Posttraumatic Onset Research Articles

Unusual presentation of Giant Dermatofibrosarcoma Protuberans

Dermatofibrosarcoma protuberans (DFSP) is an uncommon, soft tissue sarcoma with a low metastatic potential but high rate of recurrence after surgical intervention. This tumor is characterized by a long history of slow growth. DFSP usually occurs on trunk and proximal extremities but rarely touches distal extremities such as hands, fingers, or foot below knees. We present a case of giant DFSP of the distal extremity, with a post-traumatic onset in childhood and a very long course. A 45-year-old patient presented with a tumoral lesion of the foot, evolving since 35 years with an onset at the age of 10 years, after a strong trauma of the 3rd toe. Physical examination revealed a reddish purple polynodular neoplastic lesion with a firm consistency. One of these nodular masses was ulcerated with areas of necrosis. The CT scan did not detect any bone involvement. Magnetic resonance imaging revealed a heterogeneously enhancing mass lesion on the dorsal aspect of the left forefoot. In depth, this mass invaded the dorsal interosseous muscles. The histopathological study was in favor of DFSP, with evidence of spindle-shaped tumor cells arranged in a storiform pattern. On immunohistochemistry (IHC), the cells expressed intense and diffuse CD34 and were negative for Desmin and S-100. The localization or occurrence of DFSP after a long period of trauma should not mislead the diagnosis. A careful histological study with IHC should be carried out in order to set up an appropriate treatment.

Sensitivity of the SNNOOP10 list in the high-risk secondary headache detection.

To evaluate the diagnostic accuracy of the SNNOOP10 list in the detection of high-risk headaches. Patients that visited the Hospital Clínico San Carlos (Madrid) emergency department due to headache that were allocated to a Manchester Triage System level between critical and urgent were prospectively included but retrospectively analysed. A researcher blind to the patients' diagnosis administered a standardised questionnaire and afterwards a neurologist blind to the questionnaire results diagnosed the patient according to the International Classification of Headache Disorders. The primary endpoint was to assess the sensitivity of the SNNOOP10 list in the detection of high-risk headaches. Secondary endpoints included the evaluation of the sensitivity, specificity, positive predictive value, negative predictive value and area under the curve of each SNNOOP10 item. Between April 2015 and October 2021, 100 patients were included. Patients were 44 years old (inter-quartile range: 33.6-64.7) and 57% were female. We identified 37 different diagnoses. Final diagnosis was a primary headache in 33%, secondary headache in 65% and cranial neuralgia in 2%. There were 46 patients that were considered as having high-risk headache. Patients from the primary headache group were younger and more frequently female. Sensitivity of SNNOOP10 list was 100% (95% confidence interval: 90.2%-100%). The items with higher sensitivity were neurologic deficit or disfunction (75.5%), pattern change or recent onset of the headache (64.4%), onset after 50 years (64.4%). The most specific items were posttraumatic onset of headache (94.5%), neoplasm in history (89.1%) and systemic symptoms (89%). The area under the curve of the SNNOOP10 list was 0.66 (95% CI: 0.55-0.76). The red flags from the SNNOOP10 list showed a 100% sensitivity in the detection of high-risk headache disorders.

ID:15744 Atypical Complex Regional Pain Syndrome or Functional Neurologic Disorder: A Case Report

A 41 year-old, male was referred by neurology to the outpatient pain clinic with an initial tentative diagnosis of a functional neurologic disorder. Upon interview the patient endorsed an approx. 3 year history of progressive, ascending numbness and neuropathic pain in bilateral lower extremities that was precipitated following a ligamentous injury involving the right ankle. He also reported temperature sensitivity and noted delayed healing of on an ulcer on his 5th digit. On physical examination the patient was neurologically intact and did not display allodynia. EMG/NCS revealed no evidence of a pathologic process. Given the post traumatic onset of his pain and possible trophic symptoms it was hypothesized that his neurologic symptoms could be related to a sympathetically mediated process. He subsequently underwent a fluoroscopic guided unilateral lumbar sympathetic block using local anaesthetic and dexamethasone. Pre-procedurally he rated his pain as 8/10. Within two days the patient reported complete resolution of his pain with lasting benefit at 2 weeks’ follow up.

Post-traumatic onset of secondary progression of gynecomastia

Gynecomastia is a benign enlargement of the male breast which can be a source of significant anxiety and embarrassment for the patients. A great variety of etiologic factors have been investigated and discussed. However, only few studies in the literature have accentuated on the possible role of the chronic tissue trauma for the de novo development of gynecomastia. Nevertheless, the exact mechanism of its onset in such cases remains unclear. The authors report on a case of posttraumatic unilateral progression of preexisting stable gynecomastia. The possible role of a single episode of acute trauma as a trigger mechanism for the new onset of the breast enlargement is discussed.

Focal Presentations of Facioscapulohumeral Dystrophy (P04.082)

Objective: To identify additional focal presentations of FSHD. Background Facioscapulohumeral dystrophy (FSHD) is an autosomal dominant myopathy, classically presenting with facial and shoulder girdle weakness. Recently, monomelic lower limb presentations of genetically confirmed FSHD have been reported. Design/Methods: A retrospective review of our academic center medical record database of all FSHD cases seen from 1996 to 2011. Of 139 cases identified, 8 had DNA confirmation with a focal presentation. Demographic and clinical data was abstracted. Results: There were 8 cases (4 male) with mean age at onset 39 years (range 18-63) and age at diagnosis 45 years (range 20-74). Presenting symptoms were monomelic lower limb atrophy (3); unilateral shoulder atrophy (3); and axial weakness (2). Examination showed isolated focal weakness in five. CK was normal or mildly elevated. All had a single family member with “weakness”. Co-existent unusual symptoms included dyspnea (2), S1 radicular pain with calf atrophy (2), peripheral neuropathy (1) and post-traumatic onset (1). EMG showed myopathic changes in all, apart from one case with severe denervation later followed by myopathic changes. DNA analysis showed D4Z4 EcoRI fragment size ranging from 20 to 37 kilobases. Conclusions: The clinical phenotype of FSHD should be expanded to include focal atrophy with myopathic EMG findings; axial weakness; or dyspnea at presentation. These cases are challenging due to lack of typical FSHD signs and coexistent symptoms suggestive of an alternative diagnosis. Disclosure: Dr. Hassan has nothing to disclose. Dr. Jones has nothing to disclose. Dr. Milone has nothing to disclose. Dr. Kumar has nothing to disclose.

Norepinephrine-evoked pain in fibromyalgia. A randomized pilot study [ISRCTN70707830

BackgroundFibromyalgia syndrome displays sympathetically maintained pain features such as frequent post-traumatic onset and stimuli-independent pain accompanied by allodynia and paresthesias. Heart rate variability studies showed that fibromyalgia patients have changes consistent with ongoing sympathetic hyperactivity. Norepinephrine-evoked pain test is used to assess sympathetically maintained pain syndromes. Our objective was to define if fibromyalgia patients have norepinephrine-evoked pain.MethodsProspective double blind controlled study. Participants: Twenty FM patients, and two age/sex matched control groups; 20 rheumatoid arthritis patients and 20 healthy controls. Ten micrograms of norepinephrine diluted in 0.1 ml of saline solution were injected in a forearm. The contrasting substance, 0.1 ml of saline solution alone, was injected in the opposite forearm. Maximum local pain elicited during the 5 minutes post-injection was graded on a visual analog scale (VAS). Norepinephrine-evoked pain was diagnosed when norepinephrine injection induced greater pain than placebo injection. Intensity of norepinephrine-evoked pain was calculated as the difference between norepinephrine minus placebo-induced VAS scores.ResultsNorepinephrine-evoked pain was seen in 80 % of FM patients (95% confidence intervals 56.3 – 94.3%), in 30 % of rheumatoid arthritis patients and in 30 % of healthy controls (95% confidence intervals 11.9 – 54.3) (p < 0.05). Intensity of norepinephrine-evoked pain was greater in FM patients (mean ± SD 2.5 ± 2.5) when compared to rheumatoid arthritis patients (0.3 ± 0.7), and healthy controls (0.3 ± 0.8) p < 0.0001.ConclusionsFibromyalgia patients have norepinephrine-evoked pain. This finding supports the hypothesis that fibromyalgia may be a sympathetically maintained pain syndrome.

Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients

The purpose of the study was to investigate the differences between two types of onset (post-traumatic versus idiopathic) in pain, disability, and psychological distress in patients with fibromyalgia syndrome (FS). Forty-six FS patients with post-traumatic onset and 46 FM patients with idiopathic onset, who were matched in age and pain duration, were included in the study. All participants completed self-report inventories assessing their adaptation to the pain conditions, and during the medical examination, an examining physician completed an inventory (Medical Examination and Diagnostic Information Coding System; MEDICS) to indicate the degree of physical abnormality. The analysis revealed that the degrees of physical abnormality of the patients were comparable in the two groups. However, controlling for the involvement with financial compensation issues (e.g. disability, litigation), the post-traumatic FS patients reported significantly higher degrees of pain, disability life interference, and affective distress as well as lower level of activity than did the idiopathic FS patients. Furthermore, evaluation of the treatment history in these patients revealed that a significantly larger number of the post-traumatic FS patients were receiving opioid medications and had been treated with nerve block, physical therapy, and TENS. The results suggest that (1) post-traumatic onset is associated with high level of difficulties in adaptation to chronic FS symptoms and (2) FS patients are a heterogeneous group of patients.

Myofascial Pain and Fibromyalgia: Trigger Point Management

The Victorians might have called sufferers asthenic women, but the conjunction of generalized pains concentrating over muscles where many find tender spots and some nodular tensions, predominantly in women, took the name fibrositis early in this century. The syndrome split from psychogenic rheumatism in midcentury and lost the -itissuffix more recently, when attempts to demonstrate inflammation by laboratory means, thermography, and biopsy either failed or proved inconclusive or nonreproducible. Fibromyalgia became the generally accepted term in English-speaking countries. (Tendomyopathy, the preferred German term, also popular in adjacent European countries, is not cited in this book, although it would be well known to the author of an excellent first chapter reviewing current concepts of the disorder.) Considerable interest in the problem has recently led to a consensus conference on congruence of concepts, not yet published, and has excited some trial lawyers who claim posttraumatic onset to win compensation for clients