Loss Of Cutaneous Sensation Research Articles

Non-Hodgkin′s lymphoma "masquerading" as Pott′s disease in a 13-year old boy

Lymphomas are malignant neoplasms of the lymphoid lineage. They are broadly classified as either Hodgkin disease or as non-Hodgkin lymphoma (NHL). Burkitt's lymphoma, a variety of NHL, is significantly most common in sub-Saharan Africa, where it accounts for approximately one half of childhood cancers. Lymphoblastic lymphoma is less common. A case of paravertebral high grade non-Hodgkin's lymphoma (lymphoblastic lymphoma) “masquerading” as Pott's disease in a 13-year-old child is reported. The present report was informed by the unusual presentation of this case and the intent of increasing the index of diagnostic suspicion. A brief appraisal is provided of the clinical parameters, management strategies and challenges. AT was a 13-year boy that presented on account of a slowly evolving and progressively increasing hunch on the back and inability to walk over 4 and 8 months duration, respectively. There was subsequent inability to control defecation and urination. There was no history of cough. He and his twin brother lived with their paternal grandfather who had chronic cough with associated weight loss. The grandfather died shortly before the child's admission. The child had no BCG immunization. The essential findings on examination were in keeping with lower motor neurons (LMN) paralysis of the lower limbs. The upper limbs appeared normal. There was loss of cutaneous sensation from the umbilicus (T10) downward. There was a firm, (rather tense), non-tender non-pulsatile, smooth swelling over the mid-third of the back (T6-L1) the mass had no differential warmth. It measures about 20×12 cm. Chest radiograph showed no active focal lung lesion, but the thoraco-lumbar spine showed a vertebral planner at L1 and a wedged collapse of T11-T12 vertebrae. There was sclerosis of the end plates of all the vertebral bodies with associated reduction in the bone density. He had an excision biopsy on the 90th day on admission, following which his clinical state rapidly deteriorated. He died within 48 h post surgery. This report aims at raising the local index of clinical suspicion by highlighting the reality of rarities, even in the presence of inadequate diagnostic facilities!

Cutaneous Innervation of Lower Eyelid

The loss of skin sensation or numbness after lower blepharoplasty is not uncommon. The aim of this study is to elucidate the infraorbital nerve (ION) and zygomaticofacial nerve (ZFN) in detail. Twenty-one hemifaces of 14 fresh Korean adult cadavers were dissected. Infraorbital nerve and ZFN came out of infraorbital foramen and zygomaticofacial foramen. They ran along superficial to the periosteum within and beneath the epimysium of the orbicularis oculi muscle and then through orbicularis oculi muscle perpendicularly and distributed to the skin. The distal branch approached to the lower border of the tarsal plate. Most terminal branches (93.8%) of ION were distributed medial to the lateral canthus. Only a few branches (6.2%) were lateral to the lateral canthus. Most (99.4%) terminal branches of ZFN were distributed lateral to the lateral canthus. Very few (0.6%) branches were medial to the lateral canthus. We conclude that the skin-muscle flap infringes less than the skin flap on the terminal branches of ION and ZFN in exposure of the orbital floor as well as in lower blepharoplasty.

Abdominal wall pseudohernia following video-assisted thoracoscopy and pleural biopsy

A rare case of pseudohernia of the abdominal wall following video-assisted thoracoscopy (VAT) and pleural biopsy in a 61-year-old male is presented. The patient presented with a recurrent pleural effusion following fractured ribs after a road traffic accident. Computerised tomography (CT) showed thickened pleura, which was biopsied using VAT. Access to the pleural cavity was obtained with two laparoscopic ports inserted at the 8th intercostal space on the posterior chest wall. Following the procedure, the patient experienced sharp pain over the right hypochondrium, which was followed by the development of a diffuse bulge associated with the loss of skin sensation. Ultrasound and CT disclosed no musculofascial defect. Electromyography showed denervation changes affecting the muscles innervated by the 8th intercostal nerve. With expectant treatment over a year, cutaneous sensation recovered partially; however, the size of the pseudohernia remained unchanged. To the authors' knowledge, this is the first report of a pseudohernia in the English literature following VAT and pleural biopsy.

Tactile allodynia in patients with postherpetic neuralgia: Lack of change in skin blood flow upon dynamic stimulation

Tactile allodynia is a common, troublesome feature of neuropathic pain. Allodynia has been proposed to involve abnormal Aβ-afferent coupling in the dorsal horn resulting in C-fibre activation and increased skin blood flow (SBF). Thus, changes in SBF could provide an objective measure of allodynia. We searched for this mechanism in patients with postherpetic neuralgia (PHN) with varying degrees of cutaneous sensory loss. We mapped the allodynic area in PHN patients using cotton buds and von Frey hairs. Quantitative thermal testing was performed to assess small fibre function in the affected and mirror-image areas. At a subsequent visit the area of allodynia was remapped. Then the SBF in the affected and control areas was quantified before and after allodynic stimulation using laser Doppler imaging and subsequent single point continuous monitoring to detect rapid changes. We enrolled 10 PHN patients (medians: age 77 yrs, duration 20 months, ongoing pain 5). The allodynic area (range 11–546 cm 2) was stable across the sessions. Thermal testing showed similar ( n=5) or reduced ( n=5) warmth and pain sensation in the affected versus control area. Following allodynic stimulation (median evoked pain-5) we saw no changes in SBF using either imaging (repeated measures ANOVA, P=0.73) or single point monitoring. This was the case for all patients regardless of the degree of sensory impairment in the affected dermatome. In conclusion, in a representative population of PHN patients we found no evidence of changes in SBF in response to allodynic stimulation. Hence, SBF measurements are not suitable for assessing allodynia.

Effect of partial foot anaesthesia on normal gait

The role of cutaneous sensation during gait is controversial. Hence this double-blind study investigated the effect of partial foot anaesthesia on gait velocity. Twenty healthy female subjects were randomly allocated to treatment or control groups. Velocity was determined from three walking trials over a compliant foam walkway. Eutectic Mixture of Local Anaesthetics (EMLA) or Vitamin E Cream was applied to the undersurface of the feet of subjects in treatment or control groups respectively. All subjects rested in sitting for 60 minutes and gait was reassessed. Mean velocity significantly decreased by 6.06m/min following EMLA, which suggests that cutaneous input is important for gait in less predictable environments, and that loss of cutaneous sensation may contribute to gait deficits.

Effect of facilitation of sensation from plantar foot-surface boundaries on postural stabilization in young and older adults.

One of the more pervasive effects of aging is loss of cutaneous sensation, which appears to correlate with impaired postural control and increased risk of falling. This study examined the potential for compensating for the destabilizing effects of reduced cutaneous sensitivity by placing a raised edge underneath the perimeter of the plantar foot surface, so as to facilitate sensation from the stability boundaries of the base of support. The main experiment involved 14 healthy older adults (aged 65-73) selected because they were known, from a previous study, to have moderate plantar cutaneous insensitivity. We also report results of an initial experiment involving 7 healthy young adults (aged 23-31). In both experiments, we studied effects of the plantar facilitation on control of rapid stepping reactions evoked by unpredictable postural perturbation, applied via sudden platform movement in forward, backward, and lateral directions. We also studied effects on "feet-in-place" responses evoked by continuous pseudorandom platform motion in mediolateral and anteroposterior directions. Subjects were blindfolded in all tests. Plantar facilitation reduced the incidence of "extra" limb movements, beyond the initial step, during forward-step reactions in the older adults. There also appeared to be an improved ability to control feet-in-place reactions: young subjects were better able to recover balance without stepping when falling backward (given instructions to "try not to step"), and both young and older subjects reduced the extent to which the center of foot pressure approached the posterior foot boundary during continuous anteroposterior platform motion. This study provides evidence that mechanical facilitation of sensation from the boundaries of the plantar surface of the foot can improve the efficacy of certain types of stabilizing reactions evoked by unpredictable postural perturbation. The results may be directly transferable to the design of special footwear insoles to reduce instability and risk of falling in older adults.

Control of compensatory stepping reactions: Age-related impairment and the potential for remedial intervention

Stepping is a prevalent and functional reaction to loss of balance, yet this element of postural control has only recently begun to receive due attention. It is likely that the impaired ability to execute compensatory stepping reactions is an important contributor to the unsteadiness, loss of balance confidence, and risk of falling that is associated with aging and age-related pathology. Even healthy, active older adults appear to experience difficulty in controlling stepping reactions, as evidenced by a tendency to require multiple steps to recover equilibrium. There seems to be a particular problem in controlling lateral stability. When stepping in response to forward or backward loss of balance, older adults often experience difficulty in countering the tendency of the body to fall laterally during the step. When stepping in response to lateral loss of balance, they often have problems controlling movement of the swing foot so as to avoid collision with the stance limb. The problems in controlling lateral stability may be particularly relevant given the prevalence of lateral falls in older adults and the links to risk of hip fracture. With regard to mechanisms, early findings implicate age-related loss of cutaneous sensation from the plantar surface of the foot as an important contributing factor. Loss of strength may also play a role. Neural lesions, due to stroke or Parkinson' s disease, can result in profound difficulties in controlling the reactions. It is expected that studies of compensatory stepping will lead to development of new and improved diagnostic and therapeutic approaches for detecting and treating specific causes of imbalance and falling. Potential areas for remedial intervention include sensory aids, footwear, strength training, and balance training. Such interventions, if proven effective, may have a significant impact on the ability of clinicians to help older adults maintain as active and independent a lifestyle as possible, without undue fear or risk of falling.

Diabetic sensory neuropathy effect on ankle joint movement perception

Objective: To determine if diabetic subjects with lower extremity cutaneous sensory neuropathy also have a loss of ankle joint movements of ankle joint movement perception and measures of cutaneous sensory function was also investigated. Design: Diabetic subjects with and without sensory neuropathy and individuals without diabetes participated in this study. Setting: All subjects were community-living individuals. Participants: Fifty-one subjects, ages 40 to 68. Seventeen of the 34 subjects with diabetes had significant distal sensory neuropathy as determined by cutaneous perception of mechanical vibration. All individuals without diabetes were volunteers from the community. Most subjects with diabetes were recruited through direct referral from their physicians. Interventions: Ankle joint movement perception threshold (JMPT) was assessed using a device designed for this study. Cutaneous sensory function under both halluces was measured for vibration perception using a vibrometer and for touch-pressure perception using Semmes-Weinstein monofilaments. Main Outcome Measures: Ankle JMPTs (degrees) were compared to measurements of cutaneous vibration perception (volts) and touch-pressure perception (monofilaments force ratings). Results: Diabetic subjects with cutaneous sensory neuropathy demonstrated a significant loss of ankle movement perception ( p < .01). Correlation between JMPT and cutaneous sensory tests ranged from Spearman's rank r = .43 to .67. Conclusions: Although individuals with cutaneous sensory loss secondary to diabetic neuropathy also demonstrated loss of movement perception at the ankle, the relatively low explained variance between the two types of assessment (18% to 45%) indicates that the severity of ankle joint movement perception deficits cannot be directly implied from cutaneous sensory tests.

Neurologic aspects of cobalamin deficiency.

We reviewed 153 episodes of cobalamin deficiency involving the nervous system that occurred in 143 patients seen over a recent 17-year period at 2 New York City hospitals. Pernicious anemia was the most common underlying cause of the deficiency. Neurologic complaints, most commonly paresthesias or ataxia, were the first symptoms of Cbl deficiency in most episodes. The median duration of symptoms before diagnosis and treatment with vitamin B12 was 4 months, although long delays in diagnosis occurred in some patients. Diminished vibratory sensation and proprioception in the lower extremities were the most common objective findings. A wide variety of neurologic symptoms and signs were encountered, however, including ataxia, loss of cutaneous sensation, muscle weakness, diminished or hyperactive reflexes, spasticity, urinary or fecal incontinence, orthostatic hypotension, loss of vision, dementia, psychoses, and disturbances of mood. Multiple neurologic syndromes were often seen in a single patient. In 42 (27.4%) of the 153 episodes, the hematocrit was normal, and in 31 (23.0%), the mean corpuscular volume was normal. Neutropenia and thrombocytopenia were unusual even in anemic patients. In nonanemic patients in whom diagnosis was delayed, neurologic progression frequently occurred although the hematocrit remained normal. In 27 episodes, the serum cobalamin concentration was only moderately decreased (in the range of 100-200 pg/ml) and in 2 the serum level was normal. Neurologic impairment, as assessed by a quantitative severity score, was judged to be mild in 99 episodes, moderate in 39 and severe in 15. Severity of neurologic dysfunction before treatment was clearly related to the duration of symptoms prior to diagnosis. In addition, the hematocrit correlated significantly with severity, independent of the longer duration of symptoms in nonanemic patients. Four patients experienced transient neurologic exacerbations soon after beginning treatment with cyanocobalamin, with subsequent recovery. Followup evaluation was adequate to assess the neurologic response to vitamin B12 therapy in 121 episodes. All patients responded, and in 57 (47.1%), recovery was complete, with no remaining symptoms or findings on examination. The severity score was reduced by 50% or greater after treatment in 91% of the episodes. Residual long-term moderate or severe neurologic disability was noted following only 7 (6.3%) episodes. The extent of neurologic involvement after treatment was strongly related to that before therapy as well as to the duration of symptoms. The percent improvement over baseline neurologic status after treatment was inversely related to duration of symptoms and hematocrit. Some evidence of response was always seen during the first 3 months of treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Cutaneous Ulceration: An Unusual Complication of Intravenous Pentamidine Therapy

Pentamidine is one of two agents currently used to treat infections with Pneumocystis carinii. The intramuscular route of administration is associated with cutaneous side effects such as dermal necrosis, sterile abscesses and ulcer formation at the injection site, while urticaria may develop near the site of intravenous drug infusion. This is a report of a renal transplant patient with Pneumocystis pneumonia who developed chemical cellulitis and ulceration following the extravasation of intravenous pentamidine into the soft tissues of the left hand and forearm. The area healed slowly over 7 weeks, but there was a residual loss of cutaneous sensation. In a review of the literature no report of a similar case was found.

Cauda equina syndrome secondary to long-standing ankylosing spondylitis.

Fourteen patients with cauda equina syndrome secondary to long-standing ankylosing spondylitis are described. The roughly symmetrical neurological deficits were very slowly progressive and began long after the onset of the spondylitis, usually well after the rheumatological symptoms had stopped. Eventually every patient had cutaneous sensory loss in the fifth lumbar and sacral dermatomes. All patients developed urinary sphincter disturbances of a lower motor neuron type. There was prominent loss of rectal sphincter tone, and all but 2 patients had bowel complaints, including incontinence and severe constipation. Seven patients had mild to moderate weakness in the lumbosacral myotomes. Seven patients had pain in the rectum or lower limbs. Electromyographic abnormalities were consistent with multiple lumbosacral radiculopathies. Myelography and computed tomographic scanning of the lumbosacral spine showed characteristic enlargement of the caudal sac and dorsal arachnoid diverticula that had eroded the laminae and spinous processes. Recognition of this syndrome, coupled with computed tomographic scanning of the lower spinal canal, allows one to omit myelography, a procedure that is difficult because of the associated spine abnormalities. Surgical intervention should be avoided.

Preparations for pressure sores

Sores may occur over pressure areas in any patient who is immobile. They result from ischaemia of the skin or underlying tissues. Mechanisms include direct pressure on small blood vessels, shearing forces, and activation of the clotting system by damaged endothelium. Factors which increase the risk of the immobile patient developing sores include loss of cutaneous sensation, vascular disease, anaemia, malnutrition, obesity, incontinence, and any chronic debilitating disease.

Recessive hereditary sensory neuropathy

Clinical features in 2 cases of a recessive form of hereditary sensory neuropathy and the light and electron microscopy of sural nerve biopsy in 1 of them are described. The patients showed symptoms typical of this form of the disease; it should be stressed however that the loss of cutaneous sensation appeared to be limited to the distal parts of the lower extremities and involved all modalities of cutaneous sensation. Histological examination of sural nerve revealed a marked reduction in the number of myelinated fibres due to Wallerian-like axonal degeneration, of which various stages were represented. In addition, segmental demyelination, probably secondary to axonal changes, was seen. The unmyelinated fibres were also involved, but to a lesser degree than the myelinated fibres. The observations indicate a progressive nature of the pathological process.

Hyperextension Injuries of the Cervical Spine

To the Editor.— Hyperextension injuries of the cervical spine are often not appreciated clinically. I have shown this x-ray film (Fig 1) to many clinicians, radiologists, orthopedic surgeons, internists, and neurologists and the correct diagnosis was rarely made. Report of a Case.— A 39-year-old man was found semicomatose on the floor of his apartment. He was an alcoholic and had been previously admitted for a seizure disorder. He was found to have a skin contusion on the right side of his forehead, paralysis of both lower extremities and right arm, weakness of his left arm, and loss of skin sensation below the level of the upper part of the chest. His neck was extended backward, and obvious pain was elicited on minimal manipulation. A cervical spinal cord lesion was suspected. The x-ray film was interpreted as normal except for demineralization of bone. Further studies, including lumbar puncture and cisternal myelography,

A study of the mechanisms of cutaneous sensory loss in leprosy.

A study of the mechanisms of cutaneous sensory loss in leprosy.

A histologically verified bilateral anterolateral chordotomy without cutaneous sensory loss. A case report.

An 18-year old male, with intractable pain from sarcoma of the left iliac bone, was submitted to bilateral upper thoracic chordotomy in two stages. There was no post-operative relief of pain, and no detectable loss of touch, cutaneous pain or temperature sensibility. The patient finally died from the progress of his primary disease. Histological examination of the spinal cord revealed bilateral ascending degeneration of the spinothalamic tracts, completely on the right and partially on the left. The persistence of left-sided pain may be explained by preservation of ipsilateral spinothalamic fibers. With regard to the absence of cutaneous sensory loss the authors tentatively suggest that the reticular formation of the spinal cord, as a sort of atavism, has been, in this patient, primarily concerned with the transmission of impulses promoting pain and temperature sensations. On the other hand, it may be supposed that the intact ascending fibers, represented by the not interrupted spinothalamic fibers and/or the multisynaptic system, have been directly or indirectly activated, the central differentiation between the various types of stimuli applied depending on the spatial pattern of discharge from the peripheral nerve terminals.