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Mhiri M, Ben Abdelwahed M, Dhiflaoui MA, Ben Dhia R, Gouta N, Jemni I, Baklouti R, Zakhama M, Gueddiche A, Loghmari MH, Ben Chaabene N, Safer L, Frih-Ayed M. Hepatic myelopathy neurological complication of chronic liver disease: two case reports. J Med Case Rep 2024; 18:281. [PMID: 38880918 PMCID: PMC11181619 DOI: 10.1186/s13256-024-04495-2] [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] [Received: 11/01/2023] [Accepted: 03/06/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Hepatic myelopathy is a very rare neurological complication of chronic liver disease. Patients habitually present with progressive pure motor spastic paraparesis. This neurological dysfunction is almost always due to cirrhosis and portocaval shunt, either surgical or spontaneous. CASES REPORT We report two cases of a 57-year-old man and a 37-year-old woman with progressive spastic paraparesis linked to cirrhosis and portal hypertension. The two patients are of Tunisian origin (north Africa). Magnetic resonance imaging of the spinal cord of two patients was normal, while brain magnetic resonance imaging showed a T2 hypersignals of the pallidums. These signs, in favor of hepatic encephalopathy in the two patients with cirrhosis with isolated progressive spastic paraparesis without bladder or sensory disorders, help to retain the diagnosis of hepatic myelopathy. CONCLUSION Hepatic myelopathy is a severe and debilitating neurological complication of chronic liver disease. The pathogenesis is misunderstood and seems to be multifactorial, including the selective neurotoxic role both of ammonia and other pathogenic neurotoxins. Usually a pathological brain magnetic resonance imaging showing a hepatic encephalopathy was documented, contrasting with a normal spinal cord magnetic resonance imaging that contributed to diagnosis of hepatic myelopathy. Conservative therapies such as ammonia-lowering measures, diet supplementation, antispastic drugs, and endovascular shunt occlusion show little benefit in improving disease symptoms. Liver transplantation performed at early stage can prevent disease progression and could probably allow for recovery.
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Affiliation(s)
- Mariem Mhiri
- Departement of Neurology, CHU Fattouma Bourguiba, Fattouma Bourguiba Hospital, Avenue 1Er Juin. 5000, Monastir, Tunisia.
| | | | | | - Rihab Ben Dhia
- Departement of Neurology, CHU Fattouma Bourguiba, Fattouma Bourguiba Hospital, Avenue 1Er Juin. 5000, Monastir, Tunisia
| | - Narjes Gouta
- Departement of Neurology, CHU Fattouma Bourguiba, Fattouma Bourguiba Hospital, Avenue 1Er Juin. 5000, Monastir, Tunisia
| | - Imen Jemni
- Departement of Gastro-Enterology, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Raoua Baklouti
- Departement of Gastro-Enterology, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Mejda Zakhama
- Departement of Gastro-Enterology, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Arwa Gueddiche
- Departement of Gastro-Enterology, CHU Fattouma Bourguiba, Monastir, Tunisia
| | | | - Nabil Ben Chaabene
- Departement of Gastro-Enterology, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Leila Safer
- Departement of Gastro-Enterology, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Mahbouba Frih-Ayed
- Departement of Neurology, CHU Fattouma Bourguiba, Fattouma Bourguiba Hospital, Avenue 1Er Juin. 5000, Monastir, Tunisia
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Li J, Wan S, Wen F, Li Q, Cui Y, Lu Z, Lin H. Liver Transplantation Reverses Hepatic Myelopathy in the Decompensated Phase of Cirrhosis: Case Report and Literature Review. J Clin Transl Hepatol 2024; 12:436-442. [PMID: 38638382 PMCID: PMC11022064 DOI: 10.14218/jcth.2023.00487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/14/2024] [Accepted: 02/05/2024] [Indexed: 04/20/2024] Open
Abstract
Hepatic myelopathy (HM) is a rare neurological complication in the end stage of many liver diseases and is characterized by bilateral spastic paraparesis without sensory and sphincter dysfunction. It occurs owing to metabolic disorders and central nervous system dysfunction associated with cirrhosis. Without timely and effective clinical intervention, the prognosis of these patients is devastating. Although liver transplantation (LT) is an effective treatment for HM, the prognosis of these patients remains unsatisfactory. Early recognition and diagnosis of this disease are essential for improving patient prognosis. Here, we report a case of hepatitis B virus-associated decompensated cirrhosis with HM. The patient recovered well after LT. We also summarize the clinical characteristics and post-transplant outcomes of 25 patients with HM treated by LT through 2023, including this case.
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Affiliation(s)
| | | | - Fukai Wen
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qingyu Li
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yifeng Cui
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Zhaoyang Lu
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Han Lin
- Department of Hepatic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Holroyd KB, Berkowitz AL. Metabolic and Toxic Myelopathies. Continuum (Minneap Minn) 2024; 30:199-223. [PMID: 38330479 DOI: 10.1212/con.0000000000001376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article reviews the clinical presentation, diagnostic evaluation, and treatment of metabolic and toxic myelopathies resulting from nutritional deficiencies, environmental and dietary toxins, drugs of abuse, systemic medical illnesses, and oncologic treatments. LATEST DEVELOPMENTS Increased use of bariatric surgery for obesity has led to higher incidences of deficiencies in nutrients such as vitamin B12 and copper, which can cause subacute combined degeneration. Myelopathies secondary to dietary toxins including konzo and lathyrism are likely to become more prevalent in the setting of climate change leading to drought and flooding. Although modern advances in radiation therapy techniques have reduced the incidence of radiation myelopathy, patients with cancer are living longer due to improved treatments and may require reirradiation that can increase the risk of this condition. Immune checkpoint inhibitors are increasingly used for the treatment of cancer and are associated with a wide variety of immune-mediated neurologic syndromes including myelitis. ESSENTIAL POINTS Metabolic and toxic causes should be considered in the diagnosis of myelopathy in patients with particular clinical syndromes, risk factors, and neuroimaging findings. Some of these conditions may be reversible if identified and treated early, requiring careful history, examination, and laboratory and radiologic evaluation for prompt diagnosis.
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Li JHW, Touboul A, Zouari F, Cheung PT, Wei E, Wong EC, Zhou IY, Yuen MF, Seto WK, Mak LY, Chan RW. Portable electrical impedance tomography (EIT) system stages non-alcoholic fatty liver disease for potential screening and monitoring at home. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083484 DOI: 10.1109/embc40787.2023.10339955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
This study demonstrates the feasibility of predicting NAFLD using multi-spectral electrical impedance tomography (EIT), group source separation, constant reference EIT and anthropometric measures. Vibration-controlled Transient Elastography (VCTE) Controlled Attenuated Parameter (CAP; n = 121) and magnetic resonance imaging-proton density fat fraction (MRI-PDFF; n = 34) achieved a sensitivity of 70.9% and specificity of 73.8% with our CAP predicting model and sensitivity of 77.8% and specificity of 80.0% with our MRI-PDFF predicting model. In summary, a portable EIT can be a cost-effective and self-administrable alternative for widespread home-based and community-based diagnostic screening and treatment monitoring of NAFLD.Clinical Relevance- Portable multi-spectral EIT system has the sensitivity and specificity to potentially unlock biomedical imaging in telemedicine for home-based and community-based screening, staging and monitoring for NAFLD.
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Zhu Z, Liu Y, Wu W, Huang D, Guo Y, Zheng H, Wang N, Xu Z, Li X, Qin J, Liu L, Nashan B. Liver Transplantation Reverses Hepatic Myelopathy in Hepatitis B-Related Decompensated Liver Cirrhosis: Case Report and Review of the Literature. Transplant Proc 2021; 54:158-160. [PMID: 34961599 DOI: 10.1016/j.transproceed.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
Severe neurologic complications after chronic liver disease greatly affect the patient's quality of life. Hepatic myelopathy (HM) is a rare but devastating disease, in chronic liver disease. The limbs of patients with HM show slowly progressive symmetrical spastic paralysis without sensory loss. Management of this severe neurologic complication is challenging. These patients often require timely and effective clinical intervention. Although liver transplantation is one of the effective treatments for HM, the prognosis of these patients remains poor, many of them spend their lives in wheelchairs. Here, we report a patient with HM after hepatitis B virus related decompensated liver cirrhosis who recovered well after liver transplant. This work was carried out in compliance with the Helsinki Congress and the Declaration of Istanbul.
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Affiliation(s)
- Zebin Zhu
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Yang Liu
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Wei Wu
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Dehao Huang
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Yafei Guo
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Hao Zheng
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Ning Wang
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Zhijun Xu
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Xuefeng Li
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Jiwei Qin
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Lianxin Liu
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Björn Nashan
- Department of Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China.
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Abstract
Metabolic and toxic causes of myelopathy form a heterogeneous group of disorders. In this review, we discuss the causes of metabolic and toxic myelopathies with respect to clinical presentation, pathophysiology, diagnostic testing, treatment, and prognosis. This review is organized by temporal course (hyperacute, acute, subacute, and chronic) and etiology (e.g., nutritional deficiency, toxic exposure). Broadly, the myelopathies associated with dietary toxins (neurolathyrism, konzo) and decompression sickness present suddenly (hyperacute). The myelopathies associated with heroin use and electrical injury present over hours to days (acutely). Most nutritional deficiencies (cobalamin, folate, copper) and toxic substances (nitrous oxide, zinc, organophosphates, clioquinol) cause a myelopathy of subacute onset. Vitamin E deficiency and hepatic myelopathy cause a chronic myelopathy. Radiation- and intrathecal chemotherapy-induced myelopathy can cause a transient and/or a progressive syndrome. For many metabolic and toxic causes of myelopathy, clinical deficits may stabilize or improve with rapid identification and treatment. Familiarity with these disorders is therefore essential.
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Affiliation(s)
- Michaël C C Slama
- Department of Neurology, St. Elizabeth's Medical Center, Boston, Massachusetts
| | - Aaron L Berkowitz
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Liu XH, Graham ZA, Harlow L, Pan J, Azulai D, Bauman WA, Yarrow J, Cardozo CP. Spinal Cord Injury Reduces Serum Levels of Fibroblast Growth Factor-21 and Impairs Its Signaling Pathways in Liver and Adipose Tissue in Mice. Front Endocrinol (Lausanne) 2021; 12:668984. [PMID: 34046014 PMCID: PMC8147560 DOI: 10.3389/fendo.2021.668984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/23/2021] [Indexed: 01/21/2023] Open
Abstract
Spinal cord injury (SCI) results in dysregulation of carbohydrate and lipid metabolism; the underlying cellular and physiological mechanisms remain unclear. Fibroblast growth factor 21 (FGF21) is a circulating protein primarily secreted by the liver that lowers blood glucose levels, corrects abnormal lipid profiles, and mitigates non-alcoholic fatty liver disease. FGF21 acts via activating FGF receptor 1 and ß-klotho in adipose tissue and stimulating release of adiponectin from adipose tissue which in turn signals in the liver and skeletal muscle. We examined FGF21/adiponectin signaling after spinal cord transection in mice fed a high fat diet (HFD) or a standard mouse chow. Tissues were collected at 84 days after spinal cord transection or a sham SCI surgery. SCI reduced serum FGF21 levels and hepatic FGF21 expression, as well as β-klotho and FGF receptor-1 (FGFR1) mRNA expression in adipose tissue. SCI also reduced serum levels and adipose tissue mRNA expression of adiponectin and leptin, two major adipokines. In addition, SCI suppressed hepatic type 2 adiponectin receptor (AdipoR2) mRNA expression and PPARα activation in the liver. Post-SCI mice fed a HFD had further suppression of serum FGF21 levels and hepatic FGF21 expression. Elevated serum free fatty acid (FFA) levels after HFD feeding were observed in post-SCI mice but not in sham-mice, suggesting defective FFA uptake after SCI. Moreover, after SCI several genes that are implicated in insulin's action had reduced expression in tissues of interest. These findings suggest that downregulated FGF21/adiponectin signaling and impaired responsiveness of adipose tissues to FGF21 may, at least in part, contribute to the overall picture of metabolic dysfunction after SCI.
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Affiliation(s)
- Xin-Hua Liu
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zachary A. Graham
- Research Service, Birmingham VA Medical Center, Birmingham, AL, United States
- Department of Cell, Developmental and Integrative Biology, University of Alabama-Birmingham, Birmingham, AL, United States
| | - Lauren Harlow
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, United States
| | - Jiangping Pan
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, United States
| | - Daniella Azulai
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, United States
| | - William A. Bauman
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joshua Yarrow
- Research Service and Brain Rehabilitation Research Center, Malcolm Randall VA Medical Center, North Florida/South Georgia Veterans Health System, Gainesville, FL, United States
- Division of Endocrinology, Diabetes, and Metabolism, University of Florida College of Medicine, Gainesville, FL, United States
| | - Christopher P. Cardozo
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY, United States
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Research Service, Birmingham VA Medical Center, Birmingham, AL, United States
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Koul R, Lal BB, Pamecha V, Sarin S, Alam S. Liver Transplantation Reverses Hepatic Myelopathy in 2 Children With Hepatitis A Infection. Child Neurol Open 2021; 8:2329048X20983763. [PMID: 33490305 PMCID: PMC7804343 DOI: 10.1177/2329048x20983763] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/12/2020] [Accepted: 12/06/2020] [Indexed: 01/28/2023] Open
Abstract
Objectives To report 2 children with acute hepatic myelopathy after hepatitis A infection who recovered completely after living donor liver transplantation. Methods All the children admitted into liver intensive care unit (LICU) from November 1st 2018 to 31st October 2019, were evaluated for the neurological features. The data was collected from the admission register of the LICU unit in children below 15 years age. Medical records of these children were reviewed and data collected. Established clinical criteria were used to categorize the various grades of hepatic encephalopathy/myelopathy. Results 37 children were seen over 1-year period between 6 months to 15 years age. There were 24 male(64.9%) and 13 females. Acute liver failure was seen in 19 (51.3%) and acute on chronic liver failure in 18 (48.7%). There were 10 cases of hepatitis A in acute liver failure group,10 of 19 cases (52.6%), while Wilson's disease and undetermined etiology group formed the chronic group. 2 cases of hepatic myelopathy were seen in acute liver failure following hepatitis A infection. Both these children underwent live liver donor transplantation and recovered completely. Further in hepatitis A group,3 children had spontaneous recovery, 4 died and 1 child was discharged with end of life care. Overall out of all 37 children with liver failure,20 (54%) were discharged, 6 (16.2%) were advised end of life care and 11 (29.8%) died. Conclusion Two cases (10.5%) of reversible hepatic myelopathy were seen in acute liver failure group of 19 cases. 18 out of 37 (48.6%) children had residual neurological features at discharge time.
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Affiliation(s)
- Roshan Koul
- Pediatric Neurology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Bikrant Bihari Lal
- Pediatric Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Viniyendra Pamecha
- Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Shiv Sarin
- Pediatric Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Seema Alam
- Pediatric Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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Wang T, Shen J. Usefulness of Simplified Nutritional Appetite Questionnaire (SNAQ) in Appetite Assessment in Elder Patients with Liver Cirrhosis. J Nutr Health Aging 2018; 22:911-915. [PMID: 30272092 DOI: 10.1007/s12603-018-1086-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Appetite has received little attention in health care and researches in liver cirrhosis. The Simplified Nutritional Appetite Questionnaire (SNAQ), a self-assessment nutritional screening tool, could be used to screen the risk of malnutrition and weight loss. Our objective was to assess the usefulness of SNAQ in appetite assessment in patients with liver cirrhosis. METHODS Seventy patients were enrolled. Appetite assessment was applied in the enrolled patients by completing SNAQ. Weight, hemoglobin, albumin, pro-albumin and Child-Pugh class were evaluated and recorded. The correlation between SNAQ score and these indexes was also evaluated. The most discriminating SNAQ value was calculated, which separated the participant at risk of weight loss. RESULTS In participants with SNAQ < 14, the BMI, hemoglobin, albumin and pro-albumin were significantly less than those in participants with SNAQ ≥ 14. The correlation between SNAQ and these indexes were also observed (hemoglobin: r = 0.334, p = 0.005; albumin: r = 0.384, p = 0.001; pro-albumin: r = 0.342, p = 0.004; BMI: r = 0.550, p = 0.000). The SNAQ scores reduced along with the increase of Child-Pugh class. An SNAQ score under 11.5 was the best clinical indicator of elder people at risk of weight loss. CONCLUSIONS SNAQ can be used to evaluate the appetite loss and predicting the weight loss in patients with liver cirrhosis. The SNAQ tool also can be used by clinicians and nurses to identify patients with a poor appetite who are at risk of weight loss.
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Affiliation(s)
- T Wang
- Jiaqing Shen, MD, PhD, Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Canglang District, Suzhou 215006, Jiangsu Province, China. Tel: +86-512-65223637, Fax: +86-512-65223637, e-mail:
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Brain white matter fiber tracts involved in post-transjugular intrahepatic portosystemic shunt hepatic myelopathy. Neuroreport 2017; 28:1164-1169. [DOI: 10.1097/wnr.0000000000000898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Hepatic myelopathy (HM) is characterized by progressive weakness and spasticity of the lower extremities, which is a severe spinal cord involvement rarely occurring in patients with cirrhosis or other chronic liver diseases. The diagnosis is assigned after the exclusion of other clinical entities leading to spastic paraparesis. Liver transplantation represents a potentially treatment for HM in early stage.
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Affiliation(s)
- Li Li
- Jing- Ying Li, Xiu-Hui Li, Center for Combined TCM and Western Medicine, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Chun-Yan Gou
- Jing- Ying Li, Xiu-Hui Li, Center for Combined TCM and Western Medicine, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
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Feltracco P, Cagnin A, Carollo C, Barbieri S, Ori C. Neurological disorders in liver transplant candidates: Pathophysiology and clinical assessment. Transplant Rev (Orlando) 2017; 31:193-206. [DOI: 10.1016/j.trre.2017.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 12/29/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
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Koike H, Nakamura T, Ikeda S, Takahashi M, Kawagashira Y, Iijima M, Katsuno M, Sobue G. Alcoholic Myelopathy and Nutritional Deficiency. Intern Med 2017; 56:105-108. [PMID: 28049986 PMCID: PMC5313434 DOI: 10.2169/internalmedicine.56.7364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/20/2016] [Indexed: 12/30/2022] Open
Abstract
A patient with chronic alcoholism presented with myelopathy and low serum folate and cobalamin levels. A 42-year-old alcoholic man had gait disturbance for 4 months. A neurological examination revealed marked spasticity with increased deep tendon reflexes and extensor plantar responses of the lower limbs. His cobalamin level was decreased and his serum folate level was particularly low. His plasma ammonia level was not increased. Abstinence and folic acid and cobalamin supplementation stopped the progression of his neurological deficits. This case indicates that nutritional deficiency should be monitored closely in patients with chronic alcoholism who present with myelopathy.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
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Abstract
Amyotrophic lateral sclerosis (ALS) is a dreadful, devastating and incurable motor neuron disease. Aetiologically, it is a multigenic, multifactorial and multiorgan disease. Despite intense research, ALS pathology remains unexplained. Following extensive literature review, this paper posits a new integrative explanation. This framework proposes that ammonia neurotoxicity is a main player in ALS pathogenesis. According to this explanation, a combination of impaired ammonia removal- mainly because of impaired hepatic urea cycle dysfunction-and increased ammoniagenesis- mainly because of impaired glycolytic metabolism in fast twitch skeletal muscle-causes chronic hyperammonia in ALS. In the absence of neuroprotective calcium binding proteins (calbindin, calreticulin and parvalbumin), elevated ammonia-a neurotoxin-damages motor neurons. Ammonia-induced motor neuron damage occurs through multiple mechanisms such as macroautophagy-endolysosomal impairment, endoplasmic reticulum (ER) stress, CDK5 activation, oxidative/nitrosative stress, neuronal hyperexcitability and neuroinflammation. Furthermore, the regional pattern of calcium binding proteins' loss, owing to either ER stress and/or impaired oxidative metabolism, determines clinical variability of ALS. Most importantly, this new framework can be generalised to explain other neurodegenerative disorders such as Huntington's disease and Parkinsonism.
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Affiliation(s)
- Bhavin Parekh
- Department of Biomedical Science, University of Sheffield, Sheffield, S10 2TN, UK
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Abstract
Hepatic and gastrointestinal disorders can produce a wide spectrum of neurologic complications both affecting the central nervous system (CNS) and the peripheral nervous system. These manifestations range in severity from coma in acute liver failure and acute pancreatitis, to minor cognitive changes in chronic portosystemic encephalopathy and hepatitis C. Cerebrovascular diseases can complicate hepatitis C infection and inflammatory bowel disease. Demyelinating disorders may co-exist with inflammatory bowel disease. Anti-tumor necrosis factor alpha drugs may induce demyelination. Ataxia may occur in malabsorption syndromes and in gluten related disorders. Characteristic movement disorders are key features of acquired hepatocerebral degeneration and of Whipple disease. Multiple types of neuropathy can be found in association with hepatitis, inflammatory bowel disease and gluten related disorders.
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Affiliation(s)
- José M Ferro
- Department of Neurosciences, Service of Neurology, Hospital de Santa Maria, University of Lisbon, Av. Prof. Egas Moniz, 1649-035, Lisboa, Portugal,
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