One-year outcomes following rehabilitation for chronic hip-related groin pain: ancillary analysis of a pilot randomized clinical trial

Purpose: Rehabilitation to address modifiable factors associated with chronic hip-related groin pain (CHRGP) may lead to reduced pain and improved function, yet little is known about its effectiveness. We assessed the preliminary effects of two interventions that target two distinct mechanisms, sensory disturbances and abnormal movement patterns. Sensory disturbances such as peripheral and central sensitization may contribute to pain persistence long after initial injury. Joint mobilization (JtMob) may impart a neurophysiological response within the nervous system that results in pain reduction and improved mobility. Abnormal movement patterns may create altered mechanical stresses on hip joint structures, resulting in pain and activity limitations. Movement pattern training (MoveTrain) may improve movement patterns and thus patient function. Method(s): Patients with CHRGP, 18-40, were enrolled. Assessments included self-report questionnaires, clinical exam, and quantitative sensory testing. Outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS), a patient-reported outcome;frontal plane kinematics of hip, pelvis, and trunk during single leg squat;and pain pressure threshold (PPT) assessed at the anterior groin of the most bothersome hip and dominant thenar eminence (local and generalized pressure hypersensitivity, respectively). Patients were randomized to JtMob or MoveTrain in a 1:1 ratio stratified by sex and HOOS Symptoms. Treatment for both groups included 10 individualized visits over 12 weeks with a trained physical therapist (PT);assessment of patient goals and education which focused on patient-specific tasks reported by the patient to be symptom-producing;instruction in a home exercise program (HEP);and handouts that provided education, description and benefits of assigned treatment and instructions for HEP. The key element of JtMob was PT-provided manual techniques using specific criteria to determine the joint mobilization techniques and parameters used for each patient. The patient's symptom report to each technique was monitored and if indicated, the technique modified according to our outlined procedures. The HEP included flexibility exercises. The key element of MoveTrain was task-specific instruction to correct abnormal movement patterns displayed during daily and patient-specific tasks. For example, hip adduction was minimized during a step descent. The HEP included repeated practice of modified tasks. Task difficulty was progressed based on each patient's performance. Immediately after treatment completion, patients returned for follow up assessment. To assess treatment sustainability after the active treatment phase, we collected HOOS at 6 and 12 months (extended follow-up), and kinematics and PPT at 12 months. Data from patients who provided any data after baseline were analyzed with a repeated measures analysis of variance (RM-ANOVA) with baseline value as a covariate, patient as a random effect, and an autoregressive covariance structure. After adjusting for baseline, the between-group difference in change from post-treatment to each extended follow-up results from pre-planned statistical contrasts in a RM-ANOVA that includes main effects for treatment group, visit and the group by visit interaction. The within-group treatment effect at each extended follow-up was calculated by subtracting the earlier time point from the later follow-up within each treatment group. Dependent samples t-tests were used to assess the degree of within-group change. Result(s): Demographics and outcome data are provided in Tables 1 and 2, respectively. Thirty-three patients with CHRGP were randomized and 29 (88%) provided post-treatment data. Four patients did not complete treatment or post-treatment testing (3 due to COVID pandemic, 1 lost to follow up);6 patients did not complete 12 month laboratory testing (due to pandemic), but did complete 12 month questionnaires. Previously, we reported that both groups reported clinically important improvements in HOOS subscales and MoveTrain group improved hip and pelvis kinematics immediately after treatment compared to baseline. After adjusting for baseline, there were no between-group differences in change in outcomes between post-treatment and extended follow-up when comparing JtMob and MoveTrain, indicating that treatment effects immediately post-treatment were maintained at 12 months after treatment completion. Conclusion(s): Our preliminary findings suggest that 12 weeks of JtMob or MoveTrain, may result in improvements in patient-reported pain and function and these effects may persist 12 months after treatment completion. A future, larger trial to definitively assess the efficacy of JtMob and MoveTrain and identify factors associated with long-term outcomes will improve our ability to develop treatment strategies for people with CHRGP. [Formula presented] [Formula presented]Copyright © 2023

Guillain-Barre syndrome following COVID-19 vaccination: a case report and an updated review

Background: Coronavirus disease-2019 (COVID-19) has caused a pandemic that has recently affected every aspect of life. Fortunately, many vaccines with high safety and efficacy profiles were developed timely to face this pandemic. In a very short time, billions of people were vaccinated. In the meantime, a wide range of neurological syndromes are being reported. Guillain-Barre syndrome (GBS) which is a rare immune-mediated post-infectious peripheral neuropathy was reported after both the COVID-19 infection itself and many types of its vaccines. Method(s): We are reporting a case of post-AstraZeneca vaccine GBS and reviewing the literature of all reported post-COVID-19 vaccines GBS till July 2021. Result(s): 29 adult patients were reported. Of them 58.6% were males. Their mean age is 58.2 years. The median time to clinical onset after vaccine administration was 13.2 days. 86.2% of patients had their symptoms following immunization with the 1st dose of AstraZeneca vector-based covid vaccine. Facial palsy was the most predominant single symptom in 75.8% of patients. Conclusion(s): Guillain-Barre syndrome is a well-recognized but still rare adverse event following vaccination against COVID-19. Although preliminary data incriminates viral vector-based vaccines more than the other types, active post-vaccination surveillance and more powerful statistics are mandatory to reach a solid conclusion regarding the presence of a causal relation.Copyright © 2022

Transverse myelitis as neurologic sequelae in a COVID-19 recovered patient

Background: Months after the initial report of an unknown cause of pneumonia outbreak in Wuhan, China, the SARS-COV-2 continues its rampant spread globally. This novel corona virus has been known to cause severe respiratory illness. It is important to be wary of the complications that would soon present at the Out-patient centers after being cured from the infection. Case: This is a case of a 59-year-old, female who came in at the Out-Patient Clinic with progressive bilateral pins and needles sensation of the feet after recovering from COVID-19 infection followed by a sensory level on T7-T10. Case Report: Here we present a case of transverse myelitis as a complication of COVID-19 infection, the first to have occurred after recovery from the virus. With the success of treatments and recoveries, possible post infectious sequelae could be the next wave that could come into the present picture of the pandemic. Conclusion(s): Post infectious transverse myelitis after recovering from COVID-19 is a possibility and that documentation of such cases and other complications must be reported.Copyright © 2022

A Case of Sars-Cov-2 Omicron Variant Associated Acute Encephalomyelitis

With the ongoing pandemic of SARS-CoV-2 many neurological complications in relation to COVID-19 infection as well as immune-mediated and vaccine-associated phenomena have been described. To our knowledge, there has been no publication of a case of SARS-CoV-2 Omicron variant associated acute encephalomyelitis. We present a case of a 73-year-old woman with no relevant Background history who is otherwise fit and well and fully vaccinated. She suffered from mild COVID symptoms and had a positive PCR test with presumptive Omicron variant on day 2. Five days into her respiratory illness she developed in quick suc- cession sensory disturbances of hands and feet, bilateral asymmetric flaccid leg weakness, and mild arm weakness. She had absent deep tendon reflexes in the legs and diminished deep tendon reflexes in the right arm. MRI of brain and spine showed signal changes in the brainstem, cervical and low thoracic cord in keeping with acute encephalomyelitis. Her CSF showed an inflammatory picture with raised protein of 1.27g/L and no cells. At the time of submission, the patient received treatment with five days of intravenous steroids followed by ongoing plasma exchange and no comment on treatment response can be made at this stage.

Meningoradiculitis post-COVID-19 mRNA vaccination: A case report

We present a rare case of meningoradiculitis occurring after mRNA COVID-19 vaccination. This patient, with a history of inflammatory arthritis following rubella vaccination, presented to the emergency department 4 days after her vaccination with both central and radicular nervous system symptoms. Symptoms included pain, sensory and motor deficits in L5 roots distribution, along with signs of central irritation, such as headache, difficulty concentrating and a Babinski sign. MRI showed bilateral L5 nerve roots enhancement. Lumbar puncture showed elevated protein and IgG, and relevant serologies excluded common causes. Prednisone and physical therapy helped the patient to achieve near complete recovery nine weeks after presentation. We concluded that this patient presented meningoradiculitis probably secondary to her vaccination in a context of possible overactive immune system. While such presentations might be rare, and do not constitute a general reason to abstain from vaccination, they must be well recognized and treated.Copyright © 2022

MOTOR CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY IN A CHILD.

Motor chronic inflammatory demyelinating polyneuropathy (M-CIDP) is a form of atypical CIDP. This article presents a clinical observation of M-CIDP in a 15-year-old boy, as well as a description of laboratory and instrumental diagnostic data. The boy had a chronic development (> 2 months) of flaccid tetraparesis, predominantly of the proximal muscles of the limbs, without sensory disorders. According to electroneuromyography, there were signs of demyelinating lesions of the proximal parts of the peripheral nerves. There was an increase in the thickness of the nerves of the upper limbs according to ultrasound. In the liquor protein-cell dissociation, as well as in the blood, IgG antibodies to the surface glycoprotein S of the SARS-CoV-2 coronavirus were found. The clinical and neurophysiological picture corresponded to the reliable criteria for CIDP. The therapy with intravenous immunoglobulins had a significant positive effect in the form of an increase in the strength of the limb muscles.Copyright © Russian Neurological Journal. All rights reserved.

MOTOR CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY IN A CHILD.

Motor chronic inflammatory demyelinating polyneuropathy (M-CIDP) is a form of atypical CIDP. This article presents a clinical observation of M-CIDP in a 15-year-old boy, as well as a description of laboratory and instrumental diagnostic data. The boy had a chronic development (> 2 months) of flaccid tetraparesis, predominantly of the proximal muscles of the limbs, without sensory disorders. According to electroneuromyography, there were signs of demyelinating lesions of the proximal parts of the peripheral nerves. There was an increase in the thickness of the nerves of the upper limbs according to ultrasound. In the liquor protein-cell dissociation, as well as in the blood, IgG antibodies to the surface glycoprotein S of the SARS-CoV-2 coronavirus were found. The clinical and neurophysiological picture corresponded to the reliable criteria for CIDP. The therapy with intravenous immunoglobulins had a significant positive effect in the form of an increase in the strength of the limb muscles.Copyright © Russian Neurological Journal. All rights reserved.

Serum negative neuromyelitis optica spectrum disorder after vaxzevria vaccination: A case report

Background: Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disease, targeting the central nervous system, rarely associated with vaccination. Case report: We report a case of a 47 year-old healthy woman who presented, ten days after the first dose of SARS-CoV-2 Vaccine AstraZeneca (Vaxzevria), with back pain, tetraplegia, urinary retention, dysarthria and dysphagia. The patient was diagnosed NMOSD. She underwent intravenous-corticosteroids, vein-Immunoglobulin and plasma-exchange without significant improvement . Conclusion(s): The absence of any possible related conditions, the temporal relation with anti-SARS-CoV-2 vaccination, suggest that, in our case, NMOSD may be due to the cross reaction from Vaxzevria.Copyright © 2021 The Author(s)

Remote Upper Limb group intervention post stroke increases intensity and improves wellbeing

Introduction: Increasing the intensity for upper limb rehabilitation post stroke has been emphasized in research and evidence. COVID-19 limitations with face-to-face therapy, have increased the opportunities to consider remote rehabilitation to provide the intensity needed. The aim of the group is to provide a goal based, structured exercise programme for upper limb among stroke survivors. Method(s): The Remote Upper Limb group has started to be part of the service that CST provides since 2020. The group consists of a warm-up, exercises using activity station, and functional exercises where we use items available at patients' home. The exercises are designed to address these areas: shoulder, elbow, forearm, wrist fingers, activities, and functional activities. The group also provides education session for the upper limb including pain, sensory deficits, specificity, subluxation, oedema and, learned non-use. Standardised outcome measures are taken at the beginning and the end of the group and used to measure progression and improvement. Result(s): The remote upper limb group intervention has emerged as a promising intervention to increase intensity and achieve patients' outcomes. The outcome measures have shown clinically significant improvement in patients' physical outcomes and their wellbeing. The patients report opportunities for peer support as their main benefit. Conclusion(s): The remote upper limb group is an intervention that increases patients' intensity and improves well-being in a costly effective way for both therapists and stroke survivors.

Agranulocytosis following intravenous immunoglobulin administration in a patient with Guillain-Barre Syndrome triggered by COVID-19: A case report

Neutropenia during recovery after coronavirus disease 2019 (COVID-19), as well as neutropenia after intravenous immunoglobulin (IVIG) administration are very rare hematological abnormalities. We report the first case of agranulocytosis following IVIG administration in patients with Guillain-Barre syndrome (GBS) triggered by COVID-19. A 62-year-old female patient was admitted to the Emergency Department due to progressive limb weakness and sensory disturbances that began two weeks before admission. Five weeks before admission she was treated for COVID-19 and has fully recovered. She was diagnosed with Guillain-Barre syndrome (GBS), and treatment with IVIG was started. Twenty hours after the first dose of IVIG, blood analysis showed neutropenia and thrombocytopenia, and after the fifth dose she developed agranulocytosis followed by mild increase in body temperature. Granulocyte colony-stimulating factor (G-CSF) was administered and after 12 hours the leukocyte lineage recovered. According to the previous findings, neutropenia after IVIG administration might be related to CD11b, and COVID-19 is associated with an increase in immature neutrophil populations in the later stages of the disease defined by their expression of CD11b. Meanwhile, some finding suggests that corticosteroid pretreatment prevent neutropenia after IVIG administration, which might be important because many patients with post-COVID GBS have been treated with corticosteroids for COVID-19. Copyright © 2022, ASEAN Neurological Association. All rights reserved.

DURAL VENOUS SINUS THROMBOSIS: A RARE PRESENTING CONSEQUENCE OF COVID-19

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The severe acute respiratory syndrome coronavirus (SARS-COV2) and its resulting coronary virus 2019 syndrome (COVID-19) has resulted in an unprecedented global pandemic affecting more than 250 million people and resulting in at least 5 million deaths worldwide. Clinical manifestations of the Covid-19 disease process include but are not limited to respiratory dysfunction and failure, coagulopathy, malaise and cytokine storm. We report a case of dural sinus thrombosis (DST) as a sequelae to COVID-19. CASE PRESENTATION: A 26-year-old woman with a history of migraines presented with sudden diffuse headache and photosensitivity. She reported no palpitations, oral ulcers, dizziness, diaphoresis, slurred speech, weakness, paresthesias or recent head trauma. Her presenting vital signs were within normal range. Physical exam was negative for focal neurologic deficits, weakness, or sensory loss. A rapid pregnancy test was negative. D-dimer was 7,200 ng/mL (reference <500 ng/mL). A COVID test was positive. A computed tomography (CT) of the head revealed diffuse hypodensity in the torcula and the transverse sinuses bilaterally extending into the cerebellar folia, suspicious for DST, which was confirmed on magnetic resonance venography. A full hypercoagulable panel resulted negative. It was determined that the patient's coronavirus disease infection resulted in a prothrombotic state and her dural sinus vein thromboses. The patient was started on a high intensity heparin drip for seven days, then transitioned to Dabigatran and Topiramate for management of headache upon discharge. DISCUSSION: COVID-19 typically manifests as fever, hypoxia, and dyspnea. If coagulopathy were to occur, the most common of them are deep vein thromboses. Cerebral thrombotic events, specifically, a DST has been underreported in literature. It is suspected that the burden of cerebral thrombosis in COVID-19 patients is 0.08%. In the same study, it was also identified that 31% of those who developed a cerebral thrombosis also had other hypercoagulable risk factors not present in this patient. Advancement in neuroimaging has allowed these thrombotic issues to be identified, however, early recognition, especially with a lack of risk factors, creates a less straightforward management plan. Our patient manifested a DST in the setting of an active COVID-19 infection. Higher levels of evaluation are required in patients who test positive for Covid-19 when clinically indicated. Such indications include headaches that are new in onset, severe in nature, and diffuse. Delayed diagnosis and management can be permanently damaging. CONCLUSIONS: Dural venous sinus thrombosis is a rare, yet deadly complication of COVID-19. All risk factors and other etiologies of hypercoagulable states should be ruled out followed by early detection based on clinical and physical exam, and accompanied by appropriate imaging followed by prompt intervention. Reference #1: Baldini, T., Asioli, G. M., Romoli, M., Carvalho Dias, M., Schulte, E. C., Hauer, L., Aguiar De Sousa, D., Sellner, J., & Zini, A. (2021). Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. European journal of neurology, 28(10), 3478–3490. https://doi.org/10.1111/ene.14727 Reference #2: Hemasian, H., & Ansari, B. (2020). First case of Covid-19 presented with cerebral venous thrombosis: A rare and dreaded case. Revue neurologique, 176(6), 521–523. https://doi.org/10.1016/j.neurol.2020.04.013 Reference #3: Thompson, A., Morgan, C., Smith, P., Jones, C., Ball, H., Coulthard, E. J., Moran, E., Szewczyk-Krolikowski, K., & Rice, C. M. (2020). Cerebral venous sinus thrombosis associated with COVID-19. Practical neurology, practneurol-2020-002678. Advance online publication. https://doi.org/10.1136/practneurol-2020-002678 DISCLOSURES: No relevant relationships by Steven Douedi No relevant relationships by slam Elkherpitawy No relevant relationships by Justin Ilagan No relevant relationships by David Kountz No relevant relationships by Anton Mararenko No relevant relationships by Mihir Odak

Neuropathies Amidst the Pandemic: Remote Phenotype Validation and Assessment of Patient Needs

The past two years have been significantly overshadowed by the respiratory virus Covid-19. This has shown a relevant impact on health care systems, so that at a specialized neuromuscular center, we experienced a shortness of personnel and time, and in parallel, we were facing many unanswered questions addressed to us by patients with rare diseases. In this study, we developed a new questionnaire to assess patient needs, concerns, and symptoms confronting the global pandemic. We included individuals with hereditary neuropathies (n=15), autoimmune-inflammatory neuropathies (n=26), or idiopathic small fiber neuropathies (n=45). For validation, we used previous clinical examination reports. Forty-six percent of the included patients were female, 52% male, and one patient diverse. The mean age at examination was 52.67±13.37 years (range: 19-79 years). Most of the patients (59%) reported mild to moderate limitations in their daily life activities due to Covid-19. Severe impairment was reported in 28%. Due to the pandemic, 54% of the patients reported to be concerned about their own and 76% about their relatives' health. Patients with a positive family history were 2.4x more likely to be seriously worried about other family members. We observed that patients with more wide-spread sensory loss reported higher impairment levels than those with distal sensory loss only. Overall, 37% of the patients said that contracting Covid-19 was their main concern, including the presumed risk of a severe course. Further 34% were worried that their neuropathy might worsen if they ever contracted Covid-19. Thirtythree percent of the patients experienced limitations in their treatment options, e.g. by not being able to continue their physical therapy. Seven percent were concerned about social distancing, as daily care required direct interactions with others. Whereas 65% of the included individuals confirmed that they felt appropriately informed by their treating physicians, 21% wished to receive more information. Sixteen percent, however, said that they did not dare to ask their questions in order to not disturb the health care personnel amidst the crisis. Patients with hereditary, autoimmune, or small fiber neuropathies did not show any differences in their Covid-related dailylife impairment. Previous clinical results correlated with patient-reported sensory levels;and gait unsteadiness was reported significantly more often in patients with afferent ataxia. We conclude that Covid-19 imposes a relevant daily-life burden on neuropathy patients. Patient-reported outcome measures are a valid remote strategy if in-person visits are not possible.

Overview of COVID-19 Infection and NM Disease Associated with COVID-19 Infection (e.g., GBS/neuritis, Myositis)

The COVID-19 pandemic caused by infection by SARS-CoV-2 has been associated with several neuromuscular disorders including various inflammatory neuropathies (e.g., Guillain-Barre syndrome) and myopathies (e.g., rhabdomyolysis, myositis). Temporal associations however do not imply causality. In this lecture, Dr. Amato will review the literature regarding to neuromuscular complications associated with SARS-CoV-2 infection. There are conflicting studies but if SARS-CoV-2 infection indeed causes GBS it is likely quite rare (probably < 1 case per 100000 infection). Less is known about other infl ammatory neuropathies (mononeuritis, plexitis, or CIDP). Larger epidemiological studies are needed to better define the causality. Elevated serum creatine kinase and myalgias are common in hospitalized patients with COVID-19 and in some myositis has been demonstrated on muscle biopsy. Furthermore, autopsy series have shown myositis and neuritis in patients who died from COVID-19 though virus has not been demonstrated in muscle or peripheral nerve. The inflammation is primarily felt to be due to cytokine release and not direct viral invasion of muscle or nerve. Finally, many affected patients have lingering symptoms (Long COVID) or Post-Acute Sequelae of COVID-19 (PASC) that often include neuromuscular symptoms (fatigue, weakness, lightheadedness, sensory loss and pain) that are of unclear nature.

Haematological Malignancy Presenting in an Unusual Manner

Chronic lymphocytic leukaemia is a haematological malignancy that occurs due to an increased proliferation of mature B lymphocytes. It is considered to be the most common leukaemia in adults. Hyponatremia is commonly seen in such patients. This case report is about a 75-year-old male, who presented with giddiness, followed by altered sensorium. However, the patient had no motor weakness or sensory loss. Initially, a diagnosis of posterior circulation stroke was made but Magnetic Resonance Imaging (MRI) brain did not show associated signs. The routine investigations showed highly elevated total leukocyte count and hyponatremia. The patient was worked up for malignancy and diagnosed with Chronic lymphocytic leukaemia. Oncology reference was taken and treated with tablet Ibrutinib. On discharge, the patient's mentation improved, and he is on regular follow-up.

TRANSVERSE MYELITIS: A RARE BUT SERIOUS COMPLICATION OF COVID-19 VACCINATION

CASE: The patient is a 66-year-old male presenting with progressive ambulatory dysfunction and lower extremity weakness that began ten days ago. Notably, the patient was admitted to the hospital two months prior with similar complaints. At that time, he was diagnosed with transverse myelitis after MRI showed a spinal cord lesion concerning for demyelination at T3-T4. The patient was treated with IV steroids and discharged. Neurology impression at time of discharge was transverse myelitis possibly related to Covid vaccination two weeks prior to admission. The patient states he was doing fine after initial discharge before recurrence of his progressive weakness and difficulty walking that led to the current admission. He denies fever, chest pain, abdominal pain, and bladder/ bowel incontinence. The patient is a former smoker and denies current alcohol or drug use. Past medical history includes WPW status post ablation, stable thoracic aortic aneurysm, peripheral neuropathy secondary to past alcohol abuse, osteoarthritis, GERD, and anxiety. Family history is remarkable for cancer, coronary artery disease, and diabetes in his father. Medications include metoprolol, tamsulosin, pantoprazole, olanzapine, and venlafaxine. Neurological exam is positive for atrophy and decreased vibratory sensation in bilateral lower extremities. His gait is not assessed due to safety concerns, but the patient notes he has begun using a cane to assist with ambulation. Otherwise, physical exam is unremarkable. Imaging studies include MRI showing T3-T4 hyperintensity, as seen during previous admission two months prior. Labs including ANA, rheumatoid factor, SPEP, CSF studies, and AQP-4 were negative. After an unrevealing workup, the patient experienced symptomatic improvement with IV steroids and was discharged home. IMPACT/DISCUSSION: Our case illustrates a clinical picture of Covid-19 vaccine-related transverse myelitis, a rare but serious complication of the vaccine. The prolonged course of this patient's complications is concerning, although the benefit of receiving the vaccine remains unquestionable. Furthermore, although the timing of symptom onset and vaccination suggests a relation, there are other diagnoses that could explain the presentation and further research is needed regarding vaccine-related side effects. This case emphasizes the importance of maintaining a high index of suspicion for neurological issues of unclear etiology following recent Covid-19 vaccination despite their rare occurrence. CONCLUSION: Teaching points: Diagnostic criteria for transverse myelitis includes sensory, motor, or autonomic dysfunction attributable to spinal cord, no evidence of cord compression, bilateral symptoms with clear sensory level, and inflammation defined by CSF analysis, elevated IgG, or MRI enhancement. Neurological complications of the Covid vaccine include general symptoms such as headache, fever, and fatigue, Bell's palsy, encephalomyelitis, myelitis, and cerebral venous sinus thrombosis.

Super Slow Conduction Velocitiesin Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)

Objective: NA Background: Chronic inflammatory demyelinating polyneuropathy (CIDP) is characterized on nerve conduction study (NCS) by prolonged distal latencies, slowed conduction velocities, prolonged late responses, conduction blocks, and temporal dispersion. Unmyelinated fibers typically conduct action potentials at speeds of 0.5-10 m/s;myelinated fibers conduct an order of magnitude faster, e.g. 50-70 m/s. While very slow conduction velocities < 25 m/s are typically associated with the genetic neuropathies as in the Charcot-Marie Tooth neuropathies, CIDP can manifest with slow conduction velocities. Prompt recognition of CIDP is crucial for the timely initiation of immunotherapy. Design/Methods: NA Results: This case series of three CIDP patients demonstrates very slow conduction velocities and prolonged distal latencies. An 81-year-old woman with history of multiple sclerosis and chronic myelogenous leukemia presented with inability to walk over a few months with diffuse sensory loss. NCS showed absent motor responses in the leg, partial conduction blocks in the arm, prolonged ulnar motor distal latency 7.9 ms (normal ≤3.4ms), and very slow conduction velocities < 15 m/s. A 50-year-old woman with prior history of COVID-19 presented with diffuse weakness. NCS showed ulnar motor distal latency of 23.2 ms, slowed motor conduction velocities < 30 m/s. After treatment initiation with intravenous immunoglobulin, sensory responses improved, and conduction velocities increased to > 30 m/s. A 49-year-old woman presented with 3 months of bilateral weakness and sensory symptoms two weeks after a COVID-19 vaccination. NCS showed ulnar motor distal latency of 14 ms and slowed motor conduction velocities < 30 m/s. Conclusions: Very slow conduction velocities are a feature not just of the genetic neuropathies but also of acquired demyelination as seen in CIDP, and the latter is distinguished by abnormal temporal dispersion and conduction blocks. Astute electrophysiologists should modify sweep speed and gain to increase sensitivity for delayed or dispersed responses.

Post-acute sequelae of SARS-CoV-2 infection (PASC): peripheral, autonomic, and central nervoussystem featuresin a child

Objective: To describe treatment with intravenous immune globulin (IVIG) of severe central, peripheral and autonomic (CNS, PNS, ANS) post-acute sequelae of SARS-CoV-2 infection (PASC) in a child. Background: PASC is defined as failure to recover from acute COVID-19 in those persistently symptomatic for>30 days from onset of infection with any pattern of tissue injury that remains evolving including the nervous system. Design/Methods: A child underwent extensive evaluation of the CNS, PNS and ANS according to the authors protocol for COVID-19 neurologic illness. Results: A 12-year-old girl was initially well until March 2020 until exposure to other family members testing positive for COVID-19 infection she contracted an upper respiratory infection illness with loss of taste, and excessive fatigue followed in July 2020 by burning, weakness, slurred speech and impaired cognition leading to a bedbound state and a concern she was suffering from conversion disorder. Examination in September 2020 showed mild delirium, tetraparesis, stocking sensory loss and areflexia. Electrodiagnosis showed mixed chronic distal demyelinating and axonal changes. Epidermal nerve fiber studies showed reduced calf and thigh densities. Autonomic studies showed symptomatic hypotension with tilting and reflex tachycardia. Brain FDG PET/MRI showed hypometabolism of bilateral anterior and mesial temporal, superior parietal, and lateral occipital lobes, anterior cingulate cortices, and the cerebellar hemispheres with hippocampus volumes <5% of age-matched controls. Lumbar puncture showed a total protein of 136 mg/dL. EEG and Mayo Clinic ENS2 panel did not show evidence of autoimmune encephalitis. From October 2020 to February 2021, she received monthly 2 g/kg/month of intravenous immune globulin (IVIg) with overall clinical improvement. Conclusions: The underlying basis of PASC, especially in the CNS, has not yet been fully appreciated awaiting controlled clinical and autopsy studies. IVIg is effective initial therapy of PASC to modulate neurologic post-infectious immunity. COVID Long Hauler and Long COVID are inappropriate terms for PASC.

Autoimmune Acute Myelitis with Guillain-Barré Syndrome and Cerebellar Ataxia after COVID-19 Infection: a Case Report

Objective: We aim to report clinical characteristics of an extremely rare case of myelitis with Guillain-Barré syndrome (GBS) and cerebellar ataxia (CA) after COVID-19 infection. Background: There have been many reports about neurological complications following the world pandemic of COVID-19. We found about 100 GBS, 50 myelitis, and 10 CA cases after COVID-19 infection. To best our knowledge, this is the first report of myelitis with GBS and CA accompanied by multiple autoantibodies. Design/Methods: NA Results: A 60-year-old man with fever and cough was diagnosed with mild COVID-19 infection. Fourteen days later from the onset, he developed gait disturbance and fell frequently. On hospitalization, he exhibited fever, hypoxemia, mild consciousness disturbance, flaccid paraplegia, mild numbness and severe deep sensory disturbance in the lower limbs, bladder and bowel disturbance, mild muscle weakness in the fingers, myoclonus in the extremities, and CA. The PCR of COVID-19 was negative. Blood investigations showed elevated inflammatory markers with dehydration, rhabdomyolysis, and hypercoagulation. Cerebrospinal fluid (CSF) analysis presented mild pleocytosis and elevated protein without anti-COVID-19 antibodies. Contrast-enhanced CT showed massive pulmonary embolisms and deep venous thromboses. Brain SPECT showed cerebellar hypoperfusion despite no abnormalities in brain MRI. Spine MRI revealed longitudinal hyperintense lesions mainly in the dorsal white matter, compatible with myelitis. Additional investigations of autoantibodies realized anti-GM3, TPI, GluR, and NMDAR IgG antibodies in serum, and anti-GluR and NMDAR IgG antibodies with increased granzyme B in CSF. Treatments of corticosteroid and intravenous immunoglobulin resulted in complete recovery to consciousness disturbance, muscle weakness of fingers, myoclonus, and CA, while paraparesis with deep sensory and bladder and bowel disturbance remained. Conclusions: We highlight the possibility of the coexistence of several post-infectious autoimmune neurological complications in patients of COVID-19. It is important to search autoantibodies carefully corresponding to clinical manifestations for appropriate treatments and understanding of pathophysiology.