1
|
Biddle K, Kaul A. Lingual Raynaud's phenomenon: a rare presentation. BMJ Case Rep 2022; 15:e251988. [PMID: 36357109 PMCID: PMC9660575 DOI: 10.1136/bcr-2022-251988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A woman in her mid-60s presented to transient ischaemic attack (TIA) clinic with a 3-year history of intermittent sensory changes and white discolouration affecting the left side of her tongue. Following extensive investigation, a provisional diagnosis of posterior circulation TIA was made, and the patient was commenced on clopidogrel therapy. Despite anti-platelet treatment, she continued to have identical episodic symptoms. She was referred to the rheumatology team for assessment of possible underlying autoimmune pathology. On rheumatology assessment, the patient reported colour changes on the tongue, associated with numbness, followed by paraesthesia of the affected area. A comprehensive assessment excluded secondary causes and a diagnosis of primary Raynaud's phenomenon of the tongue was made. The diagnosis of TIA was revoked. This case illustrates a rare presentation of a common condition and highlights the sensory symptoms which are associated with Raynaud's phenomenon.
Collapse
Affiliation(s)
- Kathryn Biddle
- Rheumatology, St George's Healthcare NHS Trust, London, UK
| | - Arvind Kaul
- Rheumatology, St George's Healthcare NHS Trust, London, UK
| |
Collapse
|
2
|
Ozasa K, Noma N, Nakata J, Imamura Y. Unilateral Trigeminal Sensory Neuropathy with Sjögren's Syndrome with Liver and Renal Impairment. Neurol Int 2021; 13:464-468. [PMID: 34564290 PMCID: PMC8482271 DOI: 10.3390/neurolint13030045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 12/02/2022] Open
Abstract
Liver and renal involvement is a rare event in Sjögren’s syndrome. Sjögren’s syndrome is characterized by the progressive immune-mediated destruction of epithelial tissues of the salivary and lacrimal glands. Sensory ganglionitis, accompanied by T-cell invasion, occurs in patients with Sjögren’s syndrome, resulting in sensory neuropathy of the face or limbs. Patients are assessed by quantitative sensory testing. A 76-year-old woman presented with numbness of her left face and was subsequently diagnosed with Sjögren’s syndrome and primary biliary cirrhosis, and was found to have renal failure. Detection of her serum anti-Ro/SSA antibody was strongly positive. Shirmer’s test or a salivary volume in the gum test also showed positive results. Her somatosensory disturbance severity was higher in the trigeminal area than in the forearm, suggesting that the trigeminal nerve is more susceptible than other parts of the nervous system in patients with Sjögren’s syndrome and primary biliary cirrhosis. A simple sensory test could be performed during regular check-ups, as sensory deficits might develop after patients are diagnosed with Sjögren’s syndrome and primary biliary cirrhosis.
Collapse
Affiliation(s)
- Kana Ozasa
- Department of Oral Diagnostic Sciences, Nihon University School of Dentistry, Tokyo 101-8310, Japan; (K.O.); (Y.I.)
| | - Noboru Noma
- Department of Oral Diagnostic Sciences, Nihon University School of Dentistry, Tokyo 101-8310, Japan; (K.O.); (Y.I.)
- Clinical Research Division, Dental Research Institute, Nihon University, Tokyo 101-8310, Japan
- Correspondence: ; Tel.: +81-332198099
| | - Jumi Nakata
- Division of International Medicine, Towa Hospital, Tokyo 120-0003, Japan;
| | - Yoshiki Imamura
- Department of Oral Diagnostic Sciences, Nihon University School of Dentistry, Tokyo 101-8310, Japan; (K.O.); (Y.I.)
- Clinical Research Division, Dental Research Institute, Nihon University, Tokyo 101-8310, Japan
| |
Collapse
|
3
|
Chen WC, Li YS, Huang P. Isolated trochlear palsy as the only presentation of midbrain infarction: a case report. J Int Med Res 2021; 49:3000605211008292. [PMID: 33906530 PMCID: PMC8111274 DOI: 10.1177/03000605211008292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/16/2021] [Indexed: 11/16/2022] Open
Abstract
Trochlear palsy often results from traumatic, congenital and microvascular disorders. An intra-axial lesion as a cause of trochlear palsy is uncommon. Moreover, it usually accompanies other neurological deficits. Isolated trochlear palsy as the only presentation of brainstem stroke is unexpected. This current case report describes a 74-year-old male that presented with trochlear palsy without other neurological signs. Brain magnetic resonance imaging (MRI) revealed an acute midbrain infarction. The case report also reviews recent literature and provides a stepwise algorithm for clinicians to approach patients with trochlear palsy. Despite its rarity, clinicians are advised to consider ischaemic stroke as a cause of trochlear palsy even without other neurological deficits. Early MRI should be performed for prompt and proper management.
Collapse
Affiliation(s)
- Wen-Ching Chen
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Ying-Sheng Li
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Poyin Huang
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
- Department of Neurology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung
- Neuroscience Research Centre, Kaohsiung Medical University, Kaohsiung
- Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| |
Collapse
|
4
|
Colaci M, Cassone G, Manfredi A, Sebastiani M, Giuggioli D, Ferri C. Neurologic Complications Associated with Sjögren's Disease: Case Reports and Modern Pathogenic Dilemma. Case Rep Neurol Med 2014; 2014:590292. [PMID: 25161786 PMCID: PMC4139080 DOI: 10.1155/2014/590292] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/14/2014] [Accepted: 07/18/2014] [Indexed: 12/14/2022] Open
Abstract
Objectives. Sjögren's syndrome (SS) may be complicated by some neurological manifestations, generally sensory polyneuropathy. Furthermore, involvement of cranial nerves was described as rare complications of SS. Methods. We reported 2 cases: the first one was a 40-year-old woman who developed neuritis of the left optic nerve as presenting symptom few years before the diagnosis of SS; the second was a 54-year-old woman who presented a paralysis of the right phrenic nerve 7 years after the SS onset. An exhaustive review of the literature on patients with cranial or phrenic nerve involvements was also carried out. Results. To the best of our knowledge, our second case represents the first observation of SS-associated phrenic nerve mononeuritis, while optic neuritis represents the most frequent cranial nerve involvement detectable in this connective tissue disease. Trigeminal neuropathy is also frequently reported, whereas neuritis involving the other cranial nerves is quite rare. Conclusions. Cranial nerve injury is a harmful complication of SS, even if less commonly recorded compared to peripheral neuropathy. Neurological manifestations may precede the clinical onset of SS; therefore, in patients with apparently isolated cranial nerve involvement, a correct diagnosis of the underlying SS is often delayed or overlooked entirely; in these instances, standard clinicoserological assessment is recommendable.
Collapse
Affiliation(s)
- Michele Colaci
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Giulia Cassone
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Andreina Manfredi
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Marco Sebastiani
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Dilia Giuggioli
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| | - Clodoveo Ferri
- Chair and Rheumatology Unit, Medical School, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo 71, 41100 Modena, Italy
| |
Collapse
|
5
|
Manjila S, Moon K, Weiner MA, Cohen ML, Leigh RJ, Megerian CA, Bambakidis NC. Cavernous Malformation of the Trochlear Nerve: Case Report and Review of the Literature on Cranial Nerve Cavernomas. Neurosurgery 2011; 69:E230-8; discussion E238. [DOI: 10.1227/neu.0b013e31821cb28f] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE:
Cavernous malformations (CMs) arising intrinsically to the cisternal segment of the trochlear nerve are extremely rare. This case of a trochlear nerve cavernous angioma is the third to be reported in the neurosurgical literature and the first to be resected by a middle fossa approach.
CLINICAL PRESENTATION:
The authors present a case of a 31-year-old woman with progressive left-sided headache and left hemisensory symptoms, whose magnetic resonance imaging showed a solid enhancing tumor in the left ambient cistern at the level of the midbrain-pontine junction causing significant brainstem compression. Intraoperatively, a left trochlear nerve cavernous angioma circumferentially enveloping the nerve was visualized. The angioma was microsurgically resected by a middle fossa approach under frameless stereotactic guidance. Gross total resection of the intrinsic trochlear nerve lesion was achieved, although the trochlear nerve could not be preserved intact.
CONCLUSION:
CMs should be considered in a possible differential diagnosis of cisternal trochlear nerve tumors. Surgical resection remains the standard of care, and is indicated for relief of compressive symptoms and prevention of future bleeds. Postoperative diplopia often persists; however, resolution of diplopia reported in the literature can be attributed to either regeneration after direct surgical repair of the sacrificed nerve or a spontaneous adaptation over time.
Collapse
Affiliation(s)
- Sunil Manjila
- Department of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Karam Moon
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Mark A Weiner
- Department of Surgery, Aultman Hospital, Canton, Ohio
| | - Mark L Cohen
- Departments of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - R John Leigh
- Departments of Neuro-Ophthalmology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Cliff A Megerian
- Departments of Otolaryngology and Neurotology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Nicholas C Bambakidis
- Department of Neurological Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| |
Collapse
|
6
|
Abstract
This chapter covers the very large number of possible disorders that can affect the three ocular motor nerves, the neuromuscular junction, or the extraocular muscles. Conditions affecting the nerves are discussed under two major headings: those in which the site of damage can be anatomically localized (e.g., fascicular lesions and lesions occurring in the subarachnoid space, the cavernous sinus, the superior orbital fissure, or the orbit) and those in which the site of the lesion is either nonspecific or variable (e.g., vascular lesions, tumors, "ophthalmoplegic migraine," and congenital disorders). Specific comments on the diagnosis and management of disorders of each of the three nerves follow. Ocular motor synkineses (including Duane's retraction syndrome and aberrant regeneration) and disorders resulting in paroxysms of excess activity (e.g., neuromyotonia) are then covered, followed by myasthenia gravis and other disorders that affect the neuromuscular junction. A final section discusses disorders of the extraocular muscles themselves, including thyroid disease, orbital myositis, mitochondrial disease, and the muscular dystrophies.
Collapse
Affiliation(s)
- Christian J Lueck
- Department of Neurology, The Canberra Hospital, and Australian National University Medical School, Canberra, Australia.
| |
Collapse
|
7
|
Sürücü O, Sure U, Mittelbronn M, Meyermann R, Becker R. Cavernoma of the trochlear nerve. Clin Neurol Neurosurg 2007; 109:791-3. [PMID: 17669588 DOI: 10.1016/j.clineuro.2007.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 06/11/2007] [Accepted: 06/15/2007] [Indexed: 11/30/2022]
Abstract
Here we present the case of a 53-year old man with progressive double vision due to isolated left trochlear nerve palsy. Cranial magnetic resonance imaging (MRI) showed a small tumor within the left quadrigeminal cistern that did not increase in size after several months. Explorative neurosurgical intervention revealed a left trochlear nerve cavernoma. The lesion was microsurgically excised followed by end-to-end anastomosis of the trochlear nerve. After a one-year follow up, double vision totally disappeared and cranial MRI showed no recurrence. Cerebral cavernous malformations usually become symptomatic in seizures or focal neurological deficits after intracerebral hemorrhage. Rarely, cavernomas arise from cranial nerves. To the authors' knowledge, this is the first report on a symptomatic cavernous malformation arising from the trochlear nerve and on its successful surgical management.
Collapse
Affiliation(s)
- Oguzkan Sürücü
- Department of Neurosurgery, University of Marburg, Germany.
| | | | | | | | | |
Collapse
|
8
|
Affiliation(s)
- L P Frohman
- Department of Ophthalmology, UMD-New Jersey Medical School, Newark 07103-2441, USA
| |
Collapse
|
9
|
Urban PP, Keilmann A, Teichmann EM, Hopf HC. Sensory neuropathy of the trigeminal, glossopharyngeal, and vagal nerves in Sjögren's syndrome. J Neurol Sci 2001; 186:59-63. [PMID: 11412873 DOI: 10.1016/s0022-510x(01)00501-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Isolated cranial nerve involvement in primary Sjögren's syndrome (primary SS) has rarely been described. We report the case of a patient with sensory neuropathy of the trigeminal and also the glossopharyngeal and vagal nerves, which has not been identified previously. The electrophysiological findings in our patient with primary SS confirmed trigeminal sensory neuropathy with abnormal blink reflexes and abnormal cutaneous masseter inhibitory reflexes.
Collapse
Affiliation(s)
- P P Urban
- Department of Neurology, University Hospital of Mainz, Langenbeckstrasse 1, D 55101 Mainz, Germany.
| | | | | | | |
Collapse
|
10
|
Abstract
Sjögren's syndrome (SS) is a systemic lymphoproliferative, autoimmune disease, which is characterized by dryness of the eyes, mouth, and other mucous membranes. The nervous system may be affected in up to 20% of the cases of primary or secondary SS. We present a case of a 54-year-old woman with trochlear nerve palsy complicating Sjögren's syndrome secondary to rheumatoid arthritis. We suggest that all patients with multiple cranial neuropathies, especially when associated with rheumatoid arthritis, should be carefully examined for the possible presence of secondary SS.
Collapse
Affiliation(s)
- K Chu
- Department of Neurology, Seoul National University Hospital, Neuroscience Research Institute, SNUMRC, 28 Yongon-dong, Chongno-gu, 110-744, Seoul, South Korea
| | | | | | | |
Collapse
|