Acute Flaccid Myelitis With Neuroradiological Finding of Brachial Plexus Swelling

Acute Flaccid Myelitis: Review of Clinical Features, Diagnosis, and Management with Nerve Transfers

BACKGROUND

Acute flaccid myelitis (AFM) is a devastating neurologic condition in children, manifesting as acute limb weakness and/or paralysis. Despite increased awareness of AFM following initiation of U.S. surveillance in 2014, no treatment consensus exists. The purpose of this systematic review was to summarize the most current knowledge regarding AFM epidemiology, cause, clinical features, diagnosis, and supportive and operative management, including nerve transfer.

METHODS

The authors systematically reviewed the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Included articles reported on (1) AFM diagnosis and (2) patient-specific data regarding epidemiology, cause, clinical features, diagnostic features, or management of AFM.

RESULTS

Ninety-nine articles were included in this review. The precise cause and pathophysiologic mechanism of AFM remain undetermined, but AFM is strongly associated with nonpolio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2-weighted magnetic resonance imaging, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness.

CONCLUSIONS

Supportive care and physical therapy are the foundation of a multidisciplinary approach to managing AFM. For patients with persistent limb weakness, nerve transfer has shown promise for improving function in distal muscle groups. Surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.

Central nervous system as a target of novel coronavirus infections: Potential routes of entry and pathogenic mechanisms

Since the COVID-19 pandemic started in December 2019, there have been several reports of patients succumbing to neurological complications. Early reports were suggestive of a possibility, while by early 2020 it was clearly evident that although SARS-CoV-2 primarily attacks the respiratory system, the brain is one of the most affected organs post-recovery. Although it may be premature to comment on the long-term effects of COVID-19 in brain, some reliable predictions can be made based on the data currently available. Further, exploring the CNS connections of SARS-CoV-2 is of keen interest for neuroscience researchers. As soon as the virus enters the nasal region, it is exposed to the olfactory nervous system which is interlinked with the visual system, and hence we explore the mechanism of entry of this virus into CNS, including brain, olfactory and retinal nervous systems. In this review, we have thoroughly reviewed reports about both SARS-CoV-1 and SARS-CoV-2 with respect to their ability to breach the blood-brain and blood-retinal barriers. We have compiled different neurological conditions resulting from COVID-19 and looked into viral infections related to COVID-19 to understand how the virus may gain control of the olfactory and visual systems. Once the dust settles on the pandemic, it would be interesting to explore the extent of viral infection in the CNS. The long-term effects of this virus in the CNS are not yet known, and several scientific research papers evolving in this field will throw light on the same.

Acute flaccid myelitis: cause, diagnosis, and management

Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.

The Utilization of Nerve Transfer for Reestablishing Shoulder Function in the Setting of Acute Flaccid Myelitis: A Single-Institution Review

BACKGROUND

Acute flaccid myelitis (AFM) is a rare disease of young children. The typical presentation involves acute-onset flaccid paralysis in one or more extremities with a nonspecific viral prodrome. Long-term outcomes demonstrate that functional recovery plateaus around six to nine months. The purpose of this study was to evaluate the efficacy of nerve transfers for restoring shoulder function in these patients.

METHODS

A retrospective review of all patients diagnosed with AFM at a single institution. Shoulder function was evaluated using the active movement scale (AMS). Children at a minimum of six months after diagnosis with plateaued shoulder AMS scores of 4 or less were indicated for surgery.

RESULTS

Eleven patients were identified with a mean time from symptom onset to surgery of 12 months. Average follow-up was 19 months. The mean AMS score at follow-up for shoulder external rotation and abduction was 4.6 and 2.8, respectively. A total of six different nerve transfers with five different donor nerves were used individually or in conjunction with each other. The most common transfers were from the spinal accessory nerve to the suprascapular nerve (n = 8) and from the intercostal nerves ×3 to the axillary nerve (n = 5). Patients who received a transfer from the radial nerve to the axillary nerve (n = 2) had the best functional returns, with the mean AMS score of 6.5 in both external rotation and abduction at follow-up.

CONCLUSION

Nerve transfer procedures may help restore shoulder function in the setting of AFM. Combination procedures that involve a transfer from the radial nerve to the axillary nerve may provide the best functional results.