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Tam YS, Chen E, Poh ZE, Chia G, Provido M, Hum A, Lee HX. Ketamine in Severe Leptomeningeal Pain. J Palliat Med 2022; 26:591-595. [PMID: 36269856 DOI: 10.1089/jpm.2022.0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Carcinomatosis meningitis is a rare but deadly complication of medulloblastoma. Surgical and systemic treatment options are often limited in advanced stages of the cancer. Meningeal irritation from raised intracranial pressure causes leptomeningeal pain that may respond poorly to opioids and common adjuvant analgesics. We present the case of a terminally ill patient with severe leptomeningeal pain that responded to a trial of ketamine as an adjunct to opioids.
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Affiliation(s)
- Yong Seng Tam
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Elizabeth Chen
- Singhealth, Singapore General Hospital, Singapore, Singapore
| | - ZhiSheng Edmund Poh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Gerksin Chia
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Mahrley Provido
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Allyn Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,The Palliative Care Centre for Excellence in Research and Education (PalC), Singapore, Singapore
| | - Hsien Xiong Lee
- Department of Palliative Medicine and Supportive Care, Woodlands Health, Singapore, Singapore
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2
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Yates J, Devere T, Sakurai-Burton S, Santi B, McAllister C, Frank K. Case Report: Angiostrongylus cantonensis Infection Presenting as Small Fiber Neuropathy. Am J Trop Med Hyg 2022; 107:367-369. [PMID: 35895403 PMCID: PMC9393434 DOI: 10.4269/ajtmh.22-0199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/11/2022] [Indexed: 08/03/2023] Open
Abstract
Angiostrongylus cantonensis is an emerging parasite that is the most common cause of eosinophilic meningitis worldwide. Human infection typically presents with headache, neck stiffness, and paresthesia. We report a case of a woman with PCR positive A. cantonensis infection who presented with symptoms of small fiber neuropathy (SFN) but no headache. SFN was confirmed by skin biopsy. After failing standard medications for neuropathy, she was treated with intravenous lidocaine with considerable improvement. However, she required medications for 1 year to treat her chronic neuropathy. Infection by A. cantonensis should be added to the list of causes of SFN, and its potential to cause chronic sequelae should be appreciated.
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Affiliation(s)
| | | | | | - Brock Santi
- University of Hawai’i John A. Burns School of Medicine, Honolulu, Hawai’i
| | - Cali McAllister
- University of Hawai’i John A. Burns School of Medicine, Honolulu, Hawai’i
| | - Kiana Frank
- University of Hawai’i Pacific Biosciences Research Center, Honolulu, Hawai’i
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3
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Wun MK, Malik R, Yu J, Chow KE, Lau M, Podadera JM, Webster N, Lee R, Šlapeta J, Davies S. Magnetic resonance imaging in dogs with neuroangiostrongyliasis (rat lungworm disease). Parasitology 2021; 148:198-205. [PMID: 32951620 PMCID: PMC11010213 DOI: 10.1017/s0031182020001742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 09/01/2020] [Accepted: 09/11/2020] [Indexed: 11/06/2022]
Abstract
The magnetic resonance imaging (MRI) appearance of the brain and spinal cord in humans with neuroangiostrongyliasis (NA) due to Angiostrongylus cantonensis infection has been well reported. Equivalent studies in animals are lacking. This case series describes clinical and MRI findings in 11 dogs with presumptively or definitively diagnosed NA. MRI of the brain and/or spinal cord was performed using high-field (1.5 T) or low-field (0.25 T) scanners using various combinations of transverse, sagittal, dorsal and three-dimensional (3D) T1-weighted (T1W), transverse, sagittal and dorsal T2-weighted (T2W), T2W fluid-attenuated inversion recovery (FLAIR) and T2*-weighted (T2*W) gradient echo (GRE), dorsal T2W short tau inversion recovery (STIR) and post-gadolinium transverse, sagittal, dorsal and 3D T1W and transverse T2W FLAIR sequences. In 4/6 cases where the brain was imaged, changes consistent with diffuse meningoencephalitis were observed. Evidence of meningeal involvement was evident even when not clinically apparent. The spinal cord was imaged in 9 dogs, with evidence of meningitis and myelitis detected in regions consistent with the observed neuroanatomical localization. Pathognomonic changes of neural larva migrans, as described in some human patients with NA, were not detected. NA should be considered in the differential diagnosis of dogs with MRI evidence of focal or diffuse meningitis, myelitis and/or encephalitis, especially in areas where A. cantonensis is endemic. If not precluded by imaging findings suggestive of brain herniation, cerebrospinal fluid (CSF) collection for cytology, fluid analysis, real-time polymerase chain reaction (qPCR) and enzyme-linked immunosorbent assay (ELISA) testing should be considered mandatory in such cases after the MRI studies.
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Affiliation(s)
- Matthew K. Wun
- Veterinary Specialist Services, 1-15 Lexington Rd, Underwood, QLD4119, Australia
| | - Richard Malik
- Centre for Veterinary Education, The University of Sydney, Camperdown, NSW2006, Australia
- School of Veterinary and Animal Science, Charles Sturt University, Wagga Wagga, NSW 2650, Australia
| | - Jane Yu
- Sydney School of Veterinary Science, The University of Sydney, Camperdown, NSW2006, Australia
| | - Kathleen E. Chow
- Sydney Veterinary Emergency & Specialists, 675 Botany Rd, Rosebery, NSW2018, Australia
| | - Michelle Lau
- Sydney School of Veterinary Science, The University of Sydney, Camperdown, NSW2006, Australia
| | - Juan M. Podadera
- Sydney School of Veterinary Science, The University of Sydney, Camperdown, NSW2006, Australia
| | - Natalie Webster
- IDEXX Telemedicine Consultants, 124/45 Gilby Rd, Mount Waverley, VIC 3149, Australia
| | - Rogan Lee
- Centre for Infectious Diseases & Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, Westmead Hospital, NSW 2145, Australia
| | - Jan Šlapeta
- Sydney School of Veterinary Science, The University of Sydney, Camperdown, NSW2006, Australia
| | - Sarah Davies
- Veterinary Imaging Associates, 52-56 Atchison St, St Leonards, NSW 2065, Australia
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4
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Lee R, Pai TY, Churcher R, Davies S, Braddock J, Linton M, Yu J, Bell E, Wimpole J, Dengate A, Collins D, Brown N, Reppas G, Jaensch S, Wun MK, Martin P, Sears W, Šlapeta J, Malik R. Further studies of neuroangiostrongyliasis (rat lungworm disease) in Australian dogs: 92 new cases (2010-2020) and results for a novel, highly sensitive qPCR assay. Parasitology 2021; 148:178-186. [PMID: 32829721 PMCID: PMC11010165 DOI: 10.1017/s0031182020001572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023]
Abstract
The principal aim of this study was to optimize the diagnosis of canine neuroangiostrongyliasis (NA). In total, 92 cases were seen between 2010 and 2020. Dogs were aged from 7 weeks to 14 years (median 5 months), with 73/90 (81%) less than 6 months and 1.7 times as many males as females. The disease became more common over the study period. Most cases (86%) were seen between March and July. Cerebrospinal fluid (CSF) was obtained from the cisterna magna in 77 dogs, the lumbar cistern in f5, and both sites in 3. Nucleated cell counts for 84 specimens ranged from 1 to 146 150 cells μL-1 (median 4500). Percentage eosinophils varied from 0 to 98% (median 83%). When both cisternal and lumbar CSF were collected, inflammation was more severe caudally. Seventy-three CSF specimens were subjected to enzyme-linked immunosorbent assay (ELISA) testing for antibodies against A. cantonensis; 61 (84%) tested positive, titres ranging from <100 to ⩾12 800 (median 1600). Sixty-one CSF specimens were subjected to real-time quantitative polymerase chain reaction (qPCR) testing using a new protocol targeting a bioinformatically-informed repetitive genetic target; 53/61 samples (87%) tested positive, CT values ranging from 23.4 to 39.5 (median 30.0). For 57 dogs, it was possible to compare CSF ELISA serology and qPCR. ELISA and qPCR were both positive in 40 dogs, in 5 dogs the ELISA was positive while the qPCR was negative, in 9 dogs the qPCR was positive but the ELISA was negative, while in 3 dogs both the ELISA and qPCR were negative. NA is an emerging infectious disease of dogs in Sydney, Australia.
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Affiliation(s)
- Rogan Lee
- Parasitology Laboratory, Centre for Infectious Diseases and Microbiology Lab Services, Level 3 ICPMR, Westmead Hospital, NSW, Australia
| | - Tsung-Yu Pai
- Parasitology Laboratory, Centre for Infectious Diseases and Microbiology Lab Services, Level 3 ICPMR, Westmead Hospital, NSW, Australia
| | - Richard Churcher
- North Shore Veterinary Specialist Centre, 63 Herbert St, Artarmon, NSW2064, Australia
| | - Sarah Davies
- Veterinary Imaging Associates, PO Box 300, St. LeonardsNSW1590, Australia
| | - Jody Braddock
- Sydney Veterinary Emergency and Specialists, 675 Botany Road, RoseberryNSW2018, Australia
| | - Michael Linton
- Sydney Veterinary Emergency and Specialists, 675 Botany Road, RoseberryNSW2018, Australia
| | - Jane Yu
- Sydney School of Veterinary Science, University of SydneyNSW2006, Australia
| | - Erin Bell
- Sydney Veterinary Emergency and Specialists, 675 Botany Road, RoseberryNSW2018, Australia
| | - Justin Wimpole
- Small Animal Specialist Hospital, Level 1, 1 Richardson Place, North Ryde, NSW2113, Australia
| | - Anna Dengate
- Northside Veterinary Specialists, 335 Mona Vale Rd, Terrey Hills, NSW2084, Australia
| | - David Collins
- Northside Veterinary Specialists, 335 Mona Vale Rd, Terrey Hills, NSW2084, Australia
| | - Narelle Brown
- Animal Referral Hospital, 250 Parramatta Rd, HomebushNSW2140, Australia
| | - George Reppas
- Vetnostics, 60 Waterloo Road, 60 Waterloo Rd, Macquarie ParkNSW2113, Australia
| | - Susan Jaensch
- Vetnostics, 60 Waterloo Road, 60 Waterloo Rd, Macquarie ParkNSW2113, Australia
| | - Matthew K. Wun
- Veterinary Specialist Services, 1-15 Lexington Rd, Underwood, QLD4119, Australia
| | - Patricia Martin
- Veterinary Pathology Diagnostic Services (VPDS), Building B14, the University of Sydney NSW2006, Australia
| | - William Sears
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Jan Šlapeta
- Sydney School of Veterinary Science, University of SydneyNSW2006, Australia
- Veterinary Pathology Diagnostic Services (VPDS), Building B14, the University of Sydney NSW2006, Australia
| | - Richard Malik
- Centre for Veterinary Education, B22, University of Sydney, NSW2006, Australia
- School of Veterinary and Animal Science, Charles Sturt University, Wagga Wagga, NSW2678, Australia
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Kramer K, Yates J, McMillan JK, Gosnell W, Murphy GS, Blalock E, Lteif L, Smith O, Kahili-Heede M, Ansdell V. Special Feature: Diagnosis and Treatment of Neuroangiostrongyliasis in Hawai'i. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2020; 79:353-357. [PMID: 33313517 PMCID: PMC7726619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Angiostrongylus cantonensis is a metastrongylid lungworm of rats with a global distribution and the cause of neuroangiostrongyliasis in humans. In Hawai'i, neuroangiostrongyliasis cases have occurred sporadically since 1960; however, in 2001, the number of cases on Maui and Hawai'i Island began to increase significantly. Since most human treatment trials have been conducted in Thailand, where the disease is usually mild, there is a need to develop treatment protocols for Hawai'i, where there is a broader disease spectrum. In 2018, preliminary guidelines for the diagnosis and treatment of neuroangiostrongyliasis were developed for Hawai'i's physicians. This article summarizes those guidelines and provides additional recommendations for individuals who recently ingested an infected intermediate host.
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Affiliation(s)
- Kenton Kramer
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (KK, JKM, WG, GSM, OS, VA)
| | - Johnnie Yates
- Travel and Tropical Medicine, Hawai‘i Permanente Medical Group Inc, Honolulu, HI (JY)
| | - Jourdan K. McMillan
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (KK, JKM, WG, GSM, OS, VA)
| | - William Gosnell
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (KK, JKM, WG, GSM, OS, VA)
| | - Gerald S. Murphy
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (KK, JKM, WG, GSM, OS, VA)
| | - Elizabeth Blalock
- Spark M. Matsunaga Veteran Affairs Medical Center, Honolulu, HI (EB)
| | | | - Olivia Smith
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (KK, JKM, WG, GSM, OS, VA)
| | - Melissa Kahili-Heede
- Health Sciences Library, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (MK)
| | - Vernon Ansdell
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawai‘i at M?noa, Honolulu, HI (KK, JKM, WG, GSM, OS, VA)
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Cucueco K, Bathen K, Fischberg D. Lidocaine Infusion for Refractory Pain from Rat Lungworm Disease - Honolulu, Hawai'i. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2020; 79:246-248. [PMID: 32789295 PMCID: PMC7417640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Human infection with Angiostrongyloides cantonensis, or rat lungworm disease, manifests most commonly with neurologic symptoms that often include severe diffuse pain. While pain is reported by the majority of patients with rat lungworm disease, there are presently no published guidelines on the approach to pain management for these patients. Here we report a case of rat lungworm disease where severe refractory pain was the most prominent symptom and an intravenous lidocaine infusion was used as a successful treatment modality. Intravenous lidocaine has been shown to be safe and effective in neuropathic pain, refractory cancer pain, and peri-operative pain management. To our knowledge, this is the first case report on the use of lidocaine infusion for the management of refractory pain from rat lungworm disease, and among the first reports of any approach, to pain management for rat lungworm disease. We suggest that a lidocaine infusion protocol be considered when pain from rat lungworm disease fails to respond to first-line analgesics.
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Affiliation(s)
- Kirth Cucueco
- Correspondence to: Kirth Cucueco MD; 1356 Lusitana St., 7th Fl., Honolulu, HI;
| | - Kristin Bathen
- Pain & Palliative Care Department, The Queen's Medical Center, Honolulu, HI (KB, DF)
| | - Daniel Fischberg
- Pain & Palliative Care Department, The Queen's Medical Center, Honolulu, HI (KB, DF)
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Edmonds KP, Saunders IM, Willeford A, Ajayi TA, Atayee RS. Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations. Drugs 2019; 80:115-130. [PMID: 31820362 DOI: 10.1007/s40265-019-01234-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.
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Affiliation(s)
- Kyle P Edmonds
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Andrew Willeford
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA
| | - Toluwalase A Ajayi
- Digital Medicine, Scripps Research Translational Institute, La Jolla, CA, 92037, USA
| | - Rabia S Atayee
- Doris A. Howell Palliative Care Teams, University of California San Diego, La Jolla, CA, 92093, USA.
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, 92093, USA.
- Department of Pharmacy, University of California San Diego Health, La Jolla, CA, USA.
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