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Neuromyelitis optica spectrum disorders (NMOSD) is a demyelinating syndrome of the central nervous system. This case report describes a 31-year-old woman whose electromyography revealed radiculopathy in the left L5-S1 spinal segment without anatomical abnormalities on lumbosacral magnetic resonance imaging (MRI). She was diagnosed with NMOSD based on gadolinium contrast whole spine and brain MRI and anti-aquaporin-4 antibody findings. Her peripheral nervous system might have been damaged during the early course of NMOSD. Therefore, it is necessary to consider NMOSD for patients who have radiculopathy in electromyography if lumbosacral MRI shows no abnormalities.
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A 54-year-old man with poliomyelitis had been using a conventional, passive knee-ankle-foot orthosis (KAFO) with a drop ring lock knee joint for about 40 years. A stance control KAFO (SCKAFO) with an electromagnetically controlled (E-MAG) knee joint system was prescribed. To correct his gait pattern, he also underwent rehabilitation therapy, which included muscle re-education, neuromuscular electrical stimulation, strengthening exercises for the lower extremities, and balance training twice a week for about 4 months. Both before and after rehabilitation, we conducted a gait analysis and assessed the physiological cost index in energy expended during walking in a locked-knee state and while he wore a SCKAFO with E-MAG. When compared with the pre-rehabilitation data, the velocity, step length, stride length, and knee kinematic data were improved after rehabilitation. Although the SCKAFO with E-MAG system facilitated the control of knee motion during ambulation, appropriate rehabilitative therapy was also needed to achieve a normal gait pattern.
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Osteomyelitis is a bone infection caused by bacteria or other germs. Gram-positive cocci are the most common etiological organisms of calcaneal osteomyelitis; whereas, non-tuberculous mycobacteria (NTM) are rarely documented. We reported a case of NTM calcaneal osteomyelitis in a 51-year-old female patient. She had been previously treated in many local clinics with multiple local steroid injection over 50 times and extracorporeal shock-wave therapy over 20 times with the impression of plantar fasciitis for 3 years prior. Diagnostic workup revealed a calcaneal osteomyelitis and polymerase chain reaction assay on bone aspirate specimens confirmed the diagnosis of non-tuberculous mycobacterial osteomyelitis. The patient had a partial calcanectomy with antitubercular therapy. Six months after surgery, a follow-up magnetic resonance imaging showed localized chronic osteomyelitis with abscess formation. We continued anti-tubercular therapy without operation. At 18-month follow-up after surgery and comprehensive rehabilitation therapy, she was ambulating normally and able to carry out her daily activities without any discomfort.
Citations
To examine the correlation between obesity and pulmonary function in polio survivors.
This study was conducted based on a questionnaire survey and physical examination. The questionnaire included gender, age, paralyzed regions, physical activity levels, and accompanying diseases. The physical examination included measuring body mass index, waist circumference, muscle power, total fat amount, body fat percentage, and lean body mass. In addition, pulmonary function was tested based on forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), ratio of FEV1 to FVC, and chest circumference. Five university hospitals and a local health clinic participated in this study.
Pearson and partial correlation coefficients that used data collected from 73 polio survivors showed that obesity had a negative correlation with pulmonary function.
This study found that pulmonary function has a negative correlation with obesity for polio survivors. Therefore, it is necessary to develop specialized exercise programs to help polio survivors reduce their weight and strengthen their respiratory muscles.
Citations
Japanese encephalitis (JE) shows characteristic brain lesions, including bilateral thalamus, midbrain, internal capsule, basal ganglia, and occasionally involves an anterior horn cell. We encountered a case of a 44-year-old man who initially presented with encephalitis, which was finally diagnosed as Japanese encephalomyelitis with syringomyelia. The patient showed severe motor weakness followed by delayed recovery of functional motor activities. Cervical magnetic resonance imaging showed syrinx formation at the C5 level suggesting myelitis, and abnormal electromyographic findings were noted. Clinicians should consider the possibility that the spinal cord may be involved; an example would be syringomyelia due to myelitis in a case of JE presenting with severe and prolonged motor weakness.
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Epidural steroid injections (ESI) are a common treatment for back pain management. ESI-related complications have increased with the growing number of procedures. We report a case of cervical meningomyelitis followed by multiple lumbar ESI. A 60-year-old male with diabetes mellitus presented to our hospital with severe neck pain. He had a history of multiple lumbar injections from a local pain clinic. After admission, high fever and elevated inflammatory values were detected. L-spine magnetic resonance imaging (MRI) revealed hematoma in the S1 epidural space. Antibiotic treatment began under the diagnosis of a lumbar epidural abscess. Despite the treatment, he started to complain of weakness in both lower extremities. Three days later, the weakness progressed to both upper extremities. C-spine MRI revealed cervical leptomeningeal enhancement in the medulla oblongata and cervical spinal cord. Removal of the epidural abscess was performed, but there was no neurological improvement.
Citations
Infection Risk of Lumbar Epidural Injection in the Operating Theatre Prior to Lumbar Fusion Surgery
Hip and pelvic pain during pregnancy or after delivery is a common problem in young females, and in most cases this problem has a self-limiting course. The patient described in this case suffered from severe hip pain after childbirth. MR imaging study was performed and it showed arthritis of bilateral hip joints and osteomyelitis of femoral heads with an abscess in the surrounding muscle. Infection, such as septic arthritis or osteomyelitis, is an extremely rare cause of peripartum joint pain. The patient's clinical symptoms and laboratory findings improved with antibiotic therapy. However, limitation of motion of the bilateral hip joints persisted although the patient continued rehabilitative therapy for 15 months, and the patient had to undergo bilateral total hip replacement. Hereby, we present a case of severe osteomyelitis and pyogenic arthritis of bilateral femoral heads and hip joints after delivery, which eventually required bilateral total hip replacement.
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Acute transverse myelitis (ATM) is an upper motor neuron disease of the spinal cord, and concomitant association of peripheral polyneuropathy, particularly the axonal type, is rarely reported in children. Our cases presented with ATM complicated with axonal type polyneuropathy. Axonal type polyneuropathy may be caused by acute motor-sensory axonal neuropathy (AMSAN) or critical illness polyneuropathy and myopathy (CIPNM). These cases emphasize the need for nerve and muscle biopsies to make the differential diagnosis between AMSAN and CIPNM in patients with ATM complicated with axonal polyneuropathy.
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To obtain information on the socioeconomic, medical, and functional status of polio survivors, and to use these results as the preliminary data for establishing the middle-aged cohort of polio survivors.
The subjects were recruited based on the medical records of multiple hospitals and centers. They were assessed through a structured questionnaire over the phone. Post-poliomyelitis syndrome (PPS) was identified according to the specified diagnostic criteria. Differences between polio survivors with or without PPS were evaluated, and the risk factors for PPS were analyzed by the odds ratio (OR).
Majority of polio survivors were middle-aged and mean age was 51.2±8.3 years. A total of 188 out of 313 polio survivors met the adopted criteria for PPS based on the symptoms, yielding a prevalence of 61.6%. Mean interval between acute poliomyelitis and the development of PPS was 38.5±11.6 years. Female gender (OR 1.82; confidence interval [CI] 1.09-3.06), the age at onset of poliomyelitis (OR 1.75; CI 1.05-2.94), the use of orthoses or walking aids (OR 2.46; CI 1.44-4.20), and the history of medical treatment for paralysis, pain or gait disturbance (OR 2.62; CI 1.52-4.51) represented independent risk factors for PPS.
We found that the majority of Korean polio survivors entered middle age with many medical, functional, and social problems. Female gender, early age of onset of poliomyelitis, the use of orthoses or walking aids, and the history of medical treatment for paralysis, pain or gait disturbance were identified as the significant risk factors for PPS. A comprehensive and multidisciplinary plan should be prepared to manage polio survivors considering their need for health care services and the risk factors for late effects, such as PPS.
Citations
Primary Sjögren syndrome, which involves lesions in both the brain and spinal cord, is rarely reported. Related symptoms, such as intractable pain due to central nervous system involvement, are very rare. A 73-year-old woman diagnosed with primary Sjögren syndrome manifested with subacute encephalopathy and extensive transverse myelitis. She complained of severe whole body neuropathic pain. Magnetic resonance imaging demonstrated a non-enhancing ill-defined high intensity signal involving the posterior limb of the both internal capsule and right thalamus on a T2 fluid-attenuated inversion recovery image. Additionally, multifocal intramedullary ill-defined contrast-enhancing lesion with cord swelling from the C-spine to L-spine was also visible on the T2-weighted image. Her intractable pain remarkably improved after administration of concomitant oral doses of gabapentin, venlafaxine, and carbamazepine.
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Candida species inhabit the skin and mucous membranes of healthy individuals with low virulence, and osteomyelitis due to candida is very rare. However, the incidence of invasive candidal infection caused by intravenous drug use, broad-spectrum antibiotics, and indwelling central venous catheter is increasing. A 73-year old man visited the outpatient clinic complaining of right shoulder pain that radiated to the right acromioclavicular joint. He had undergone multiple injection procedures followed by nonsteroidal anti-inflammatory drug therapy for several weeks. The ultrasonographic findings showed a heterogeneous mass around the right acromioclavicular joint, while the right shoulder MRI and the overall findings of the body bone scan were suggestive of osteomyelitis. Pathologic findings of ultrasonographically guided joint aspiration fluid showed acute and chronic nonspecific inflammation, while the tissue culture and staining revealed Candida parapsilosis.
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To compare the motor recovery following transverse myelitis in pediatric patients with and without spinal cord atrophy.
From January 1995 through December 2009, twenty children (8 boys and 12 girls with an onset at 5.7±3.8 years) that were diagnosed with transverse myelitis at a Children's Hospital in Korea, and undertaken an initial and follow-up spine magnetic resonance image (MRI) were included. Medical records and spine MRI scans were reviewed retrospectively. An initial MRI was taken 5.1±8.7 days after the onset. The interval between an initial and follow-up MRIs was 33.4±23.0 days. The motor recovery differences between subjects with and without spinal cord atrophy on follow-up MRIs were determined. Motor recovery was defined as the elevation of one or more grades of manual muscle tests of the Medical Research Council.
Eight patients had developed spinal cord atrophies and 12 patients had not. Of the 8 patients with spinal cord atrophy, 7 showed no motor improvement. Among the 12 patients without atrophy, 11 had motor improvement. Spinal cord atrophy on follow-up MRIs were related to the risk of no motor improvement (odds ratio=77.0, 95% confidence interval [4.114-1441.049], p-value=0.001).
Children with transverse myelitis who had developed spinal cord atrophy on follow-up MRIs had poor motor recovery than those who had not. The appearance of spinal cord atrophy on follow-up MRI could be an indicator of poor prognosis in pediatric transverse myelitis.
Citations
Method: Thirty-five female Lewis rats were used in the study. Thirteen rats used as normal cystometrogram controls. Twenty-two rats induced EAE were divided into two groups: ten rats as control and twelve rats as dexamethasone injection group. Bladder dysfunction by cystometrogram, severity of weakness, and duration of paralysis were evaluated every other day after the onset of paralysis.
Results: Dexamethasone injection group compared to control group presented short duration of bladder dysfunction (2.5 vs. 4.2 day, p＜0.05) and paralysis (4.5 vs. 7.3 day, p＜0.05). There was a trend for lesser paralysis in the dexamethasone injection group, than control group (weakness scores were 2.4 vs. 3.6, p＞0.05), but it was not statistically significant.
Conclusion: Dexamethasone ameliorates the course of paralysis and bladder dysfunction in EAE. We suggest that dexamethasone treatment is an effective method in treating neurogenic bladder and paralysis in multiple sclerosis.
Objective: To investigate the clinical feature and quantitative electromyographic (QEMG) findings in the patients with post-polio syndrome (PPS).
Method: Eleven patients who had clinical evidences of antecedent poliomyelitis were evaluated with standardized clinical history, physical examination and QEMG study. If a patient had fulfilled provisional criteria for PPS, he was regarded as PPS and six patients had fulfilled the criteria. Other patients were treated as control group with stable poliomyelitis. Manual muscle testing and needle EMG study including quantitative motor unit analysis was performed at the tibialis anterior and vastus medialis muscles. The existence of abnormal spontaneous activity and parameters of quantitative motor unit analysis, mean duration and amplitude of motor unit action potentials (MUAPs), were compared between PPS and control groups. The correlation between the muscle strength and parameters of QEMG was investigated.
Results: Abnormal spontaneous activities were noted in 4 out of 11 patients (36.4%) and three of these 4 patients were PPS. Mean duration and amplitude of MUAPs of tibialis anterior and vastus medialis muscles were not different significantly between the PPS and stable poliomyelitis group (p＞0.05). The parameters of MUAPs were poorly correlated with muscle strength.
Conclusion: Distribution of abnormal spontaneous activities and parameters of QEMG study were not different in PPS and stable poliomyelitis patients. QEMG study may not have additional benefit in differentiating PPS from stable poliomyelitis.
Objective: In patients with a history of acute paralytic poliomyelitis, late progressive muscle weakness, fatigue, pain may arise, a symptom complex of known as post-poliomyelitis syndrome (PPS). Dysphagia may also develop in some PPS patients. The purpose of this study was to assess the presence of is swallowing difficulty in polio survivors and to describe the nature of the swallowing difficulty.
Method: Polio survivors answered the questionnaire pertaining to swallowing function and received a videofluroscopic evaluation of the oral and pharyngeal phases using 3 consistencies of material: liquid barium; semisolid barium paste; boiled yolk of an egg coated with barium.
Results: Of the 16 subjects, 8 had subjective symptoms of swallowing difficulties. All of the 6 PPS patients, regardless of whether they had symptoms of swallowing difficulties, had some abnormal oropharyngeal function through video fluoroscopic swallowing study.
Conclusion: In patients with post-polio syndrome, there is progressive deterioration of swallowing functions similar to that in the muscles of the limbs. This swallowing dysfunction is not related with their subjective symptoms.
Objective: This study was performed to evaluate the prevalence of new neuromuscular symptoms and disabilities and the psychological characteristics-depressioin, anxiety, type A behavior, loneliness, and also to determine any relationships between physical and neuropsychological characteristics in a group of post-polio syndrome (PPS).
Method: By 70 answered questionnaire, the polio survivors were grouped into PPS and Non- PPS. This questionnaire consisted of questions about acute polio problems; new health problems, fatigue severity scale, visual analog scale, weakness scale, Frenchay activity index, ambulation disability index; socio-economic problems; neuro-psychological inventories, Beck depression index, Spielberger state-trait anxiety inventory, revised UCLA loneliness scale, type A personality score.
Results: The median time from polio to the onset of new health problems was 27.6 years. Fatigue, muscle and/or joint pain, weakness in previously affected and unaffected muscles were most common newly appearing problems. The symptoms of PPS was consistent with the distribution of the anterior horn cell; spinal cord, brain stem, cerebral hemisphere, Reticular Activating System (RAS). Neuro-psychological evaluations revealed that fatigue scale was correlated with depression, type A personality.
Conclusion: In PPS group, pain, weakness, fatigue, autonomous symptoms, decreased concentration were more serious than in Non-PPS group. The fatigue in PPS group was correlated with type A personality, depression, sleep disturbance and concentration problem.
The Postpoliomyelitis syndrome(PPS) is characterized by new neuromuscular symptoms such as muscle weakness, joint pain, fatigue, and occasional new neuromuscular impairments. Although the development of PPS shows individual differences, it usually occurs many years after the recovery from an acute paralytic poliomyelitis. The purpose of this study was to investigate the incidence and the clinical features of PPS.
The subjects were 33 patients(26 males and 7 females) who had partial recoveries of motor function, ten or more years of functional stabilities, and residual muscle atrophies. The mean age was 36.8⁑7.7 years with the range of 23∼59 years. The average onset age of acute poliomyelitis was 2.3⁑1.5 years. The questionnaires asking their current physical conditions and three major categories of PPS symptoms, weakness, fatigue, and pain were used.
As the sequelae of poliomyelitis, 66.7% of the subjects showed scoliosis and 39.4% had claw toes. Thirty six percents of the subjects were using orthoses including wheelchair, KAFO, and crutches.
According to the questionnaire study, 72.5% of subjects had at least one of the three major symptoms. And 36.4% of them reported all of three categories of PPS symptoms. The onset age of the new neuromuscular symptoms was 34.2⁑8.3 years which was about 32 years after the original acute poliomyelitis.
Further researches to investigate the importance and the impacts of proper managements and to develop educational plans for the PPS including exercise programs, cardiopulmonary and energy-conservation trainings are recommended.
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