Penile calciphylaxis in patients with end-stage kidney disease undergoing dialysis: invasive treatment and pain management

INTRODUCTION

Penile calciphylaxis is rarely reported in dialysis patients.

METHODS

We experienced cases of dialysis patients who had penile calciphylaxis between 2003 and 2020.

RESULTS

Seven patients undergoing dialysis were treated for penile necrosis (hemodialysis [HD], 5; peritoneal dialysis [PD], 1; hybrid therapy comprising PD and HD, 1). Their mean age was 62.8 years and their mean dialysis vintage 116.1 months. All had severe penile pain and were clinically diagnosed with calciphylaxis. Four received partial penectomy and three received percutaneous transluminal angioplasty (PTA) due to rapid aggravation. The number of analgesia types and the critical-care pain observation tool score significantly decreased after invasive treatment (both, P = 0.008). The 90-day and 1-year survival rates after onset were 85.7% and 57.1%, respectively.

CONCLUSION

In dialysis patients, penile calciphylaxis has poor prognosis; however, invasive treatments for pain management are effective. PTA may be beneficial in dialysis patients in poor condition. This article is protected by copyright. All rights reserved.

Phrenic nerve conduction in infancy and early childhood

Diaphragmatic action potentials (DAPs) were mapped on the thorax bilaterally in 16 neurologically normal infants and 8 boys aged 1 to 4 years during artificial ventilation after thoracic surgery. Transcutaneous stimulation was used to activate the phrenic nerve at the supraclavicular fossa at the end of an artificial inspiration. The DAPs were of positive polarity and were recorded on the ipsilateral anterolateral chest wall over the sixth to the eighth intercostal spaces, with a maximal peak at the seventh intercostal space. The DAP latencies gradually decreased from 6 to 8 ms at birth to about 5 ms at the age of 1 year, despite an increase of conduction distance. Statistical analyses revealed that DAP amplitude did not correlate with age. The latencies and amplitudes of the DAPs displayed little interside variation. The results are valuable not only as a reference for the diagnosis of patients with phrenic nerve palsy, but also as an indicator of the normal development of the phrenic nerve.

Hyperexcitability of cervical motor neurons during neck flexion in patients with Hirayama disease

We recorded the motor evoked potentials (MEPs) from the affected thenar muscles during neck flexion in 4 patients in the early progressive phase of Hirayama disease. The MEP size significantly increased during neck flexion in patients compared with normal controls. In 2 patients who were treated with a neck collar, the intrinsic muscle atrophy gradually recovered together with increased grip power, and the time course of changes in MEP during neck flexion became normal after treatment with a neck collar for 7-16 months. The technique described here would be useful for evaluating the vulnerability of cervical motor neurons and the therapeutic effect of the neck collar in Hirayama disease.

[A case presenting progressive hand clumsiness and discriminative sensory impairment]

A 58-year-old right-handed woman had presented slowly progressive clumsiness of the right hand over the past 8 years. The clumsiness of the right hand was characterized by difficulty in using scissors and a comb or in imitating finger patterns that resembled to limb kinetic apraxia. Mild rigidity, weakness and synkinetic movement were noted in the right upper extremity. Two-point discrimination, traced-figure identification and stereognosia were impaired on the right hand. However, she was neither demented nor aphasic. Brain MRIs revealed atrophy of the pre- and post-central gyri with marked preponderance on the left postcentral gyrus. 99mTc-ECD-SPECT uptake was decreased in the above brain atrophy areas. Upper limb SEPs were normal, but transcranial magnetic stimulation over the cortical hand motor area failed to evoke potentials from the right thenar muscles. These unique features seem to reflect focal cerebral degenerative process of unknown etiology, which may be classified into an asymmetric cortical degeneration syndrome (Caselli and Jack, 1992).

[Cervical flexion-induced changes of motor evoked potentials by transcranial magnetic stimulation in a patient with Hirayama disease--juvenile muscular atrophy of unilateral upper extremity]

A 16-year-old girl noticed weakness in the left hand in 1990, which gradually progressed over the next 2 years but then stabilized. Her neurologic and electrophysiological signs were compatible with juvenile muscular atrophy of unilateral upper extremity (Hirayama disease). Cine MRIs demonstrated a mild cervical cord atrophy at the C6 spine level together with an engorged epidural vein at the C4-C6 extradural spaces during neck flexion. Transcranial magnetic stimulation over the motor cortex was carried out with a pickup placed on the contralateral abductor brevis muscle. While neck flexion was maintained, the amplitude of the evoked potentials steadily attenuated and the central motor conduction time lengthened as time passed. After 8 minutes, she began to feel some dullness in the left upper limb. These phenomena were reversible and were observed only on the affected limb. The above facts not only supported the presence of a reversible cortico-efferent dysfunction in Hirayama disease, but also appeared to justify the use of neck collars to treat those afflicted with this entity.