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Dal Bo CR, De Carvalho FD, De Carvalho MB, Sakajiri RK, Torquato MDC, Miniello L, Gleizer RDA. Young man with acute flaccid tetraparesis. Pract Neurol 2024:pn-2023-004027. [PMID: 38316521 DOI: 10.1136/pn-2023-004027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/07/2024]
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Valbuena Valecillos A, Yatham P, Alderman M, Shapiro L, Tiozzo E, Gober J. Acute Intermittent Porphyria: A Review and Rehabilitation Perspective. Cureus 2023; 15:e44260. [PMID: 37772218 PMCID: PMC10526832 DOI: 10.7759/cureus.44260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
Acute intermittent porphyria (AIP) is an uncommon metabolic disease that impacts multiple organs and can manifest in many ways. It is often misdiagnosed due to its nonspecific symptoms. Neurovisceral signs and symptoms should alert physicians to consider AIP in the differential after excluding more common causes. Identifying the underlying cause is critical in preventing acute attacks, and trigger avoidance is the optimal approach to managing AIP. Medications that are contraindicated should be reviewed thoroughly. Prompt intravenous hematin administration is the primary treatment for acute attacks, and additional pharmacological therapies may be necessary to treat concurrent symptoms. A severe neurological manifestation of AIP is flaccid paralysis or severe motor weakness, which can develop into total quadriplegia and respiratory insufficiency. A comprehensive rehabilitation program is an integral aspect of the treatment plan. Since the incidence of this disease is low, functional prognosis is not well-known. As a result, it is challenging to determine the most appropriate structure, intensity, and duration of rehabilitation therapy. By extending the treatment plan, individuals with tetraplegia due to AIP can continue to make functional gains years after the onset of weakness. Understanding the disease's functional prognosis will aid in coordinating resources and improving healthcare expenditures.
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Affiliation(s)
- Adriana Valbuena Valecillos
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Puja Yatham
- Department of Medicine, Herbert Wertheim College of Medicine, Miami, USA
| | - Matison Alderman
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Lauren Shapiro
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Eduard Tiozzo
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Joslyn Gober
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
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El Hage S, Safi S, Assouad E, El Kareh A, Mokled E, Salameh P. Acute flaccid paralysis incidence rate and epidemiology in children in Lebanon: a rise in numbers in the post-vaccination and refugee crisis era. Afr Health Sci 2022; 22:116-124. [PMID: 36407402 PMCID: PMC9652653 DOI: 10.4314/ahs.v22i2.14] [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] [Indexed: 12/15/2022] Open
Abstract
Background Acute flaccid paralysis (AFP) is a clinical syndrome characterized by the acute onset of weakness and paralysis with reduced muscle tone. This study explored the incidence and different aspects of AFP in Lebanese children between 2009 and 2019. Methods AFP data were collected from the Lebanese Ministry of Public Health. Incidence rate according to year, age groups, clinical data, follow-up, diagnosis, and vaccination status was analyzed in the 11-years period. Results AFP incidence rates increased importantly from 0.63 per 100,000 in 2009 till 4.96 per 100,000 in 2019. Most of the patients were children under ten years of age, 40.6% of all cases were under five years old, and 37.9% were between 5 and 9 years old. Follow-up revealed that approximately two out of five patients experienced residual weakness. As for the final diagnosis, around 30% of cases were diagnosed as Guillain-Barre Syndrome (GBS). Most cases were children having received between 3 and 5 doses of polio vaccine. Conclusions The rise in cases coincided with the Syrian refugee crisis in Lebanon and the progressively deteriorating economy in the country; yet, incidence rates were in the lower margin compared with other countries.
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Affiliation(s)
- Said El Hage
- Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon, INSPECT-LB (Institut Nationale de Santé Publique, Epidémiologie Clinique et Toxicologie – Liban), Beirut, Lebanon
| | - Steven Safi
- Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Elise Assouad
- School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Antonio El Kareh
- Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Elie Mokled
- Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Pascale Salameh
- Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon, INSPECT-LB (Institut Nationale de Santé Publique, Epidémiologie Clinique et Toxicologie – Liban), Beirut, Lebanon, University of Nicosia Medical School, Nicosia, Cyprus
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Upchurch M, Donnelly JP, Deremiah E, Barthol C, Hafeez S, Anderson KE, Seifi A. Hereditary Coproporphyria Mimicking Guillain-Barré Syndrome After COVID-19 Infection. Cureus 2022; 14:e21586. [PMID: 35228944 PMCID: PMC8873389 DOI: 10.7759/cureus.21586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/23/2022] Open
Abstract
Hereditary coproporphyria (HCP) is a rare disorder caused by a deficiency of an enzyme, coproporphyrinogen oxidase, in the heme synthetic pathway. This disease has a highly variable clinical presentation with acute attacks of neurologic symptoms that can last from days to months. Rarely, it and other acute porphyrias may cause ascending paralysis, which is difficult to distinguish from Guillain-Barré syndrome (GBS). Acute attacks can be triggered by factors that increase the synthesis of heme, such as hormonal changes, certain medications, dietary changes, and infections. We report a 26-year-old female with HCP who presented with acute ascending flaccid paralysis and respiratory failure after coronavirus disease 2019 (COVID-19) infection and was initially misdiagnosed and treated for GBS. She was transferred to our neurosciences intensive care unit, where the diagnosis of acute porphyria was established. Initial improvement occurred during treatment for several weeks with hemin (Panhematin®) and continued with givosiran (Givlaari®), which was recently introduced for the prevention of acute attacks. We suggest that acute porphyria should be part of the differential diagnosis when GBS is suspected. To our knowledge, this is the first report of an attack of acute hepatic porphyria (AHP) that developed after a COVID-19 infection and the first with advanced paresis to be treated with givosiran. Her response suggests that givosiran may contribute to recovery from advanced neurological manifestations of acute porphyrias.
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de Souza PVS, Badia BDML, Farias IB, Pinto WBVDR, Oliveira ASB. Acute Hepatic Porphyria: Pathophysiological Basis of Neuromuscular Manifestations. Front Neurosci 2021; 15:715523. [PMID: 34646118 PMCID: PMC8502968 DOI: 10.3389/fnins.2021.715523] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/31/2021] [Indexed: 12/12/2022] Open
Abstract
Acute hepatic porphyria represents a rare, underdiagnosed group of inherited metabolic disorders due to hereditary defects of heme group biosynthesis pathway. Most patients have their definite diagnosis after several years of complex and disabling clinical manifestations and commonly after life-threatening acute neurovisceral episodes or severe motor handicap. Many key studies in the last two decades have been performed and led to the discovery of novel possible diagnostic and prognostic biomarkers and to the development of new therapeutic purposes, including small interfering RNA-based therapy, specifically driven to inhibit selectively delta-aminolevulinic acid synthase production and decrease the recurrence number of severe acute presentation for most patients. Several distinct mechanisms have been identified to contribute to the several neuromuscular signs and symptoms. This review article aims to present the current knowledge regarding the main pathophysiological mechanisms involved with the acute and chronic presentation of acute hepatic porphyria and to highlight the relevance of such content for clinical practice and in decision making about therapeutic options.
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Affiliation(s)
- Paulo Victor Sgobbi de Souza
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Bruno de Mattos Lombardi Badia
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Igor Braga Farias
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Acary Souza Bulle Oliveira
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW The patient who presents with an acute spinal cord syndrome with weakness/paralysis of the limbs presents a diagnostic. Two important syndromes are acute transverse myelitis (ATM) and acute flaccid paralysis (AFP). Both can be caused by a number of infectious and noninfectious causes. Since 2014 there have been outbreaks of acute flaccid myelitis (a subgroup of AFP) in the United States, with a national surveillance program underway. In addition, there have been increasing reports of ATM from new and emerging pathogens, and opportunistic infections in immunocompromised hosts. RECENT FINDINGS Infectious causes of ATM or AFP need to be ruled out first. There may be important clues to an infectious cause from epidemiologic risk factors, immune status, international travel, MRI, and laboratory findings. We summarize key features for the more common pathogens in this review. Advances in laboratory testing have improved the diagnostic yield from cerebrospinal fluid, including real-time polymerase chain reaction, metagenomic next-generation sequencing, and advanced antibody detection techniques. These tests still have limitations and require clinical correlation. SUMMARY We present a syndromic approach to infectious myelopathies, focusing on clinical patterns that help narrow the diagnostic possibilities.
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Sunagar K, Abraham SV. The Curious Case of the "Neurotoxic Skink": Scientific Literature Points to the Absence of Venom in Scincidae. Toxins (Basel) 2021; 13:toxins13020114. [PMID: 33546362 PMCID: PMC7913497 DOI: 10.3390/toxins13020114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 11/16/2022] Open
Abstract
In contrast to the clearly documented evolution of venom in many animal lineages, the origin of reptilian venom is highly debated. Historically, venom has been theorised to have evolved independently in snakes and lizards. However, some of the recent works have argued for the common origin of venom in “Toxicofera” reptiles, which include the order Serpentes (all snakes), and Anguimorpha and Iguania lizards. Nevertheless, in both these contrasting hypotheses, the lizards of the family Scincidae are considered to be harmless and devoid of toxic venoms. Interestingly, an unusual clinical case claiming neurotoxic envenoming by a scincid lizard was recently reported in Southern India. Considering its potentially significant medicolegal, conservation and evolutionary implications, we have summarised the scientific evidence that questions the validity of this clinical report. We argue that the symptoms documented in the patient are likely to have resulted from krait envenomation, which is far too frequent in these regions.
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Affiliation(s)
- Kartik Sunagar
- Evolutionary Venomics Lab, Centre for Ecological Sciences, Indian Institute of Science, Bangalore 560012, Karnataka, India
- Correspondence:
| | - Siju V Abraham
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur 680005, Kerala, India;
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Sundar K, Venkatasubramanian S, Shanmugam S, Arthur P, Subbaraya R, Hazeena P. False positive immunoassay for acetyl choline receptor antibody (AChR Ab) in patients exposed to polyvalent antisnake venom. J Neuroimmunol 2017; 311:68-70. [DOI: 10.1016/j.jneuroim.2017.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
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Kumar S, Bhalla A, Sharma N, Dhibar DP, Kumari S, Varma S. Clinical, Biochemical Characteristics and Hospital Outcome of Acute Intermittent Porphyria Patients: A Descriptive Study from North India. Ann Indian Acad Neurol 2017; 20:263-269. [PMID: 28904459 PMCID: PMC5586122 DOI: 10.4103/aian.aian_91_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Acute intermittent porphyria (AIP) is an inherited metabolic disease characterized by disordered heme biosynthesis. There is no recent study reported from India. MATERIALS AND METHODS It was a retrospective, observational study. Clinical records of patients of AIP with acute porphyric attacks admitted from April 2008 to December 2016 were analyzed. RESULTS Fifteen AIP patients constituted of eight females and seven males were analyzed. Mean age at presentation was 34.33 ± 15.86 years. Thirteen patients (86.67%) had acute flaccid paralysis (AFP). All of them had peripheral neuropathy. These patients concomitantly had abdominal pain, seizure, encephalopathy, autonomic hyperactivity, history of passage of dark urine, and electrolyte abnormality (hyponatremia) in various combinations. Abdominal pain was the presenting symptom in 11 (73.33%) patients. Seven (46.67%) patients had seizure episodes. Five patients (33.33%) had hyponatremia at presentation. Significantly higher percentage of them had seizure at presentation or during hospital stay (P = 0.007). These patients also had evidence of autonomic hyperactivity in the form of higher pulse rate, systolic and diastolic blood pressure at presentation. They had prolonged duration of hospital stay as well (P = 0.016). Eleven patients had partial recovery and rest four patients (26.67%) had in-hospital mortality. CONCLUSION Patients had severe neurological involvement manifesting mainly as AFP and seizure episodes. We recommend screening for AIP in patients presenting with features of AFP along with any combination of clinical/laboratory manifestations such as abdominal pain, seizure, encephalopathy, autonomic hyperactivity, passage of dark urine, and hyponatremia. Electrolyte abnormality in the form of hyponatremia was an important severity marker.
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Affiliation(s)
- Susheel Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita Kumari
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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