What you feel is not always what you've got. Jean Lhermitte (1877-1959) and the phantom limb phenomenon

Jean Lhermitte (1877-1959), the French neurologist and psychiatrist, is most often associated with the sign he described in three patients with multiple sclerosis, back in 1927. In 1937, Lhermitte analytically studied a series of 28 amputees experiencing phantom limb sensations further to amputations dating between 1891 and 1934. After having described the main clinical characteristics of this unpublished series, we will detail the ideas advanced by Jean Lhermitte regarding the phenomenon of the phantom limb. Lhermitte will use these observations to develop conceptions of consciousness and the body schema encompassing very modern resonances.

Jean-Alexandre Barré: Babinski's brilliant student

Guillain-Barré Syndrome, (GBS), is a popular eponym that comes from a paper written in 1916 by Doctors. Guillain, Barré, and Strohl. Its spectrum has been enlarged considerably since the first description of it. Jean Alexandre Barré was a French neurologist, whose name is still widely associated with that of Georges Guillain, (1876-1961). He is also known for the leg manoeuvre. As Joseph Babinski's brilliant student, (1857-1932), we wanted to briefly retrace his biography in order to highlight some of the salient points within it and subjects that are topical for young neurologists today.

CONFISEP: Impact of the Covid-19 pandemic lockdown on patients with multiple sclerosis in the north of France

We performed an online survey to assess lockdown impact in 176 patients with multiple sclerosis (PwMS) in the north of France. Access to healthcare was reduced for 38% of PwMS, mainly in physiotherapy, general practitioners and neurologists. 49.2% have implemented self-rehabilitation programs. Medical support was maintained for 39.2% through teleconsultations. 76.2% reported a negative impact of lockdown related to worsen disability. 45.5% expressed beneficial effects like strengthening family relationships, and reduced fatigue. Previous studies have found the same results on disability and discontinuation of care. However, even if this period has been challenging for PwMS, most of them have shown excellent adaptability.

Neuraxial analgesia is not associated with an increased risk of post-partum relapses in MS

Background:

Obstetrical analgesia remains a matter of controversy because of the fear of neurotoxicity of local anesthetics on demyelinated fibers or their potential relationship with subsequent relapses.

Objective:

To assess the impact of neuraxial analgesia on the risk of relapse during the first 3 months post-partum, with a focus on women who experienced relapses during pregnancy.

Methods:

We analyzed data of women followed-up prospectively during their pregnancies and at least 3 months post-partum, collected in the Pregnancy in Multiple Sclerosis (PRIMS) and Prevention of Post-Partum Relapses with Progestin and Estradiol in Multiple Sclerosis (POPARTMUS) studies between 1992–1995 and 2005–2012, respectively. The association of neuraxial analgesia with the occurrence of a post-partum relapse was estimated by logistic regression analysis.

Results:

A total of 389 women were included, 215 from PRIMS and 174 from POPARTMUS. In total, 156 women (40%) had neuraxial analgesia. Overall, 24% experienced a relapse during pregnancy and 25% in the 3 months post-partum. Women with a pregnancy relapse were more likely to have a post-partum relapse (odds ratio (OR) = 1.83, p = 0.02), independently of the use of neuraxial analgesia. There was no association between neuraxial analgesia and post-partum relapse (OR = 1.08, p = 0.78).

Conclusion:

Neuraxial analgesia was not associated with an increased risk of post-partum relapses, whatever multiple sclerosis (MS) activity during pregnancy.

Tear analysis as a tool to detect oligoclonal bands in radiologically isolated syndrome

BACKGROUND

Although radiologically isolated syndrome (RIS) is a newly defined entity, incidental findings of T2 hypersignals on brain MRI can lead to misdiagnosis or useless investigations. The detection of oligoclonal bands (OCBs) in cerebrospinal fluid (CSF) is a major indicator that helps in diagnosis of subclinical inflammatory disease of the central nervous system, but lumbar puncture still remains an invasive option.

METHODS

We have prospectively included patients with RIS, have compared the results of CSF and tear OCB detection by isoelectric focusing (IEF) and assessed concordance between OCB detection in tears and in CSF. Tears were collected using a Schirmer strip.

RESULTS

In 45 recruited RIS patients, OCBs were detected in CSF for 55% (25/45) and in tears for 50% (21/42) of samples.

CONCLUSIONS

We suggest that tear OCB detection may replace CSF OCB detection as a diagnostic tool in patients with RIS and be useful in follow-up.

Herpes encephalitis during natalizumab treatment in multiple sclerosis

In this case report we describe the first non-fatal herpes simplex virus encephalitis (HSE) case with natalizumab for multiple sclerosis (MS). A 36-year-old woman, previously treated with immunomodulatory and immunosuppressive drugs for MS, developed acute encephalitis after 6 monthly natalizumab perfusions. Brain imaging demonstrated suggestive bi-temporal lesions. Herpes simplex virus type-1 DNA was detected in cerebrospinal fluid. The patient improved gradually after a 21-day course of intravenous acyclovir, but neuropsychiatric changes remained 5 months later. Our non-fatal case of HSE and other reported cases of herpes infections provide evidence of an increased risk with natalizumab and point to the need for clinicians to maintain awareness.

[Urinary, sexual, and bowel disorders in early-stage multiple sclerosis]

Most multiple sclerosis (MS) patients experience some bladder, sexual, and/or bowel dysfunction during the course of the disease, which has been closely associated with the quality-of-life scores, including in patients with otherwise low disability. This underlines the need for identifying and treating these problems. Bladder dysfunction produces symptoms of urgency, frequency, and urge incontinence (due to bladder over activity and incomplete emptying), and is found in up to 80% of patients with MS. These symptoms occur in the early stage of the disease and require screening and rigorous monitoring. For many patients, treatment is effective and has been shown to reduce the risks of urologic complications, improve levels of continence, and enhance the patient's quality of life. Sexual disturbances are also present from the beginning and have and greatly influence the quality of life of the MS patient. The findings in the literature show substantial evidence that people with MS experience high levels of sexual dysfunction, most of them with hypoactive sexual behavior often associated with dissatisfaction in the relationship. The most common problems in women are lack of sexual interest and decreased libido, often with problems in orgasmic capacity, while men report erectile dysfunction and also lack of sexual interest. Unlike bladder dysfunction, there have been rather limited advances in the treatment of fecal incontinence and constipation specifically for patients with MS, despite a prevalence of up to 50%. Until now, the management of these problems has been empirical, with a lack of evaluated therapeutic regimes. Biofeedback retraining is an effective treatment in some patients with MS complaining of constipation or fecal incontinence. A response is more likely in patients with limited disability and a nonprogressive disease course. Since treatments and preventive strategies can manage many of these problems, we suggest increasing the focus on these aspects of the disease when consulting patients, including at early stages.

Pathologic laughing and intractable hiccups can occur early in multiple sclerosis

Pathologic laughing occurs in approximately 10% of patients with multiple sclerosis (MS), especially when patients have entered the chronic stage. We describe four patients with MS who, at an early stage, developed pathologic laughing associated, in two cases, with intractable hiccups. In two patients, MRI showed an enhanced lesion in the medulla oblongata and the mesencephalon, two regions suspected of being involved in pathologic laughing and intractable hiccups.

Treatment of progressive forms of multiple sclerosis by cyclophosphamide: a cohort study of 490 patients

There are no generally effective disease-modifying drugs for progressive forms of multiple sclerosis (MS). Some MS centres use cyclophosphamide (CYC) in secondary progressive (SP) forms of MS, especially after interferon beta-1b (INFbeta-1b) treatment failure. Moreover, there are currently no approved drugs for primary progressive (PP) MS. Using the collected data of patients with progressive MS, we studied clinical patterns that predicted a good response to CYC treatment. Secondly, we compared the therapeutic response of SPMS and PPMS patients to the treatment. Data from 490 MS patients were collected. All patients presented an SP (n = 362) or PP (n = 128) form of the disease and 476 had been treated for at least one year with a monthly pulse of CYC associated with methylprednisolone (MP). CYC treatment was justified because of at least a 1-point worsening on the Expanded Disability Status Scale (EDSS) during the previous year. The EDSS score was assessed at baseline and after 6 months (M6) and 12 months (M12) of treatment. After 12 months of CYC treatment, 78.6% of SPMS and 73.5% of PPMS patients had stabilised or had an improved EDSS score. Response to CYC was not significantly different in the two progressive forms of MS. Twenty-two patients presented noticeable drug side effects, one of whom withdrew from the treatment due to intolerance. Patients with an improved EDSS at M12 had a shorter mean progressive time course (5.1 years) than patients who stabilised or worsened (7.1 years) (p = 0.02). We also observed that poor responders at M6 were also poor responders at M12 (p < 0.001). This large cohort study showed that CYC treatment was well tolerated and suggested that a better response occurred in cases with a short progressive time course. We did not find any difference in treatment response between the two progressive forms of MS. To date, no treatment is approved for PPMS and we therefore propose a trial to test the use of CYC treatment early in the course of the disease in PPMS patients with disability progression.

[General practitioners' approach to relapsing multiple sclerosis]

Management of multiple sclerosis depends on close multidisciplinary collaboration but general practitioners play a particularly important role, especially in case of relapse, due to their close relationship with the patient. The purpose of this work was to conduct a survey of general practitioners' knowledge of relapsing multiple sclerosis and ascertain their main difficulties in patient management. One hundred seventy-seven practitioners answered a written questionnaire with two headings, diagnostic criteria for relapse and therapeutic approaches. Analysis of the results showed that this common event is under recognized. While 55.9 p.cent of the general practitioners stated they diagnosed relapse by themselves, only 2.8 p.cent knew its exact definition. Differential diagnosis accounted for a large number of mistakes. Our survey also underlined the use of certain therapeutic options (low-dose oral corticosteroid therapy) for which the effectiveness has not been demonstrated. It would be important to propose specific education on relapsing multiple sclerosis for general practitioners and improve cooperation with specialists. An integrated care network might be useful.

Multiple sclerosis, interferon beta and clinical thyroid dysfunction

The objective of this study was to investigate frequency and presentation of clinical thyroid dysfunction in patients treated with interferon beta (IFN-beta). We have collected the cases of clinical thyroid dysfunction in 700 consecutive patients receiving IFN-beta for multiple sclerosis (MS). Five patients (four women, one man) treated with IFN-beta1b developed hyperthyroidism. Three of them have secondary progressive MS, and two have relapsing-remitting MS. It was necessary to stop IFN-beta in three cases; these patients still require carbimazole after several months. In the two other cases, hyperthyroidism disappeared spontaneously. Two patients (one man and one woman) treated with IFN-beta1a developed hypothyroidism. One of them required l-thyroxine. Lastly, an increased thyroid volume without modification of thyroid hormones plasma levels was discovered in a patient receiving IFN-beta1a. Among patients treated with IFN-beta, clinical thyroid dysfunction is much rarer than laboratory thyroid dysfunction. However, this side-effect is sometimes severe.

[Comparison of spectral analysis and non-linear analysis of EEG in patients with cognitive decline]

Twenty-five elder subjects were classified in two groups according to the MMS score and the cognitive evoked potentials. Normal subjects (n = 15) had mean MMS = 27.6 and mean P3 amplitude = 7.1 uV), while patients with cognitive decline (n = 10) had respective values of 18 (MMS) and 3.3 uV (P3). Spectral analysis and non-linear analysis of EEG (recurrence plots of dynamical systems) were performed and both showed statistically significant differences between groups for all the parameters analysed. Subjects' classification with discriminant analysis was slightly better using the non-linear parameters. The recurrence plot method applied to EEGs, gave similar results as the dimension of correlation (D2) calculation, and was in favour of a more constraint and less complex dynamics of brain activity associated with cognitive decline.

[Primary progressive forms of multiple sclerosis: application of the new diagnostic criteria in French]

Approximately 15 p.100 of all cases of multiple sclerosis (MS) are primary progressive multiple sclerosis (PPMS). Diagnosis is however frequently delayed due to the lack of relapse. The commonly used Poser criteria established in 1983 are not directly applicable to this subgroup of MS patients. In 2000, Thompson et al proposed new diagnostic criteria for PPMS. The aim of our study was to apply retrospectively these new criteria to a cohort of patients from northern France (G-SEP cohort). The cohort included 184 patients (94 women and 90 men, sex ratio=1.04). Mean age at disease onset was 40.3 years (18-67 years) and mean follow-up was 9.9 (1-39 years). Only one patient was older than 65 years but 13 patients (7.1 p.100) were younger than 25 years. Patients were classed as having definite, probable or possible PPMS on the basis of clinical, MRI, cerebrospinal fluid and visual evoked potential (VEP) data. Most of the patients (61.4 p.100) had one symptom at onset; spastic paraparesis was frequent (79 p.100). Mean delay to diagnosis was 4.4 years. Ten patients (5.4 p.100) were surgically treated for cervic arthrosic myelopathy. Mean EDSS score at the end of follow-up was 5.8 (3-10). MRI was positive in 87.3 p.100 of the patients. Oligoclonal bands were found in 78.2 p.100. VEPs ware abnormal in 79.9 p.100 of the patients. Applying the Thompson criteria, 57.7 p.100 of the patients had definite PPMS, 38.7 p.100 probable PPMS. Our results are very similar to previous studies and confirm the usefulness of the new proposed criteria, which however should be prospectively tested to determine sensitivity and specificity in a new cohort of patients.

Interferon beta1a (Avonex) treatment in multiple sclerosis: similarity of effect on progression of disability in patients with mild and moderate disability

OBJECTIVE

To compare clinical responses to once-weekly intramuscular interferon-beta-1 a [IFNbeta-1 a, Avonex, Biogen] in multiple sclerosis (MS) patients with baseline Expanded Disability Status Scale (EDSS) < or = 3.5 or > 3.5.

METHODS

Patients with relapsing-remitting MS (RRMS), 124 with baseline EDSS < or = 3.5 and 64 RRMS patients with EDSS > 3.5, were consecutively recruited to receive IFNbeta-1 a 30 microg as a once weekly injection for 18 months. The primary endpoint of the study was the number of patients in each group with sustained worsening in disability, defined as 1-point deterioration in EDSS that persisted for at least 6 months during the 18 month follow-up period. Subordinate endpoints included relapse rates and the number of treatment dropouts.

RESULTS

Among patients with baseline EDSS < or = 3.5,16.9% experienced a deterioration in EDSS of at least 1 point; 22.5% experienced a deterioration of at least 0.5%. Corresponding rates in patients with baseline EDSS > 3.5 were 23.4% and 29% respectively (no significant differences between patients stratified according to baseline EDSS status). The proportion of patients discontinuing therapy was significantly higher in patients with baseline EDSS > 3.5 than in those with baseline EDSS < or = 3.5 (16/64 versus 12/124; p = 0.005). At the conclusion of follow-up, IFNbeta-1 a therapy was associated with a 31.7% reduction in relapse rate in patients with baseline EDSS < or = 3.5 and a 37% reduction in those with baseline EDSS > 3.5 (difference not significant).

CONCLUSIONS

During 18 months of treatment and follow-up, no difference was observed in clinical responses to IFNbeta-1 a between RRMS patients with mild and moderate disability but discontinuation of therapy was more frequent in the more disabled group.

[Treatment of progressive multiple sclerosis with cyclophosphamide]

Intravenous (IV) cyclophosphamide is currently used in secondary progressive (SP) and Primary progressive (PP) Multiple Sclerosis (MS) but its efficacy remains uncertain. Furthermore, it is necessary to determine which MS should be successfully treated with IV cyclophosphamide. We retrospectively investigated 111 consecutive patients with progressive MS (21 PPMS and 90 SPMS) treated in an open label fashion with IV cyclophosphamide. We analysed clinical data (gender, age, duration of progression, primary versus secondary MS). The treatment response was assessed by EDSS change after 6 months and 1 year of treatment. The annual relapse average decreased from 1.92 before treatment to 0.39 during the treatment. Age and gender did not influence response to therapy. We did not find any difference of response between PPMS and SPMS. Duration of the progressive phase in SPMS was not a predictive factor of efficacy. A better response was noted in SPMS patients with surimposed relapses than in patients without relapses during the year before treatment (p<0.05). Furthermore, the better response in SPMS patients with relapses before treatment suggests that it is necessary to treat when MS is still in an inflammatory stage.

Increased levels of antiviral MxA protein in peripheral blood of patients with a chronic disease of unknown etiology

Interferon alpha (IFN-alpha) is synthesized in response to viral infections. MxA protein, induced specifically by IFN-alpha and beta, expressed in peripheral blood cells, is detected more consistently than circulating IFN-alpha in serum of patients with viral infections. Thus, activation of the IFN-alpha/MxA system can be used as additional marker of the presence of a virus in patients. Therefore MxA protein and IFN-alpha levels were measured in patients with multiple sclerosis (MS), a chronic neurological disease of unknown etiology, in order to investigate the possible role of viruses in the expression of this disease. The means of MxA values obtained by using an immunochemiluminescent assay were significantly higher in blood of patients with remitting (n = 197) or relapsing (n = 39) multiple sclerosis (MS) patients and in patients with viral infections than in blood from healthy controls (n = 25) and from patients with bacterial infections (n = 12). Intra-individual variance in MxA levels in seven clinically stable remitting patients with MS was observed in the course of a follow-up, and high MxA levels were detected in three of them in blood samples collected consecutively over several months. By using an ultra sensitive assay, a higher MxA-inducer activity was obtained with sera from MS patients (n = 39) than with those from healthy controls (n = 12). Experiments with neutralizing antibodies proved that this activity in serum from patients was due to IFN-alpha, whereas IFN-alpha could not be detected by other methods. Altogether these results demonstrate that there is an activation of the IFN-alpha/MxA system in MS patients, which is consistent with the hypothesis that a viral infection may be associated with MS.

Silver stained isoelectrophoresis of tears and cerebrospinal fluid in multiple sclerosis

Cerebrospinal fluid (CSF) analysis aids in the diagnosis of multiple sclerosis. However, this examination is invasive. The aim of this study was to assess the potentials of a new method of tears isoelectrophoresis (IEF). Silver staining of IEF was used to examined tears and CSF from 123 patients including 60 patients with multiple sclerosis (MS), 50 other neurological patients and 13 patients with inflammatory neurological diseases. Tears were collected on a Shirmer strip placed in one eye, avoiding reflex secretion. This method of IEF with silver staining allowed the detection of oligoclonal bands in tears that were truly immunoglobulin G on immunofixation. The concordance rate between tears and CSF was 83%, meaning that CSF provided no more information than tears analysis in 83% of cases. Sensitivity in tears (72%) and CSF (75%) was very close as was specificity (respectively 84 % and 86 %). High concordance between tears and CSF is the first step in developing a non invasive test which could replace lumbar puncture, particularly when this procedure is not fearalele or is refused by the patient.

[Economic repercussions of multiple sclerosis]

Following a definition and critical examination of the various concepts utilized in health economy, the authors have made an analysis, based on a review of the literature available on this subject, of the economic repercussions of multiple sclerosis (MS) on the different individuals and organizations involved (social services, the patient, the patient's family). They have also reported the preliminary results of a French study carried out on a sample population of 157 MS patients undergoing treatment at four different neurological departments in the Nord--Pas de Calais region.

Acropathia ulcero-mutilans acquisita of the upper limbs

We report an 80-year-old woman with a bilateral mutilating acro-osteolysis of the fingers progressing over a period of 3 years. As the patient refused nerve or muscle biopsies, our diagnosis of acropathia ulcero-mutilans acquisita or Bureau-Barrière syndrome, characterized by osteolysis, remains hypothetical. Sporadic sensory mutilating acropathy of the upper limbs is rare, and we discuss the differential diagnosis.

[Traumatic bilateral paralysis of the abducens nerve without cervical fracture]

We report the case of a 75-year-old woman with an uneventful medical history who presented with sudden-onset diplopia immediately after neck trauma in a traffic accident. Clinical and ophthalmological examinations were consistent with bilateral abducens nerve palsy. The causal relationship, including the medicolegal implications and the pathophysiological mechanism are discussed. The case demonstrates that exceptionally benign trauma can cause severe diplopia. The delay to recovery may be very long, suggesting caution concerning the decision of surgical care.