Weakness Of Facial Muscles Research Articles

6556 Does Autoimmune Hashimoto’s Hypothyroidism Mask the Diagnosis of Ehlers-Danlos-Syndrome?

Abstract Disclosure: S. Azmat: None. U. Rafat: None. J.L. Gilden: None. Does Autoimmune Hashimoto’s Hypothyroidism Mask the Diagnosis of Ehlers-Danlos Syndrome? Background: Hypothyroidism is well-known to be associated with muscle weakness and fatigue. There are other etiologies for decreased muscle tone such as Ehlers-Danlos syndrome (EDS) which is group of connective tissue disorders characterized by joint hypermobility, skin hyperextensibility and tissue fragility. Other rheumatological and cardiac conditions associated with this syndrome can pose diagnostic challenges. We present case of 32-year-old female presenting with facial muscle weakness and newly diagnosed Hashimoto’s hypothyroidism. We highlight importance of keeping EDS as another differential in patients with muscle weakness allowing for accurate, prompt diagnosis and treatment to be done in timely manner. Case Description: A 32-year-old female professional musician was referred to Endocrine for mouth muscles weakness and decreasing ability to play her French Horn wind instrument with vocal dystonia and the question of whether these were symptoms of hypothyroidism. She was noted to have mild thyroid enlargement and abnormal thyroid function tests with positive thyroid antibodies. Initial TSH was 7.506 uIU/mL(0.55-4.78), free T4 0.9 ng/dL (0.76-1.46), peroxidase antibody = 96,061U/mL (0-60) and thyroglobulin of 134.9 U/mL (0-60). She also reported low energy, intermittent difficulty swallowing and decreased muscle strength. There was no prior personal and family history of hypo/hyperthyroidism or any other disorders. VS were normal, physical exam showe d no thyromegaly, reflexes revealed objective decrease but normal muscle strength. The skin was noted to be hyperextensible with passive hyperextension of fifth metacarpophalangeal joint beyond 90 degrees, thumb to flexor aspect of forearm and elbows bilaterally with positive Beighton criteria for EDS. She later admitted to intermittent palpitations and easy bruising. Subsequent lab tests were negative ANA, anti-mitochondrial, PCEL and striated muscles antibodies. Additionally she had normal IGA, PTH, AM cortisol- ACTH, vitamin B12 levels with negative 21 hydroxylases antibodies and celiac titers. She was started on levothyroxine 25 mcg and recommended for Cardiology evaluation and genetic testing. Physiotherapy was started. Upon six months follow-up she clinically felt better with improved muscle strength, swallowing and energy level. Repeat lab testing showed improved TSH of 2.67 uIU/mL(0.55-4.78) with free T4 of 1.0 ng/dL (0.76-1.46). Conclusion: This case demonstrates that although muscle weakness can be symptom of hypothyroidism one must evaluate all patients for other possible causes. We highlight importance of keeping EDS as a differential especially in female patients with muscle weakness. Though history and physical exam is crucial allowing for prompt diagnosis and treatment for other conditions. Presentation: 6/1/2024

Atypical Facio-Scapulo-Humeral Dystrophy with facial sparing: a case report

Facio-Scapulo-Humeral Dystrophy (FSHD) is an autosomal dominant and third most common inherited muscular dystrophy. Typical phenotype of FSHD initially affects the muscles of the face and upper arm. Atypical FSHD refers to genetically confirmed FSHD with phenotypic variations. Scapulo-Humeral Dystrophy (SHD) is the most common atypical form of FSDH characterized by no facial muscle weakness on clinical examination, while other signs remain consistent with FSHD. We report a 31-year-old male who presented with foot drop and had an unexpected presentation as SHD. Provisional diagnosis of SHD was based on careful medical history, physical examination findings, modest rise in muscle enzymes, and needle electromyography findings of myopathy. Muscle biopsy suggested dystrophic changes which supported the diagnosis of FSHD with facial sparing. Rehabilitation plan included patient and family counseling/education, lifestyle modifications, energy conservation strategies, right ankle foot orthosis, and therapeutic exercises with regular follow-up for monitoring of the disease.

A CASE SERIES ON THE ROLE OF PANCHAKARMA THERAPY IN THE MANAGEMENT OF ARDITA

Background: We assessed the outcome of Panchakarma therapy in Ardita roga in addition to the standard conservative approach of medical management and physiotherapy. Methods: We conducted a retrospective cohort study in 15 patients of both sexes of age group 15-60yr admitted with unilateral facial palsy. A complete history of etiologies and comorbidities and a full physical and neurological examination were conducted. Oral treatment with panchakarma therapy was given for 21 days, and the outcome was evaluated in the form of symptom relief and neurological examination. Results: Fifteen patients, including nine males and six females of age group 15-60yr, were included in this study. The aetiology was mostly idiopathic in 10 patients, followed by exposure to cold in 3 cases. The patients were presented with numbness over the face in 10 patients, followed by weakness of facial muscles. Upon examination, most had motor deficits; two patients had a taste, three had lacrimal, and six presented with altered reflexes mediated by the facial nerve. No mortality was seen in the study, and significant improvement was seen after the therapy. Conclusions: Facial nerve palsy is one of the most commonly encountered neurological pathologies in the outpatient department and is often managed conservatively. Progression can lead to permanent neurological deficits and various motor and sensory abnormalities. Thus, prompt management of this disorder can prevent such complications and improve the patient's outcome.

Linking LRP12 CGG repeat expansion to inherited peripheral neuropathy.

The causative genes for over 60% of inherited peripheral neuropathy (IPN) remain unidentified. This study endeavours to enhance the genetic diagnostic rate in IPN cases by conducting screenings focused on non-coding repeat expansions. We gathered data from 2424 unrelated Japanese patients diagnosed with IPN, among whom 1555 cases with unidentified genetic causes, as determined through comprehensive prescreening analyses, were selected for the study. Screening for CGG non-coding repeat expansions in LRP12, GIPC1 and RILPL1 genes was conducted using PCR and long-read sequencing technologies. We identified CGG repeat expansions in LRP12 from 44 cases, establishing it as the fourth most common aetiology in Japanese IPN. Most cases (29/37) exhibited distal limb weakness, without ptosis, ophthalmoplegia, facial muscle weakness or bulbar palsy. Neurogenic changes were frequently observed in both needle electromyography (97%) and skeletal muscle tissue (100%). In nerve conduction studies, 28 cases primarily showed impairment in motor nerves without concurrent involvement of sensory nerves, consistent with the phenotype of hereditary motor neuropathy. In seven cases, both motor and sensory nerves were affected, resembling the Charcot-Marie-Tooth (CMT) phenotype. Importantly, the mean CGG repeat number detected in the present patients was significantly shorter than that of patients with LRP12-oculopharyngodistal myopathy (p<0.0001). Additionally, GIPC1 and RILPL1 repeat expansions were absent in our IPN cases. We initially elucidate LRP12 repeat expansions as a prevalent cause of CMT, highlighting the necessity for an adapted screening strategy in clinical practice, particularly when addressing patients with IPN.

French National Protocol for diagnosis and care of facioscapulohumeral muscular dystrophy (FSHD).

Facioscapulohumeral muscular dystrophy (FSHD) is one of the most common genetically inherited myopathies in adults. It is characterized by incomplete penetrance and variable expressivity. Typically, FSHD patients display asymmetric weakness of facial, scapular, and humeral muscles that may progress to other muscle groups, particularly the abdominal and lower limb muscles. Early-onset patients display more severe muscle weakness and atrophy, resulting in a higher frequency of associated skeletal abnormalities. In these patients, multisystem involvement, including respiratory, ocular, and auditory, is more frequent and severe and may include the central nervous system. Adult-onset FSHD patients may also display some degree of multisystem involvement which mainly remains subclinical. In 95% of cases, FSHD patients carry a pathogenic contraction of the D4Z4 repeat units (RUs) in the subtelomeric region of chromosome 4 (4q35), which leads to the expression of DUX4 retrogene, toxic for muscles (FSHD1). Five percent of patients display the same clinical phenotype in association with a mutation in the SMCHD1 gene located in chromosome 18, inducing epigenetic modifications of the 4q D4Z4 repeated region and expression of DUX4 retrogene. This review highlights the complexities and challenges of diagnosing and managing FSHD, underscoring the importance of standardized approaches for optimal patient outcomes. It emphasizes the critical role of multidisciplinary care in addressing the diverse manifestations of FSHD across different age groups, from skeletal abnormalities in early-onset cases to the often-subclinical multisystem involvement in adults. With no current cure, the focus on alleviating symptoms and slowing disease progression through coordinated care is paramount.

Optimising Functional Recovery in a Paediatric Stroke patient secondary to Sickle Cell Disease: A Case Report

Out of many causes of Paediatric Stroke, Sickle Cell Disease is one of the crucial conditions with the risk of Stroke highest during the first decade that is between the ages of 2 &amp; 5 years. Reported here, however, is a case of a 10-year-old male child with sudden onset left side hemiplegia with facial muscle weakness, who was a known case of Sickle Cell disease since 6 months of age. With the inability to use the upper extremities &amp; walk independently, the patient was functionally dependent with a Fugl Meyer score of 55/126 &amp; Berg balance scale score of 18/56. After 4 months of Physiotherapy Treatment patient was able to use the Upper extremities for functional activities and was able to walk independently with a Berg balance scale score of 46/56. With very few cases of pediatric Stroke receiving Physiotherapy care being reported in the literature, this case report establishes the role of Physiotherapy in preventing long-term neurodevelopmental disability. KEYWORDS: Functional Motor Recovery, Paediatric Stroke, Physical Rehabilitation, Sickle Cell Disease.

Development of a clinical diagnostic model for Bell's palsy in patients with facial muscle weakness.

Early diagnosis of Bell's palsy is crucial for effective patient management in primary care settings. This study aimed to develop a simplified diagnostic tool to enhance the accuracy of identifying Bell's palsy among patients with facial muscle weakness. Data from 240 patients were analyzed using seven potential clinical evaluation indicators. Two diagnostic benchmarks were established: one based on clinical assessment and the other incorporating magnetic resonance imaging (MRI) findings. A multivariate logistic regression model was developed based on these benchmarks, resulting in the construction of a predictive tool evaluated through latent class models. Both models retained four key clinical indicators: absence of forehead wrinkles, accumulation of food and saliva inside the mouth on the affected side, presence of vesicular rash in the ear or pharynx, and lack of pain or symptoms associated with tick exposure, rash, or joint pain. The first model demonstrated excellent discriminative ability (area under the curve [AUC] = 0.96, 95% confidence interval [CI] 0.94 - 0.99) and calibration (P < 0.001), while the second model also showed good performance (AUC = 0.88, 95% CI 0.83 - 0.92) and calibration (P = 0.005). Bootstrap validation indicated no significant overfitting. The latent class defined by the first model significantly aligned with the clinical diagnosis group, while the second model showed lower consistency.

Intelligent bell facial paralysis assessment: a facial recognition model using improved SSD network

With the continuous progress of technology, the subject of life science plays an increasingly important role, among which the application of artificial intelligence in the medical field has attracted more and more attention. Bell facial palsy, a neurological ailment characterized by facial muscle weakness or paralysis, exerts a profound impact on patients’ facial expressions and masticatory abilities, thereby inflicting considerable distress upon their overall quality of life and mental well-being. In this study, we designed a facial attribute recognition model specifically for individuals with Bell’s facial palsy. The model utilizes an enhanced SSD network and scientific computing to perform a graded assessment of the patients’ condition. By replacing the VGG network with a more efficient backbone, we improved the model’s accuracy and significantly reduced its computational burden. The results show that the improved SSD network has an average precision of 87.9% in the classification of light, middle and severe facial palsy, and effectively performs the classification of patients with facial palsy, where scientific calculations also increase the precision of the classification. This is also one of the most significant contributions of this article, which provides intelligent means and objective data for future research on intelligent diagnosis and treatment as well as progressive rehabilitation.

The Effect of Infrared (IR) and Mirror Exercise on Increasing Muscle Strength and Functional Ability in Bell's Palsy Cases

Bell's Palsy is an acute, ipsilateral facial nerve (VII) paralysis. Bell's palsy is alsocaused by swelling and pressure on the nerve in the stylomastoid foramen whichcauses damage to the facial nerve. Problems that sufferers often experience after realizing facial muscle weakness from a physiotherapy perspective include facial asymmetry, a feeling of stiffness and thickness on the affected side of the face and decreased facial muscles. force on the affected side has the potential for spasm and tissue adhesions, as well as potential irritation to the affected side of the eye. The population of this study consisted of 30 respondents. Special examination for Bell's palsy sufferers using the Ugo Fisch scale and a treatment program using infrared (IR) and mirror exercise methods. This action aims to increase facial muscle strength, reduce muscle spasm, increase functional activity of facial muscles, and increase functional activity. The sample for this research consisted of 20 respondents. From the results of the hypothesis test, a p-value of 0.000 (alpha &lt; 0.05) is obtained as a critical limit, which means that H0 is rejected and Ha is accepted. So, the results of this therapy show a significant increase in facial muscle strength and functional ability between before and after therapy. Based on these results, the intervention given in the form of infrared (IR) and mirror exercise was effective in increasing muscle strength and functional ability as well as improving the participants' nerves.

Remarkable clinical improvement with oral nucleoside treatment in a patient with adult-onset TK2 deficiency: A case report

ObjectivesThymidine kinase 2 deficiency (TK2d) is a rare autosomal recessive mitochondrial disorder. It manifests as a continuous clinical spectrum, from fatal infantile mitochondrial DNA depletion syndromes to adult-onset mitochondrial myopathies characterized by ophthalmoplegia-plus phenotypes with early respiratory involvement. Treatment with pyrimidine nucleosides has recently shown striking effects on survival and motor outcomes in the more severe infantile-onset clinical forms. We present the response to treatment in a patient with adult-onset TK2d. MethodsAn adult with ptosis, ophthalmoplegia, facial, neck, and proximal muscle weakness, non-invasive nocturnal mechanical ventilation, and dysphagia due to biallelic pathogenic variants in TK2 received treatment with 260 mg/kg/day of deoxycytidine (dC) and deoxythymidine (dT) under a Compassionate Use Program. Prospective motor and respiratory assessments are presented. ResultsAfter 27 months of follow-up, the North Star Ambulatory Assessment improved by 11 points, he walked 195 m more in the 6 Minute-Walking-Test, ran 10 s faster in the 100-meter time velocity test, and the Forced Vital Capacity stabilized. Growth Differentiation Factor-15 (GDF15) levels, a biomarker of respiratory chain dysfunction, normalized. The only reported side effect was dose-dependent diarrhea. DiscussionTreatment with dC and dT can significantly improve motor performance and stabilize respiratory function safely in patients with adult-onset TK2d.

Assessment of Facial Function in Patients with Facial Palsy Using Patient-Based and Clinician-Based Tools

Facial palsy is a serious disorder that impairs both function and appearance resulting from facial muscle weakness. It impairs the quality of life of affected patients. There are questionnaires for general health and disease-specific assessments of quality of life accessible. Objective: To assess the facial function in patients with facial palsy using patient-based and clinician-based tools. Methods: A cross-sectional study was conducted among patient diagnosed with facial palsy. The study sample size 79 of both genders calculated via Epitools software and using convenient sampling technique. A pre-tested structured valid and reliable tool was used for the assessment of disability and facial function via Facial Clinimetric Evaluation used as patient-based tool and House-Brackmann Scoring Scale used as clinical based tool. SPSS version 25.0 was used to analyze data. Results: The mean age of the participants was 27.53 years. 59.5% were males whereas, 40.5% were females. So, a higher prevalence of males was seen. 58.2% were recorded at grade IV (moderately severe), 31.6% were at grade III (moderate level) and 10.1% were at grade V (severe) level. There was statistically significant association between House-Brackmann scores and facial clinimetric evaluation scores (p&lt;0.001) that was indicating that there was an association between disability and patient’s perception towards facial palsy. Conclusions: Facial Clinimetric Evaluation scale used as patient-based tool provide subjective experience and functional limitation experienced by facial palsy patient while House-Brackmann Scoring Scale used as clinical based tool provides objective evaluation of facial function of facial palsy patient.

A CASE STUDY ON RESTORING FACIAL SYMMETRY: AN AYURVEDIC APPROACH TO ARDITA (BELL’S PALSY)

The case study outlines the successful Ayurvedic management of Bell's palsy, referred to as Ardita in Ayurveda. The 46-year-old male patient presented with sudden onset drooping of the right upper eyelid, prominent right nasolabial fold, and dryness in the right eye after travelling. These symptoms are consistent with facial muscle weakness, which is characteristic of Bell's palsy. In Ayurveda, Ardita is correlated with the vitiation of Vata dosha, leading to facial distortion. The treatment approach adopted in this case was shamana chikitsa, a method focused on pacifying the aggravated dosha. Additionally, the Tarpana procedure, belonging to Netra-kriya-kalpana (ocular therapies), was employed along with mild ocular exercises. The shamana and Tarpana procedures were initiated from the first day of the treatment. After two weeks, there was a significant improvement in the gradation of Bell's palsy, resulting in a normal palpebral aperture of the eye. Notably, the treatment approach followed Ayurvedic principles and did not involve the use of oral steroids. This case study contributes to exploring and developing Ayurvedic treatment modalities for Bell's palsy. The successful outcome, without adverse effects, highlights the potential effectiveness of Ayurvedic interventions in managing facial muscle weakness. The emphasis on shamana and specific ocular therapies aligns with the holistic approach of Ayurveda, addressing the root cause of the condition and promoting overall well-being. In conclusion, this case study provides valuable insights into Ayurvedic management of Bell's palsy, showcasing the potential of traditional Ayurvedic principles and therapies in treating facial muscle weakness, enhancing confidence and preventing long-term facial damage.

Characteristics of Neurological Deficits in Intracranial Tumors: A Literature Review

Intracranial tumors or brain tumors are abnormal masses in the cranium that can originate from central nervous system cells or from other histopathological types. Brain tumors account for 85% to 90% of all primary central nervous system (CNS) tumors. Intracranial tumors have an incidence of 10-17 cases per 100,000 people. Clinical symptoms vary from one patient to another. The most common symptom is headache, followed by seizures, decreased consciousness, and motor and sensory neurological deficits. Other symptoms that may be found are neurological deficits (smell disturbances, visual disturbances, double vision, numbness or pain in the face, facial muscle weakness, hearing, swallowing, etc.) which are progressive and depend on the location of the tumor, seizures, cognitive decline, balance disorders and personality disorders. These signs and symptoms can be used to determine the location of the tumor before radiological investigations are carried out, according to the disturbed anatomical structure. Keywords: intracranial tumors, neurological deficits, supratentorial, infratentorial, suprainfratentorial

Bell’s palsy: a case report of unusual presentation in a patient with rhino-orbital cerebral mucormycosis

BackgroundMucormycosis is a fungal infection caused by the Mucorales order of fungi. This fungus is commonly found in soil and can cause disease in immunocompromised patients. On the other hand, Bell’s palsy is an idiopathic condition that results in the sudden onset of unilateral facial muscle weakness, affecting the facial nerve.Case presentationA 51-year-old Persian housewife with a history of poorly controlled diabetes mellitus presented with a splitting headache that had been ongoing for 1 week and an inability to close her left eye or make facial expressions on the left side of her face. The patient’s vital signs were normal, but physical examination revealed a yellow-grey scar on the left side of her hard palate and Bell’s palsy on the left side. A neurological examination showed that she could move both eyes but could not close her left eye, move up her left eyebrow, or smile. Further investigations were performed, including laboratory tests, radiologic imaging, and functional endoscopic sinus surgery. The patient underwent three rounds of debridement for bony erosion in the medial and posterior walls of the left maxillary sinus and the hard palate. Pathological examination confirmed mucormycosis infection in the hard palate and mucosa.ConclusionFungal infection must be considered a potential diagnosis for immunocompromised adults who exhibit symptoms of Bell’s palsy.

Onabotulinum toxin a treatment for posttraumatic trigeminal neuropathic pain: case series and literature review

This case series aimed to assess the treatment outcomes of onabotulinum toxin A (BTX-A) in patients with refractory posttraumatic trigeminal neuropathic pain (PTNP) and to conduct a narrative review of the evidence for BTX-A in PTNP. Thirteen patients were treated with BTX-A infiltrations. Patient demographic and pain characteristics, BTX-A administration, and treatment outcomes were retrospectively analyzed. Papers retrieved after a literature search of articles on PTNP treatment using BTX-A were reviewed. Six patients reported an improvement in pain 3 months after the initial BTX-A injection, with 4 patients reporting a 50% reduction. Two patients achieved an 80% reduction in pain score over 3 years of BTX-A therapy. Three patients reported temporary ipsilateral facial muscle weakness. The literature review revealed five case reports on the use of BTX-A in PTNP patients that reported similar effectiveness to the present cohort study. BTX-A may be a potential treatment modality for refractory PTNP, thus reducing the need for polypharmacy. Multiple intraoral BTX-A injections administered over the painful sites are well tolerated, safe and easily practiced. High-quality studies are required to evaluate the long-term therapeutic efficacy and side effects of BTX-A therapy.

Application of Mirror Therapy of the Face on Facial Muscle Ability in Stroke Patients at RST Dr. Soedjono Magelang

Stroke is a reduced blood flow and oxygen to the brain due to blockage, narrowing, or rupture of blood vessels. Stroke leading weakness of the face, according to damage in the frontal motor area. One way to overcome a facial weakness is to apply mirror therapy of the face which is a combination of mirror therapy and facial exercises. The purpose of this case study is to illustrate the application of facial mirror therapy in stroke patients with facial muscle abilities. This type of research is descriptive by using a case study approach. The subjects in this study were 2 stroke patients with the criteria for facial muscle weakness, which is having a sagging face, having a recurrent attack or having just had a stroke. The study showed that an increase in facial muscle ability in subject 1 from the sufficient category (score 21) to the good category (score 29), subject 2 from the sufficient category (score 24) to the good category (score 32). Recommendation : Nurses can apply Mirror Therapy of the Face to improve the ability of facial muscles in stroke patients.

Ramsay hunt syndrome in an immunocompromised patient

A 37-year-old male presented to the emergency department with headache, confusion, right-sided facial droop, and painful rash. One month prior, he underwent staged resection of an intraventricular neurocytoma and was placed on a postoperative dexamethasone taper. Examination revealed weakness in the right cranial nerve VII distribution (Figure 1A), clustered vesicles with erythema in the right ear canal and conchal bowl (Figure 1B), and scattered vesicles on the preauricular cheek. The right anterior third of his tongue had clusters of pustulovesicles (Figure 1C). The patient was diagnosed with Ramsay Hunt Syndrome (herpes zoster oticus) and urgently started on IV acyclovir. Confirmatory PCR was positive for varicella zoster virus. The patient was discharged with improved mental status. Skin lesions resolved after a 2-week course of IV acyclovir and valacyclovir, but at his 2-year follow-up the patient had persistent facial weakness, vestibular symptoms, and photophobia. Recognizing Ramsay Hunt Syndrome early is crucial as antiviral therapy is most effective when initiated within the first three days of facial paralysis onset. Early treatment may prevent long-term sequelae including permanent facial muscle weakness, hearing loss, corneal scarring, postherpetic neuralgia, tinnitus, vertigo, and taste perception changes. Even with prompt recognition and treatment, immunocompromised patients are likely to have a more severe disease process and less complete recovery.

Recurrent Ischemic Stroke In Elderly With Polycythemia Vera: Case Report

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: Myeloproliferative disorders can rise a risk of thrombotic events. Ischemic stroke is one of presenting symptoms can be found in such patients. These coexisting conditions can burden patients with more severe complications.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objectives&lt;/strong&gt;: To discuss a case of polycythemia vera with multiple episodes of ischemic stroke.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Case description&lt;/strong&gt;: The patient was a 70-year-old female with chief complaint of sudden rotatory dizziness with moderate to severe intensity. Nausea, vomiting, slurred speech, and facial muscle weakness were also reported. Onset of symptoms started 3 hours before hospital admission. Medical history including previous ischemic stroke in 2020 and 2015 with remaining right extremity weakness. Physical examination showed weakness, hypertension. Nystagmus horizontal bidirectional and upper motor neuron lesion of left CN VII and XII, weakness in right upper and lower extremities were observed. Physiological reflexes were increased, and pathological reflex was found. Head CT showed hypodense lesion led to her ischemic stroke diagnosis. Blood test showed increased hemoglobin count, leukocytosis but normal platelet count. Increased cell numbers and variations of size, morphology and distribution were found in peripheral smear. This finding was also supported with bone marrow examination which showed hypercellularity, panmyelosis with dysplasia of all hematopoietic lineage. Patient was diagnosed with polycythemia vera and treated accordingly.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion&lt;/strong&gt;: Further examination of hematology, such as peripheral smear or bone marrow examination should be considered in patients with recurrent episodes of stroke to rule in underlying myeloproliferative disorders.Appropriate treatment and routine hematology&lt;strong&gt; &lt;/strong&gt;follow up are in need to increase awareness of future thrombotic events or leukemic transformations.&lt;/p&gt;

Placement of High Dose Neurotoxins for Treatment-Resistant Rosacea.

Rosacea is a chronic inflammatory skin condition characterized by facial flushing, erythema, telangiectasias, and papulopustular lesions. Treatment for rosacea includes limiting inciting factors and reducing inflammation with topical and oral therapies. Traditional therapies primarily focus on the papulopustular or background erythematotelangiectatic component of rosacea, leaving symptoms of flushing poorly controlled and profoundly impacting the quality of life of patients. Neuromodulators have been speculated to improve the flushing component of rosacea by reducing mast cell degranulation and the release of neuropeptides. However, its use for symptomatic relief in refractory flushing rosacea has been limited by side effects such as facial muscle weakness or paralysis. We present the use of strategic placement of high-dose neuromodulators for treatment-resistant rosacea. This approach has resulted in the gradual stabilization of symptoms, improved quality of life, and superior side effect profile. Silence C, Kourosh AS, Gilbert E. Placement of high-dose neurotoxins for treatment-resistant rosacea. J Drugs Dermatol. 2023;22(6):605-606. doi:10.36849/JDD.7237.

Труднощі діагностики аномалії Кімерлі (власне клінічне спостереження)

Kimmerle’s anomaly is characterized by the presence of a bony arch of congenital or secondary origin in the structure of the first cervical vertebrae, which restricts the movement of the vertebral artery and causes its compression. This pathology belongs to craniovertebral malformations - congenital anatomical defects of the structure of the junction of the skull with the first cervical vertebra. Kimerly’s anomaly is diagnosed in approximately 12-30% of the population, causing vertebral artery syndrome, which is the cause of chronic ischemia in the posterior parts of the brain. Purpose - to describe the clinical case of Kimmerle’s anomaly in a teenager as an example of a long diagnostic search for this pathology. Clinical case. A 9-year-old girl complained of frequent headaches accompanied by vomiting. Similar conditions occurred every 3-4 weeks. Gastroenterological and neurological factors were not detected. The conditions were relieved by sleep, and drug therapy was not effective. During puberty, such attacks became less frequent and later disappeared. At the age of 16, the girl began to complain of neck pain, recurrent migraines, sharp «shooting» pain in the ear, accompanied by a buzzing sound, ringing, later joined by syncopal states, gait instability, and facial muscle weakness. An X-ray of the craniovertebral junction revealed Kimmerle’s anomaly. The patient’s condition improved with the use of the Shantz collar and constant physical therapy and neuroprotective therapy. Conclusions. Kimmerle’s anomaly can be asymptomatic and incidental, but in younger patients with a combination of neuro-otolaryngological symptoms and drop attacks, this pathology should be excluded. When taking anamnesis, attention should be paid to the chronology and conditions of symptom onset, as well as the patient’s medical history. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.