Primary Epstein-Barr virus infection in immunocompetent patients with acute transverse myelitis and a combination of polyradiculitis and anterior horn syndrome as neurological manifestations

Neurological manifestations of a primary Epstein-Barr virus (EBV) infection are rare. We describe a case with acute transverse myelitis and another case with a combination of polyradiculitis and anterior horn syndrome as manifestations of a primary EBV infection.The first case is a 50-year-old immunocompetent male diagnosed with acute transverse myelitis, 2 weeks after he was clinically diagnosed with infectious mononucleosis. The second case is an 18-year-old immunocompetent male diagnosed with a combination of polyradiculitis and anterior horn syndrome while he had infectious mononucleosis. The first patient was treated with methylprednisolone. After 1 year, he was able to stop performing clean intermittent self-catheterisation. The second patient completely recovered within 6 weeks without treatment.Primary EBV infection should be considered in immunocompetent patients presenting with acute transverse myelitis and a combination of polyradiculitis and anterior horn syndrome. Antiviral treatment and steroids are controversial, and the prognosis of neurological sequelae is largely unknown.

Cauda equina syndrome following an uneventful spinal anesthesia in a patient undergoing drainage of the Bartholin abscess: A case report

RATIONALE

Neuraxial anesthesia is a commonly used type of regional anesthesia. Cauda equina syndrome is an unusual and severe complication of neuraxial anesthesia, and is caused by damage to the sacral roots of the neural canal. We present a case of cauda equina syndrome following spinal anesthesia in a patient who underwent Bartholin abscess drainage.

PATIENT CONCERNS

A 23-year old female scheduled to undergo surgical drainage of Bartholin abscess. Spinal anesthesia was performed with bupivacaine and fentanyl. There were no perioperative adverse events reported. On postoperative day 1, the patient went to the emergency department describing bilateral weakness and pain of the lower extremities (LE).

DIAGNOSES

Lumbar magnetic resonance imaging showed increased gadolinium accumulation in the neural sheath at the level of the cauda equina tracts, consistent with the diagnosis of arachnoiditis and the diagnosis of cauda equina was established.

INTERVENTIONS

The patient received the following emergent treatment: 75 mg pregabalin (oral) every 12 hours, 20 mg (8 drops) tramadol (oral) every 8 hours, and 4 mg dexamethasone (intravenous) every 6 hours. On postoperative day 4, the patient still experienced bilateral flaccid paraparesis (accentuated in the left side), neuropathic pain in low extremities, and left brachial monoparesis. Hence, dexamethasone was instantly replaced with 1 g methylprednisolone (intravenous) for 5 days.

OUTCOMES

After completing 5 days of methylprednisolone, on postoperative day 9, the patient experienced less pain in left extremities, osteotendinous reflexes were slightly diminished, and she was able to walk with difficulty for 3 to 5 minutes. Greater mobility was evidenced, with right proximal and distal low extremities Medical Research Council Scale grades of 2 and 3 and left proximal and distal low extremities Medical Research Council Scale grades 1 and 2, respectively. Oral prednisone was restarted. Consequently, she was discharged home in stable conditions on postoperative day 25 with a prescription for sertraline, clonazepam, pregabalin, paracetamol, and prednisone.

LESSON

The early detection and treatment of complications after neuraxial anesthesia is essential to minimize the risk of permanent damage.

Cytomegalovirus polyradiculopathy in three Japanese patients with AIDS

Polyradiculopathy (PRP) is a rare but serious neurologic complication of cytomegalovirus (CMV) in patients with acquired immunodeficiency syndrome (AIDS). We herein report three cases of CMV PRP in patients with AIDS. Although providing a prompt diagnosis and initiating anti-CMV therapy may achieve clinical improvements, administering single-drug treatment may result in virologic failure. Therefore, introducing antiretroviral therapy is a key step for improving the treatment outcomes of CMV PRP.

Serotonergic 5-HT(1A) receptor agonist (8-OH-DPAT) ameliorates impaired micturition reflexes in a chronic ventral root avulsion model of incomplete cauda equina/conus medullaris injury

Trauma to the thoracolumbar spine commonly results in injuries to the cauda equina and the lumbosacral portion of the spinal cord. Both complete and partial injury syndromes may follow. Here, we tested the hypothesis that serotonergic modulation may improve voiding function after an incomplete cauda equina/conus medullaris injury. For this purpose, we used a unilateral L5-S2 ventral root avulsion (VRA) injury model in the rat to mimic a partial lesion to the cauda equina and conus medullaris. Compared to a sham-operated series, comprehensive urodynamic studies demonstrated a markedly reduced voiding efficiency at 12 weeks after the VRA injury. Detailed cystometrogram studies showed injury-induced decreased peak bladder pressures indicative of reduced contractile properties. Concurrent external urethral sphincter (EUS) electromyography demonstrated shortened burst and prolonged silent periods associated with the elimination phase. Next, a 5-HT(1A) receptor agonist, 8-hydroxy-2-(di-n-propylamino)-tetralin (8-OH-DPAT), was administered intravenously at 12 weeks after the unilateral L5-S2 VRA injury. Both voiding efficiency and maximum intravesical pressure were significantly improved by 8-OH-DPAT (0.3-1.0 mg/kg). 8-OH-DPAT also enhanced the amplitude of EUS tonic and bursting activity as well as duration of EUS bursting and silent period during EUS bursting. The results indicate that 8-OH-DPAT improves voiding efficiency and enhances EUS bursting in rats with unilateral VRA injury. We conclude that serotonergic modulation of the 5-HT(1A) receptor may represent a new strategy to improve lower urinary tract function after incomplete cauda equina/conus medullaris injuries in experimental studies.

Paraspinal abscess complicated by endocarditis following a facet joint injection⋆

Infectious complications secondary to lumbar facet injections are exceedingly rare, follow an indolent course, and local sequelae include abscess spread or infections of the central nervous system. We present the case of the development of a facet abscess and infective endocarditis, which developed shortly after a lumbar facet injection. With the increase in interventional pain procedures, physicians must be aware of potential infectious complications.

[Neuroborreliosis--a disease with many faces]

Borreliosis has been widely recognized in Switzerland and is often used in unclear cases with non-specific symptoms. Two illustrative cases should emphasize the current options for diagnosis and therapy of neuroborreliosis. The keystones of the diagnostic instruments are a history with typical symptoms and analysis of the cerebrospinal fluid with determination of appropriate antibodies. Therapy deals with ceftriaxon with intravenous and doxycyclin with oral application making ambulatory treatment possible.

Chronic inflammatory demyelinating polyradiculoneuropathy presenting as cauda equina syndrome in a diabetic

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may occur in association with diabetes mellitus (DM). We report a case of a poorly controlled diabetic patient who presented with rapid onset of bilateral lower extremity weakness and sensory loss associated with sacral and posterior thigh paresthesias and urinary and bowel incontinence, indicative of cauda equina syndrome (CES). Subsequent evaluation was consistent with CIDP. Monthly infusions with intravenous immunoglobulins (IVIg) with strict glycemic control using insulin resulted in remarkable clinical and electrophysiological recovery. This case report describes a rare presentation of CIDP and emphasizes the importance of early utility of electrodiagnostic (EDX) studies in the clinical evaluation of diabetic patients presenting with rapidly progressive lower extremity weakness and sensory loss associated with diminished reflexes.

Rho kinase inhibitor improves motor dysfunction and hypoalgesia in a rat model of lumbar spinal canal stenosis

STUDY DESIGN

Immunohistochemical and behavioral study using a rat cauda equina compression model.

OBJECTIVE

To investigate, after cauda equina compression by spinal canal stenosis (SCS), Rho activation in the spinal cord and cauda equina, and the effect of intrathecal administration of a Rho kinase inhibitor on hypoalgesia and motor dysfunction.

SUMMARY OF BACKGROUND DATA

Compression of the cauda equina caused by SCS is a common clinical disorder associated with sensory disturbance and intermittent claudication. Cauda equina compression is thought to reduce blood flow and result in nerve degeneration caused by various cytokines. Rho, a member of the small GTPases, is a signal transmitter. It promotes Wallerian degeneration, decreases blood flow in the spinal cord and brain, and increases expression of several cytokines. Currently, Rho kinase inhibitor is used clinically to treat progressive nerve damage due to cerebrovascular disorders. However, its effect for SCS has not been evaluated.

METHODS

Forty-two 6-week-old male Sprague-Dawley rats (200-250 g) were used. For the SCS model (n = 27), a small piece of silicon was placed under the lamina of the fourth lumbar vertebra. In the sham-operated group, laminectomies were performed at L5 only (n = 15). We examined mechanical sensitivity and motor function using von Frey hairs and a treadmill, and immunohistochemically localized Rho in the spinal ventral neurons, axons, and Schwann cells in the cauda equina. We also examined the effects of intrathecally administered Rho kinase inhibitor for hypoalgesia or motor dysfunction caused by SCS.

RESULTS

We observed motor dysfunction and hypoalgesia and activated Rho-immunoreactive cells in spinal ventral neuroreported to induce neurite and axonal outgrowth in the spinal cord and brain after nervous system injury. In addition, 1 report showed that Rho kinase was involved in Wallerian degeneration that was rescued by Rho kinase inhibitor. Furthermore, it is thought that Rho is involved in TNF-alpha and interleukin (IL) production in the central nervous system, and the production was inhibited by administering Rho kinase inhibitor in the central nervous system. Regardns, axons, and Schwann cells in the cauda equina. Intrathecal administration of Rho kinase inhibitor improved mechanical hypoalgesia and motor dysfunction caused by SCS.

CONCLUSION

Activated Rho may play an important role in nerve damage in the cauda equina in SCS. Rho kinase inhibitor may be a useful tool in determining the pathomechanism of cauda equina syndrome caused by SCS.

Malignant lymphoma originating in the cauda equina mimicking the inflammatory polyradiculoneuropathy

A 67-year-old woman was diagnosed with inflammatory polyradiculoneuropathy. The intravenously administered immunoglobulin (IVIG) treatment that she received several times over a 3-year period relieved her clinical symptoms of muscle weakness and sensory disturbances, but these symptoms had worsened thereafter despite further IVIG treatment. MRI detected a solid tumor involving the cauda equina and pathological examinations confirmed this to be malignant lymphoma. The clinical and radiological findings for the malignant lymphoma of the cauda equina in this patient were quite similar to those for the inflammatory polyradiculoneuropathy.

Cauda Equina and Conus Medullaris Syndrome in Sarcoidosis

BACKGROUND

Neurosarcoidosis is a rare manifestation of sarcoidosis. Involvement of the nervous system in sarcoidosis can range from peripheral or cranial neuropathy to central nervous system disease. Cauda equina sarcoidosis is distinctly rare.

REVIEW SUMMARY

The authors present a 58-year-old patient with systemic sarcoidosis who developed cauda equina and conus medullaris syndrome. Seventeen previous published cases of cauda equina sarcoidosis are reviewed. The history of systemic sarcoidosis, cerebrospinal fluid characteristics of lymphocytic pleocytosis with elevated protein, and evidence of acute denervation by needle electromyography are helpful in the diagnosis of this condition. Early diagnosis and treatment of cauda equina sarcoidosis usually provide a rapid recovery and yield a good prognosis.

CONCLUSION

Although rare, sarcoidosis should be considered in the differential diagnosis of cauda equina syndrome, particularly in patients with unclear etiology.

Cauda-conus syndrome resulting from neurocysticercosis

A 60-year-old male, presented with insidious onset, gradually progressive, burning paresthesia over the saddle area, sphincteric disturbance, impotence and paraparesis. Investigations revealed a ring-enhancing lesion in the conus medullaris suggestive of neurocysticercosis. This was supported by quantitative enzyme-linked immunosorbant assay from purified cell fraction of taenia solium cysticerci. On treatment with steroids he showed marked improvement.

[Extrapulmonary complications of Mycoplasma pneumoniae infections]

INTRODUCTION

Mycoplasma pneumoniae is a common cause of atypical pneumonia in children and young adults. The infection is generally mild and only a very few patients are admitted to hospital. However, extrapulmonary complications are well recognised--mostly as manifestations from the central nervous system (CNS).

MATERIAL AND METHODS

We describe 21 patients with M. pneumoniae infection seen at Rigshospitalet, Copenhagen, from 1994 to 2000.

RESULTS

The patients had fever, headache, myalgia, and cough. Biochemically, they were characterised by leucocytosis, an increased level of C-reactive protein, and infiltrations on the chest x-ray. A total of seven patients developed extrapulmonary complications to the infection in the form of encephalitis (3), polyradiculitis (1), transversel myelitis (1), erythema multiforme (3), cardial arrhythmia (1), and haemolytic anaemia (2). Three patients had more than one complication at the same time.

DISCUSSION

The incidence of patients with complications to M. pneumoniae infection was higher than that reported in the literature, probably because these patients are typically submitted to the Department of Infectious Diseases, Rigshospitalet. The pathogenesis of extrapulmonary complications to M. pneumoniae infection is unknown.

Cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome): meta-analysis of outcomes after medical and surgical treatments

The cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome) is marked by slow, insidious progression and a high incidence of dural ectasia in the lumbosacral spine. A high index of suspicion for this problem must be maintained when evaluating the patient with ankylosing spondylitis with a history of incontinence and neurologic deficit on examination. There has been disagreement in the literature as to whether surgical treatment is warranted for this condition. A meta-analysis was thus performed comparing outcomes with treatment regimens. Our results suggest that leaving these patients untreated or treating with steroids alone is inappropriate. Nonsteroidal antiinflammatory drugs may improve back pain but do not improve neurologic deficit. Surgical treatment of the dural ectasia, either by lumboperitoneal shunting or laminectomy, may improve neurologic dysfunction or halt the progression of neurologic deficit.

[Polyradiculopathy caused by cytomegalovirus in AIDS patients: successful treatment with highly active antiretroviral therapy (HAART)]

We report two male patients with AIDS, aged 23 and 30 years old respectively. One was admitted due to a progressive weakness of the left leg and urinary and fecal incontinence. The other was admitted due to a progressive paraparesia without incontinence, but with a severe lumbar pain. In both patients polymerase chain reactions for cytomegalovirus in cerebrospinal fluid were positive. Treatment with ganciclovir, for 21 and 14 days respectively and highly active antiretroviral therapy was started. Both patients experienced recovery of their neurological deficits after 98 and 88 days of therapy, respectively.

Vacuum disk and facet phenomenon in a dog with cauda equina syndrome

A 7-year-old castrated male Rottweiler was evaluated for an 18-month history of bilateral hind limb lameness, signs of pain on rising, and mild ataxia. A gas-filled lumbosacral disk space (vacuum disk phenomenon) was revealed by use of computed tomography. Additional smaller gas bubbles were in the periphery of the disk and between the degenerated L5-L6 dorsal articular facets (vacuum facet phenomenon). Vacuum disk and facet phenomena have been described in humans with degenerative disk and vertebral articular facet joint disease; gas attracted from surrounding tissues accumulates within clefts of the degenerated disk or in unstable facet joints. Vacuum disk phenomenon has been reported in dogs and indicates degenerative disk disease. The phenomenon is more commonly observed by use of computed tomography, compared with conventional radiography, and can be elicited by hyperextension of the vertebral column.