutics: Consultant: Self, St. Jude Medical, Inc.: Consultant: Self, Tenex Health, Inc.: Consultant: Self, VertiFlex Inc.: Consultant: Self, Vertos Medical, Inc.: Consultant: Self, Xalud Therapeutics, Inc.: Contracted Research: Self, Medtronic, Inc.: Served on speakers' bureau: Self, Flowonix Medical: Served on advisory board: Self, Medtronic, Inc.: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Nevro Corp: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Rachel Slangen, PhD: None, Lisa Johanek, PhD: Medtronic: Salary/Employee: Self, Maddie LaRue, PHD: Medtronic: Employee:, Cecile de Vos, PhD: None, Melissa Murphy: Medtronic: Consulting Fee:, Relievant: Consulting Fee:Copyright © 2023
ABSTRACT
Introduction: One of the consequences of COVID-19 is the incidence of mucormycosis in the jaws and subsequent osteomyelitis in patients with undiagnosed or uncontrolled comorbidities, such as diabetes mellitus and associated immunosuppression. Case Report: A 52-year-old male patient with a history of COVID-19 two months ago presented a painful ulcerative lesion of insidious onset in the palatal raphe measuring approximately 2 mm. He referred to numbness of the palatal region of one month of evolution. During the physical examination, purulent content, multiple pustules in the anterior maxillary buccal mucosa, and mobility of upper anterior teeth were observed. The CT revealed isodense bilateral images in maxillary and ethmoidal sinuses, bone sequestrations, and partial loss of anterior vestibular cortical bone. Laboratory tests revealed no abnormality, except for HbH1c: 10.2gr/dl. The patient was hospitalized for control of newly diagnosed diabetes mellitus. Maxillary incisional biopsy was performed, and microscopic analysis showed a mixed inflammatory infiltrate, fibrin deposits with eosinophilic and birefringent ribbon-like hyphae, branched at right angles, compatible with maxillary osteomyelitis secondary to mucormycosis. The treatment started with antifungal and intravenous antibiotics, followed by surgical cleaning under general anesthesia. The patient progressed favorably. Conclusion(s): Immunosuppression resulting from COVID-19 and/or uncontrolled systemic diseases can condition the appearance of rare opportunistic microorganisms causing infections such as mucormycosis. Early diagnosis and treatment make a difference in the morbidity and mortality of patients.
ABSTRACT
Introductions: The median nerve's occasional or persistent compression or entrapment in the carpal tunnel from the wrist to the hand causes carpal tunnel syndrome (CTS). The main symptoms are pain, tingling, swelling, and loss of grip strength and function in the thumb, index finger, middle finger, and thumb of thumb. This study examined Saudi adults' awareness and understanding of Carpal Tunnel Syndrome and its link with demographics and chronic conditions. Material(s) and Method(s): This cross-sectional study examined adults' knowledge, attitudes, and practices regarding carpal tunnel syndrome from 2021 to 2022 in different Saudi Arabian regions. This study used a researcher-created questionnaire. In the awareness category, general public questions included CTS clinical aspects, etiology, and effects on daily life. Practice questions covered CTS preventive and chronic diseases. Volunteers were selected following informed consent. Result(s): 420 participants aged 34.8 +/- 13.49 years. 280 (66.6%) were male, 140 (33.3%) females. 38 (9.04%) were non-Saudi workers, while 384 were Saudis. 235 (55.9%) individuals knew about wrist CTS and 161 (38.3%) about pain. 157 (37.3%) individuals experienced thumb tingling or numbness, while 117 and 142 agreed that CTS may produce thumb weakness (27.8%) and hand grip (35.2%). The older age group reported more thumb numbness or tingling than the other groups, although there was no statistical difference (p= 0.09). CTS was not associated with chronic disease;however, diabetes was the main comorbidity in all age groups (44;45.3%), especially in the middle age group (21;60%). 5.4% had CTS. CTS was rare during pregnancy (0.7%), however all age groups agreed that it could influence their employment and social life (p= 0.014 and < 0.00001). The average knowledge score was 43.3 +/- 40.5, whereas the awareness score was 50.1 +/- 44.2. These findings indicate that Saudis were aware of CTS clinical symptoms. Conclusion(s): The study examined Saudi adults' awareness and understanding of CTS and estimated the association between CTS and demographics and chronic conditions. The study found that adult CTS awareness and knowledge were sufficient and associated with age and quality of life. CTS awareness campaigns may lower risk and raise knowledge of prevention and treatment. People who work with discomfort or use computers for long periods of time without breaks are more prone to develop CTS. Larger research is needed to understand how physical exercise causes CTS.Copyright © 2023, Ibn Sina Trust. All rights reserved.
ABSTRACT
History: Transient and generalized adverse effects are common following COVID-19 vaccination;among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted. Physical Exam: Left Shoulder-No calor or erythema;significant atrophy of the anterior and middle deltoid muscle relative to right side;abduction 4/5;external rotation with shoulder adducted 4/5;range of motion for active forward flexion was 150 degrees and passive was 170 degrees;passive range of motion for external rotation was 70 degrees;internal rotation to the level of L5;sensation to light touch was intact. Right Shoulder-Range of motion, strength, and sensation were intact. Cervical Spine-Full ROM;no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests. Differential Diagnosis: 161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity 162. Brachial Neuritis 163. Mechanical Axillary Nerve Palsy 2/2 Vaccination 164. Partial-Tear of Left Supraspinatus Tendon 165. Acromioclavicular Osteoarthritis Test Results: Left Shoulder-XR:Mild pseudo-subluxation;MRI w/o contrast: 8x9mmpartial-thickness articular surface tear of the distal supraspinatus tendon (<50%fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency;Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine. Discussion(s): We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID- 19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia. Outcome(s): The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment. Follow-Up: The patient did not follow-up for a repeatEMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.
ABSTRACT
Outcomes: 1. Utilizing CRISIS approach, participants can employ a unique strategy to holistically support patients with poor coping in an acute life-threatening situation. 2. Utilizing the CRISIS approach, participants will apply an ethical tool to mitigate the incongruence that sometimes happens between two ethical principles-autonomy versus beneficence. Autonomy is not always in harmony with beneficence. We present a patient with decisional capacity hospitalized with acute reversible neuromuscular paralysis who refused treatment despite expected recovery. Her decision created moral distress for the clinicians. An improvised palliative strategy resolved the above dilemma. Case presentation: 68-year-old female admitted with new-onset unsteady gait, diplopia, and speech impairment on waking up. She was healthy until 3 weeks before admission, when she developed upper extremity numbness progressing to both legs after a COVID-19 infection. She had bulbar and axial muscle weakness and right oculomotor nerve palsy with ptosis. Positive ice pack and pyridostigmine test indicated myasthenia gravis (MG). During hospitalization, she required mechanical ventilation secondary to acute respiratory failure from progressive paralysis. Serum-negative MG diagnosed, given the response to IVIG and pyridostigmine. The patient, amid acute crisis, refused therapies and wanted to transition to DNR-comfort care despite understanding the reversibility of her illness. Her family members supported comfort care option. Neurology was conflicted with the patient's choice because MG was treatable. Palliative care, ethics, and neuropsychology consulted to establish decision-making capacity, goals-of-care, and holistic support. Intervention(s): Palliative team utilized the CRISIS approach to address the impasse between the patient and the clinicians: 1. Continue care, collaborate with the teams 2. Respond empathetically 3. Integrate patient's autonomy 4. Support holistically 5. Improvise a care plan 6. Sustain quality of life We validated patient's autonomy. We recommended allowing time for the patient/family to process her illness. We continued holistic support and symptom management and created an improvised multidisciplinary plan to help her cope with the acute illness. The above approach enabled her to opt for therapies instead of comfort care only, and she gradually recovered. Respecting patients' autonomy and incorporating beneficence via our intervention led to positive outcomes. The CRISIS approach could help other clinicians in the situation when conflict arises between autonomy and beneficence.Copyright © 2023
ABSTRACT
During the Covid-19 pandemic attempts have been made to manage patients with neurological symptoms remotely without a neurological examination. To determine the prevalence of neurological signs we prospectively assessed 101 consecutive patients who were a referred to a general neurology clinic. Three patients did not attend, leaving 98 patients (58 female, 40 male, mean age 51.0 years, standard deviation 19.9 years. 37 patients had neurological signs. (Cognitive impairment n=3, spastic tetraparesis n=1, spastic hemipa- resis n=2, hemianopia n=1, ataxia n=1, gait apraxia n=1, postural tremor n=2, bradykinesia and rigidity n=9, functional tremor n=4, anosmia n=1, combined upper and lower motor neuron signs, n=2, radicular distribution numbness n=1, distal symmetrical weakness and hypoaesthesia n=5, peripheral nerve hypo- aesthesia n=2, fatigability and lid lag n=2.) Our data showed that a large proportion of general neurology patients had neurological signs.
ABSTRACT
Arterial dissection is an uncommon complication of reversible cerebral vasocon-striction syndrome (RCVS). We describe the case of a 35-year-old woman with a migraine history who presented with recurrent thunderclap headache and focal neurological signs, including right hemiataxia. She had been diagnosed with COVID-19 disease two weeks earlier. Neuroimaging revealed multifocal stenosis of the posterior circulation arteries and dissection of the right superior cerebellar artery. She improved significantly throughout her one-week hospitalization and maintained only mild ataxia. The interplay between COVID-19 disease, RCVS, and arterial dissection requires further investigation.Copyright © Author(s) (or their employer(s)) and Sinapse 2022.
ABSTRACT
Introduction We present a case of myelin-oligodendrocyte glycoprotein antibody disease (MOGAD) requiring long-term immunosuppression triggered by a dose of the AstraZeneca COVID-19 vaccination. Relapsing MOGAD is thus far an unknown complication of COVID-19 vaccination. Case Description: A 58-year-old lady developed headache, nausea, dizziness, facial numbness, ataxia and slurred speech 8 days after the COVID-19 AstraZeneca vaccination. Her imaging showed acute disseminated encephalomyelitis (ADEM) with a white matter lesion in the left cerebellum and bilateral smaller lesions. Her cerebrospinal fluid showed 38 white cells and elevated protein. She initially responded well to steroids, however relapsed with optic neuritis 7 months later, requiring long-term immunosuppres- sion with mycophenolate mofetil. Discussion Although there have been some case reports of MOGAD following COVID-19 infection, to our knowledge this is only the second reported case of MOGAD following vaccination against COVID-19, and the first such case to require long-term immunosuppression. The other reported case also occurred following the COVID-19 AstraZeneca vaccine, and also presented with ADEM. This is in contrast to reported cases of MOGAD following COVID-19 infection, where adults mostly presented with optic neuritis. We wanted to highlight the possibility of this vaccine-related neurological complication occurring, particularly in the context of potentially frequent ongoing COVID-19 booster vaccinations.
ABSTRACT
Background & Objective: The late-term neurological effects of COVID-19 are not fully understood yet. Herein, we aimed to determine if COVID-19-related acute and late-term neurological symptoms exist in the patient group that differs from the general population during the pandemic period. Methods: Two hundred fifty patients with a history of COVID-19, whose treatments were completed at least one month before enrollment, were examined together with a control group consisting of 150 individuals that lived in the same socio-cultural environment during the same period. A survey that included questions about possible neurological symptoms that might be related to the COVID-19 infection was completed in both groups. Results: The patient and control groups were mostly similar regarding the neurological symptoms in the pre-pandemic period. The control group did not report any new symptoms except ageusia during the pandemic period. Whereas a number of neurological symptoms such as headache, ageusia and anosmia, difficulty in thinking and planning, forgetfulness, clumsiness of one or both hands, dizziness, unsteadiness, numbness in both hands and feet, and neuropathic pain occurred during the infection. Neurological symptoms, except headache and unsteadiness, prolonged to the late-term with a decreased prevalence. Conclusion: The emergence of new neurological symptoms during the pandemic in those with COVID-19 disease, unlike the control group, suggested that these symptoms are related to the infection itself. © 2023, ASEAN Neurological Association. All rights reserved.
ABSTRACT
Introduction. Herpes zoster is an acute viral syndrome caused by the reactivation of latent varicella-zoster virus from a previous infection. It is characterized by a painful, unilateral vesicular rash which is distributed over the territory of a dermatome. It is a significant global burden with the incidence very common in the Asia Pacific region. The frequency is closely related with increasing age and is the most common risk factor for reactivation of varicella-zoster virus. Herpes zoster does not often appear after administration of vaccination. But in the advent of increasing vaccinations for COVID-19, there have been reports of herpes zoster following COVID-19 vaccination. Case: This is a case of a 22-year-old healthy male with a previous history of varicella-zoster virus infection during childhood who developed headache, unilateral vesicular rash over the territory of the left trigeminal nerve and left-sided facial pain and numbness. The patient had previously received the COVID-19 vaccine four days prior to the onset of symptoms. The diagnosis of herpes zoster was made on clinical grounds with no need for additional laboratory work-up to confirm the diagnosis. The patient was treated with herpes zoster antiviral therapy and analgesics where improvement of the patient's condition was noted with eventual crusting of the lesions and without development of complications. Conclusion(s): Herpes zoster is a common disease with a benign course in immunocompetent adults. There is a need for further studies to identify risk factors and explain the possible relationship between COVID-19 vaccination and the development of herpes zoster. Due to the increasing COVID-19 vaccination of the population worldwide, there is a possibility of an increase in the number of herpes zoster cases following COVID-19 vaccination.Copyright © 2022, Philippine College of Physicians. All rights reserved.
ABSTRACT
SARS-CoV-2 infection has been associated with multiple neurological manifestations. One such manifestation, which has been described since the early stages of the COVID-19 pandemic and is relevant for current neurological practice, is Guillain-Barre syndrome (GBS). The literature describes neurotoxic mechanisms of the virus itself and the possible pathways by which it may affect the peripheral nerves in experimental studies;however, we still lack information on the mechanisms causing the immune response that gives rise to GBS in the context of SARS-CoV-2 infection. Colombia is one of the Latin American countries worst affected by the pandemic, with the third-highest number of cases in the region;thus, it is essential to recognise GBS, as this potential postinfectious complication may severely compromise the patient's functional status in the absence of timely diagnosis and treatment. We present a series of 12 cases of GBS associated with SARS-CoV-2 infection from hospitals in 4 different Colombian cities and describe the clinical presentation, laboratory and electrophysiological study findings, and treatment.Copyright © 2022 Sociedad Espanola de Neurologia
ABSTRACT
Coronavirus disease 19 (COVID-19) is the worst pandemic ever recorded in history, as of this day more than 545 million people infected and more than 6 million cumulative deaths. COVID 19 is primarily respiratory disease, however non-respiratory presentations that could be manifested are venous and arterial thromboembolic events. Both pulmonary embolism (PE) and deep vein thrombosis (DVT) are the most frequently thrombotic events in COVID-19. Knee arthroscopy surgery is the one of the most common orthopedic surgical procedures nowadays, with the most common procedures are meniscectomy, meniscal repair and cruciate ligament reconstruction. Although knee arthroscopy is known to be a safe procedure, several complications could be found with the 3 most common complications are DVT, effusion and synovitis, and PE. We reported a case series of four patients with DVT post knee arthroscopy anterior cruciate ligament reconstruction during 2021. The DVT diagnosis was retained on clinical presentation and elevated of D-dimer testing. The patient's mean age was 35,25 years, and all of the patients had no risk factors of DVT, although they had COVID-19 infection within 3 months before surgery. The most common clinical presentation was swelling on the lower leg (around the ankle) with slightly pain and numbness. Only one patient had severe pain around the thigh. All of the patients had elevated D-dimer testing result with mean of D-dimer 1250 (normal value < 500). Only one patient had sonography testing and found proximal DVT. One of the patients had DVT at post operative day (POD) 3, one at POD 4 and the other two at POD 5. Three of the patients improved with oral anticoagulant therapy using rivaroxaban (XARELTO). In one patient the symptom was not improved after two days oral anticoagulant therapy and underwent thrombectomy by vascular surgeon. DVT is the most common complication of knee arthroscopy and also the most common non-respiratory events of COVID-19 infection. Routinely administration of thromboprophylaxis agent was not recommended, pre-operative risk assessment of DVT should be used, especially in post-COVID 19 patients.
ABSTRACT
Background Left Ventricular Non-Compaction Cardiomyopathy (LVNC) is a rare genetic, developmental disorder when the left apical chamber of the heart contains bundles or pieces of muscle that extend into the chamber called trabeculations. These trabeculations are a sponge-like network of muscle fibers that typically become compacted to transform heart muscle to become smooth and solid during a normal development process. Those who have LVNC most commonly are asymptomatic. Those who are symptomatic present with syncope, palpitations, dizziness, dyspnea, fatigue and/or unexplained weight gain or swelling. LVNC has also been suggested as a rare cause of embolic stroke, in our patient's case, "due to sluggish blood flow in deep intertrabecular recesses." Case We present a 29 year old African American female, G2P0011, with a history of cleft palate repair, and recent pregnancy complicated by COVID-19 who reported to ED after having a fall the day before, leg weakness and numbness, unable to walk, headache and a left facial droop on day of admission. No family history of SCD or other cardiac disease was noted. On assessment, was found to have NIHSS of 7 with rate lateral gaze palsy, left facial palsy, and decreased strength and sensation of LUE and LLE. TPA was not given due to being outside the therapeutic window. CT head and MRI brain were consistent with acute right MCA stroke. Secondary stroke workup with TTE revealed reduced LVEF 15-20%, loosely arranged myocardium with suspected LVNC and RV apical thrombus. Cardiac MRI showed increased trabeculations consistent with LVNC. Decision-making Currently, there are no ACC/AHA guidelines on anticoagulation in the setting of LVNC. Cardiology and Neurology had an extensive multidisciplinary discussion on the need for anticoagulation specifically with Warfarin. The patient was educated extensively on the need for medical adherence with anticoagulation and guideline directed medical therapy. Conclusion The patient was started on guideline directed medical therapy for cardiomyopathy and was started on Warfarin after bridging from Lovenox. She continued with physical therapy and was noted to have improvement in residual deficits at her outpatient follow up.Copyright © 2023 American College of Cardiology Foundation
ABSTRACT
Background: Severe acute respiratory syndrome coronavirus 2 (SARS-COV2) infection has been associated with the development and persistence of various neurological symptoms in some patients. There have been few prior case reports of small fiber neuropathy (SFN) associated with this infection. However, literature is limited, and the etiology of these symptoms is unclear. Some reports suggested neuroinflammation. Objective(s): To present case series of 3 patients who developed small fiber neuropathy after SARS-COV2 infection. Method(s): We identified patients with SFN after SARSCOV2 infection from our neuromuscular database. We performed chart review and obtained clinical, demographic and, outcomes information of these patients. Result(s): The age of patients was 46, 56 and 71 years. Two female and one male. Time to neuropathy symptom evaluation in clinic from positive COVID19 test was 4 months, 6 months, and 10 months, respectively. None of the patients were hospitalized or given additional medications for COVID treatment. Patients 1& 3 had mild respiratory symptoms. Patient 2 had no symptoms, just a routine pre-op test was positive. All patients had numbness, tingling and painful paresthesias as the main symptoms. The second patient reported autonomic symptoms of heart racing and temperature dysregulation. Nerve conduction studies did not show large fiber peripheral neuropathy in any of the patients. Skin biopsy was performed at 7 months, 8 months and 13 months respectively post COVID infection and was positive in all 3 patients. There was no other etiology identified for the neuropathy Treatment included gabapentin for the first patient, the second patient received narcotic medication for a surgery and continued this for her neuropathic symptomsand the third patient is not on any medications for SFN. Conclusion(s): SFN can be associated with prior SARSCOV infection. There is need for further research to determine possible underlying neuropathological mechanisms and find effective treatments in COVID-related SFN.
ABSTRACT
Background: The introduction of the novel COVID-19 vaccination raised concerns regarding side effects from patients who had undergone breast cancer treatment. Lymph node swelling after the mRNA vaccines (Moderna, Pfizer) is a distressing side effect for women treated for breast cancer as it may indicate cancer progression or recurrence. Patients at risk of breast cancer-related lymphedema (BCRL) are fearful that lymph node swelling from the vaccine could incite or worsen BCRL. Data investigating associated side effects in this population is essential for patient education and future self-advocacy. Purpose(s): The purpose of this study was to elicit side effects associated with the COVID vaccine in women treated for breast cancer. Method(s): 4,945 surveys were sent to women over the age of 18 who had received breast cancer treatment and had been prospectively screened for BCRL with perometry. 621 participants who received an mRNA vaccine and responded to the survey were included in analysis, 469 of whom completed booster dose surveys. Participants were asked about type and duration of side effects after each vaccine dose. Solicited side effects included injection site soreness, swelling, or redness;swelling, numbness, or heaviness of the arm;generalized muscle soreness (GMS);fatigue;headache;joint pain;chills;nausea;vomiting;fever;Bell's palsy;axillary or supraclavicular lymph node swelling;other;or none of the above. We computed frequencies and the median duration of side effects for each dose. To investigate predictors of side effects, we fit multivariable logistic regression models separately for each side effect, with random effects for participants to account for clustered responses. We considered significant predictors those with p < 0.05. Result(s): Of the 621 participants, the median follow-up time between breast surgery and date of first vaccine dose was 69 months. The distribution of the top 5 side effects is presented in Table 1. Of note, the majority of participants who reported lymph node swelling (9.8% dose 1, 12.9% dose 2, 11.3% dose 3) reported it in the axilla ipsilateral to the vaccine (54.1% D1, 61.3% D2, 71.7% D3). Lymph node swelling was also reported in the axilla contralateral to the vaccine (45.9% D1, 45% D2, 24.5% D3), supraclavicular region ipsilateral (29.5% D1, 26.3% D2, 32.1% D3) and contralateral (18% D1, 18.8% D2, 9.4% D3) to the vaccine. Older patients reported each side effect significantly less frequently. Those who had received neoadjuvant chemotherapy reported significantly more GMS and headache than those who did not. Those who had received regional lymph node radiation were less likely to report GMS, as were patients who had sentinel lymph node biopsies (vs. no lymph node surgery). The median duration of side effects for all three doses was 48 hours or less, with the plurality (41.0% D1, 38.7% D2, 44.1% D3) of participants reporting side effects lasting 24 hours or less. While all side effects apart from injection site soreness were significantly more common in the second than the first doses, the duration of side effects only increased for 28.1% of participants. Conclusion(s): Over 86% of women treated for breast cancer may experience at least one side effect after any dose of the COVID-19 vaccine. This data, collected specifically for patients with breast cancer, will help enhance guidelines for structured and universal education regarding additional doses of the vaccine in the future. This will allow patients to better understand COVID vaccine side effect profiles after breast cancer treatment and self-advocate prior to future doses. (Table Presented).
ABSTRACT
Introduction: Coronavirus disease 2019 (COVID-19) was described for the first time in December 2019. Symptoms include cough, fever, myalgia, headache, dyspnea, sore throat, diarrhoea, nausea, vomiting, and loss of smell or taste. Viral-induced myocarditis and pericarditis have been described in developed countries, and SARS-CoV-2 is cardiotropic. Pericarditis can mimic myocardial infarction (MI) in its presentation and ECG findings. Case report: A 46-year-old smoker with no previous medical condition presented with left-sided chest pain, sweating, trouble breathing, palpitations, and left-hand numbness. He denied having reduced effort tolerance, orthopnea, or paroxysmal nocturnal dyspnea. Three weeks earlier, he was infected with Covid-19 category 2A infection. On examination, he is haemodynamically stable, and his respiratory and cardiovascular exams were unremarkable. His ECG showed anterior ST elevation, and the bedside echocardiography showed no hypokinesia or pericardial effusion. High-sensitive cardiac troponin T reached 5000. The emergency team contacted the on-call cardiologist for primary PCI. After analysing the serial ECG and bedside echocardiography, he decided against primary PCI due to acute pericarditis. He was started on intravenous diclofenac acid and colchicine. His pain subsided after 3 days with NSAIDs and colchicine. He was reviewed back in the clinic and had a normal ECG and ECHO. Discussion(s): Pericardial disease caused by COVID-19 has been more common since the pandemic outbreak. Mycobacterium tuberculosis, Borrelia burgdorferi, Parvovirus B19, and Epstein-Barr virus are the most common infecting agents. Most cases of acute pericarditis in developing nations are due to tuberculosis infection. Nearly half of all patients who had previously recovered from COVID-19 infection have now presented with new cardiac MRI findings indicating pericardial involvement. Fibrosis and/or oedema may be linked to persisting active pericarditis following infection resolution, which may lead to short and long-term clinical consequences. Conclusion(s): The ST elevation in post-covid patients does not always signify myocardial infarction. Despite complaints and ECG findings, this could not be an acute myocardial infarction, for which clinicians should have a high index of suspicion.Copyright © 2023
ABSTRACT
Introduction/Background: Antiphospholipid syndrome (APS) is a rare autoimmune multisystem disease characterised by thrombosis and pregnancy morbidity in the presence of persistently elevated titres of: lupus anticoagulant, anticardiolipin and/or anti-glycoprotein 1. It may be primary (occurring alone) or secondary (in combination with another disease, most commonly systemic lupus erythematosus (SLE)). Recent publications highlighted clinical criteria limitations for children and raised awareness of the burden and prevalence of non-criteria manifestations in this population. This case report adds further weight to the need to raise multi-specialty awareness of non-criteria manifestations to aid recognition and treatment of this rare condition with potentially severe sequelae. Description/Method: 13-year-old female with SLE diagnosed aged 8 in India with bilateral optic neuritis occurring two months later. ANA positive at diagnosis with low complement and thrombocytopenia. Treated with prednisolone and hydroxychloroquine. Patient moved to the UK aged 9;initial abnormal bloods: mildly positive ANA (ENA negative), thrombocytopenia, strong lupus anticoagulant. As serology not strongly suggestive and optic neuritis rare in lupus diagnosis questioned. Ophthalmology review confirmed bilateral optic atrophy without evidence of previous vasculitis. There was debate whether the postretinal demyelination was due to antiphospholipid syndrome or a primary demyelinating condition. Hydroxychloroquine stopped and azathioprine started. Following normal neurology investigations (brain, spine MRI/MRV/MRA) concluded if patient developed new APSrelated symptoms or worsening visual evoked potentials anticoagulation would be discussed. Patient remained stable over four years with chronic thrombocytopenia and ESR persistently elevated. Azathioprine changed to Mycophenolate mofetil (MMF) due to side effects. Routine medication monitoring bloods in 2022 showed ESR 97, CRP 78, Platelets 61. Review identified vasculitic rash on soles of both feet with palpable nodules and normal pulses. Further investigation confirmed antiphospholipid antibody triple positivity. Aspirin commenced, hydroxychloroquine restarted, MMF dose increased and rituximab administered. Left foot rash settled but right progressed with toe discolouration and numbness. Skin biopsy considered but not performed due to skin integrity concerns. Foot pulses remained present and normal. Bilateral lower limb doppler reported as normal;increased symptoms resulted in CT angiogram which revealed bilateral non-occlusive popliteal thrombus and left pulmonary embolus. Subsequent echocardiogram was normal. Patient was anticoagulated with low molecular weight heparin followed by warfarin. Vascular surgical team advocated medical management and patient received seven infusions of Iloprost followed by Sildenafil. She achieved near total resolution of skin changes to toes with only minimal loss of skin over tip of right great toe. Patient will now require long-termanticoagulation. Discussion/Results: APS was considered in initial differential diagnosis but patient did not meet current clinical criteria as no past evidence of thrombosis. Lupus anticoagulant was consistently strongly positive and anticardiolipin repeatedly negative. As anti-B2 glycoprotein 1 antibody is not routinely tested and must be verbally requested, it was only checked once (negative) prior to discovery of triple positivity. ANA reported as strongly positive at time of SLE diagnosis but reviewing original notes from India titre was 1:100 and therefore not highly convincing. ENA negative and complement and white cell count normal on repeat testing since. Therefore, it is probable that this patient has primary APS as opposed to secondary APS in association with SLE. However, it is possible that this patient may develop more symptoms of SLE over time. When this patient presented with foot rash there were high numbers of children presenting with varying severity of painful, itchy toes coined 'covid toes' due to suspected lin to SARS-CoV-2 infection. Patient had exposure history, and COVID antibody serology was difficult to interpret due to recent vaccination. Dermatology found appearance to be consistent with 'covid toes' and advised supportive treatment. The triple APS antibody positivity result provided probable aetiology. Providing evidence of thrombus was problematic with false reassurance from apparently normal lower limb arterial doppler when actually popliteal arteries were not checked in view of the presence of normal flow proximally at the groin and distally in the feet. This case highlights the need to continue to search for thrombus in presence of high titres antiphospholipid antibodies and particularly in the case of triple positivity as although patient presented with colour change to toes, she was entirely asymptomatic from her PE and her left foot improved spontaneously despite a left popliteal thrombus also being present. Key learning points/Conclusion: Non-criteria manifestation of thrombocytopenia (occurs in 25% paediatric APS patients) was present throughout and patient had past history of haematuria (a recognised renal non-criteria manifestation). A paediatric specific APS criteria including these may have resulted in earlier detection of triple antiphospholipid antibody positivity and thus earlier treatment escalation and possible avoidance of thrombus. It has been reported that a high proportion of children with positive antiphospholipid antibodies don't develop a thrombus. However, it is interesting that our patient was entirely asymptomatic from her pulmonary embolus which was an incidental finding on her CT angiogram. This prompts a discussion about how much imaging should be performed in those with high levels of persistent positive antiphospholipid antibodies. Rituximab resulted in normalisation of platelet count and ESR for the first time since initial presentation. Anticardiolipin antibodies normalised, lupus anticoagulant decreased from strong to moderate and anti- B2 glycoprotein levels decreased but remained positive. Rituximab is a recognised treatment for catastrophic antiphospholipid syndrome (CAPS) but not routinely used in APS. The consistently raised ESR in an apparently clinically well patient is a reminder to continue to search for causes of inflammation. As the CRP was largely in normal range, this demonstrates the unique value of the ESR. In view of anti-B2 glycoprotein 1 antibody requiring to be verbally requested, discussions are ongoing with the laboratory department regarding the possibility of electronic request and a comment with recommendation to check other two antiphospholipid antibodies following one positive antibody result. As a result of this case, a plan will be put in place to ensure annual screening of antiphospholipid antibodies in all juvenile SLE patients in our care. It is hoped that this case report promotes discussion amongst the paediatric rheumatology community regarding further research required for development of paediatric specific APS criteria and management.
ABSTRACT
Objective Acquired neuromyotonia or Isaacs' syndrome is an immune mediated inflammatory disorder characterized by involuntary continuous muscle fiber activity manifesting as twitching and stiffness along with autonomic dysfunctions like hyperhidrosis and/or tachycardia. Here we report a young male who developed acquired neuromyotonia following COVID- 19 vaccination. Background A 20-year-old male presented in our clinic with gradually progressive pain and numbness in bilateral lower limbs, tremors in both hands, shivering while walking, excessive sweating and difficulty in micturition for last 15 days. He also noticed twitching of muscles in calf and thigh muscles along with these symptoms. According to patient, these symptoms started after he took his first dose of COVID-19 vaccination (Covishield- Oxford- AstraZeneca viral vector vaccine) 10 days back. There was no history of fever or backache. He had no chronic illness and was not on any medications. Examination revealed hyperhidrosis, mild proximal muscle weakness in both lower limbs with twitching in muscles suggestive of myokymia. There were quivering and rippling movements of intrinsic muscles of both hands resembling polyminimyoclonus. In view of the above findings, possibility of acquired neuromyotonia possibly following COVID-19 vaccination was kept and further evaluation was done. Design/Methods Routine blood investigations, thyroid function test, anti-thyroid peroxidase antibodies and anti-nuclear antibodies were normal. Cerebrospinal fluid analysis was normal. Anti-VGKC antibodies were detected in serum with strongly positive anti-CASPR and weakly positive anti-LGI1 antibodies confirming diagnosis of acquired neuromyotonia. Results Pulse dose of intravenous methylprednisolone for 5 days was given which resulted in visible improvement in pain, twitching, hyperhidrosis and urinary symptoms. He was continued on oral steroids and complete resolution of his symptoms was noted over a period of 2 months. Conclusions COVID-19 vector vaccine associated acquired neuromyotonia is a rare condition, but its early recognition and treatment is the key for a favorable prognosis.
ABSTRACT
Introduction: Viruses belonging to the SARS-COV family are known for their neurotropic properties. During the COVID-19 pandemic increasing data emerged, providing evidence for CNS and PNS engagement due to SARS-COV-2 infection. Cranial nerves as well as peripheral nerves have been described to be affected. According to some recent studies, a significant number of COVID-19 patients develop neurological manifestations. Method(s): We present a case of a 38-year-old woman suffering from left-sided facial pain and hypoesthesia, as well as paraesthesia, hypoesthesia, and pain in her left arm. One to two weeks prior to these symptoms, she presented with signs of upper respiratory tract infection and loss of taste and smell. She underwent a routine neurological examination and prior to her admission to the neurology ward she tested positive with qPCR for SARS-COV-2 in a nasopharynx swab. Subsequently she underwent brain and spinal MRI, analysis of cerebrospinal fluid (CSF) and neurophysiological examinations including nerve conduction studies and blink reflex analysis. Result(s): The brain and spinal MRI, CSF analysis and nerve conduction studies of the left arm (n. medianus, n. ulnaris, and the superficial radial nerve) and the facial nerve (CN VII) showed normal results. Normal blink reflex responses were obtained from both the supraorbital nerve and infraorbital nerve. When examining the mental nerve, normal responses were obtained from the asymptomatic right side but from the symptomatic left side both ipsilateral R2 and contralateral R2 responses were absent. This indicates an afferent non-specific lesion in the left mental nerve. Conclusion(s): When considering the course of her condition and excluding other probable causes, the symptoms were regarded to be related to her SARS-COV-2 infection. Hence, with this case report we can present objective neurophysiological evidence that a specific segment of the trigeminal nerve, in this case the mental nerve, can be affected by neuralgia due to COVID-19. It is notable that the patient did not present with symptoms of typical/classic trigeminal neuralgia. She was treated with carbamazepine and the facial pain was significantly improved. To the best of our knowledge, this is the first report of a pathological blink reflex associated with COVID-19. Copyright © 2022
ABSTRACT
Background: An inflammation of the mucous membranes in the paranasal sinuses is known as paranasal sinusitis. The facial bones close to, behind, and above the nose have cavities called sinuses. All paranasal sinuses have mucous membrane lining and are joined to the nasal cavities. Case presentation: A 70 years old male came to the Ear Nose Throat department with the chief complaint of generalized headache, dull activity.Also complaint of reduce vision on both eye, blur vision of near by object and unable to see distant object, reduced sensation of smell. Patient had history of Diabetes mellitus since 5 year and having hypertension since 2 year and patient was diagnosed with covid -19 since 5 month back, was hospitalized for 15 days. On arrival physical examination of the face was carried out with shows swelling around both the eye, Nostrils finding are yellowish greenish foul smelling debris in bilateral nostrils septal perforation present posteriorly.MRI and histopathology was done later he was treated antibiotics and analgesic. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.