Thick Nerve Research Articles

Symptoms: Middle Ear Mass and Hearing Loss

Symptoms: Middle Ear Mass and Hearing Loss

Evaluation of Slit-Skin Smear Against Punch Biopsy in Diagnosing Leprosy: A Cross-sectional Study in a Tertiary Care Centre of West Bengal

Background: Leprosy is an infectious disease which faces diagnostic challenges. Slit-skin smear (SSS) is an age simple diagnostic technique, yet not commonly applied by health care providers. The study aimed to determine the effectiveness of SSS in terms of validity, diagnostic accuracy, and percentage agreement against punch biopsy in diagnosing leprosy among leprosy patients who were diagnosed with leprosy on clinical grounds only (i.e., number of skin lesions and/or peripheral nerve thickening). Methods: An evaluation study of diagnostic tests with a cross-sectional design was conducted at a tertiary care center of Bankura. In general, 70 new untreated leprosy patients, diagnosed solely by clinical grounds (i.e., count of skin lesions and/or thickening of the nerve) and attending the dermatology outpatient department (From February 2019 to January 2020) were enrolled in this study. After excluding pure neuritic, relapse, and seriously ill patients by consecutive sampling, they were subjected to both SSS and punch biopsy using a standard process. SPSS for Windows (Version 16.0., Chicago, SPSS Inc.) was used to analyze data. Z test, chi-square test, and kappa test were conducted to test the statistical significance between the effectiveness of SSS and punch biopsy. Results: The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and diagnostic accuracy of SSS were 81.81%, 95.83%, 90%, 92%, 20%, 0.19%, 102.87%, and 91.42%, respectively. Based on the results, SSS could detect acid-fast bacilli (AFB) in clinically diagnosed leprosy cases slightly less than punch biopsy, but it was statistically insignificant (Z=0.3689, P=0.71138, df=1). Finally, Cohen’s Kappa coefficient was 0.796, representing substantial agreement between SSS and punch biopsy (95% CI: 0.641-0.951). Conclusions: Overall, SSS is more or less equally effective as compared to punch biopsy in confirming leprosy cases. Interest and training on SSS among resident doctors should be emphasized accordingly.

Choroideremia Gene Therapy.

Choroideremia Gene Therapy.

Frequently Thickened Nerve in Hansen’s Disease

Background: Leprosy by definition is a chronic granulomatous infection of the skin and superficial nerves in the skin caused by Mycobacterium leprae and Mycobacterium lepromatosis. [1] It most commonly involves the nose, eyes, throat, and sometimes the testicles. The bacilli are most frequently transmitted via droplets, from the nose during close contact with untreated cases of leprosy. Leprosy was first mentioned in 700BC. Leprosy is common in tropical and subtropical Asia, some Pacific countries, Africa, and South America [2]. It is not known how leprosy is transmitted. Although skin lesions and nerve thickening manifest together, they also appear as separate entities. This study aims to find out the frequently thickened nerves in different spectrums of Hansen’s disease.
 Objectives: To determine the frequently thickened nerves in different spectrums of Hansen’s disease.
 Methods: This descriptive study was conducted in Chettinad Hospital and the Research Institute from June 2021 to August 2021. The patients were biopsy-proven Hansen's disease in a different spectrum of the disease, nerve thickening was obtained using palpation method. The Sample size was small due to the prevailing covid situation at the period during which the study was conducted.
 Results: The data collected from the examination of the different spectrum of disease, the pattern of frequently thickened nerves were evaluated. A total number of 30 patients were examined by palpation method among which 10 patients showed ulnar nerve thickening,7 patients showed greater auricular nerve thickening, 4 patients showed radial cutaneous nerve thickening, 9 patients showed sural nerve thickening.
 Conclusion: In our study, the most common thickened nerve was the ulnar nerve, secondary to that was the sural nerve. This study concludes the only examination done by palpation method, further diagnostic studies might increase the accuracy and specificity of the above-collected data.

An Epidermoid Cyst along the Sensory Branch of Digital Nerve with Focal Neuropathy: A Case Report

An epidermoid cyst is a slow-growing benign neoplasm that commonly occurs in the hand. Herein, we report a rare case of an epidermoid cyst with focal neuropathy in the left ring finger of a 38-year-old woman. Preoperatively, the patient complained of erythema, swelling, and paresthesia on her fingertips. On ultrasonography and magnetic resonance imaging, ulnar digital nerve thickening and inflammation around the nerve were observed, and a neurogenic tumor-like schwannoma was expected. An excisional biopsy with neurectomy of the involved sensory branch of the ulnar digital nerve was performed under brachial plexus block. During the operation, there is such an uncommon morphology, yellowish debris under the epineurium of the ulnar digital nerve sensory branch was involved with the epidermoid cyst and seemed to be propagating along the sensory branch from the skin surface. After the operation, the paresthesia and swelling resolved. Over the 6-month follow-up in the outpatient clinic, no complications and recurrences occurred. Thus, we reported a rare intraneural epidermoid cyst (occurred along the digital nerve) in the finger, and we believe that considering the anatomical characteristics and the surrounding structures is important during mass excision.

Measurement of the facial nerve thickness and its correlation with freezing phenomenon and hypomimia in Parkinson’s disease

ObjectiveHypomimia is one of the diagnostic features in Parkinson's disease, and freezing blocks may also occur with the degenerative process. We investigated that the thickness of the cranial facial nerve that innervates facial expressions, and the relationship between bradymimia and freezing phenomena in these patients. MethodsWe included 70 patients and healthy participants in this cross-sectional study. Clinical characteristics, modified Hoehn and Yahr (mHY) stages, Unified Parkinson's Disease Rating Scale (UPDRS) scores and Freezing of Gait Questionnaire (FOG-Q) scores of Parkinson's patients were recorded. FOG-Q was scored between 1 and 4 points. The thickness of the facial nerve and its neighborhoods of numerically equal groups were measured radiologically in the internal acoustic channel (IAC) with magnetic resonance imaging of temporal lobe. Right and left facial nerve thicknesses were compared. ResultsThe right facial nerve thicknesses of the patient and control groups were measured as 0.97 ± 0.12 mm and 1.20 ± 0.10 mm at the proximal level and 0.71 (0.69–0.81) mm and 1.21 (1.13–1.24) mm at the distal level, respectively (P < 0.001). Notably, the facial nerve was more atrophied on the right than on the left (P < 0.001). Facial nerve to IAC ratio (%) was significantly lower and cerebrospinal fluid thickness distance (%) measurement was significantly higher (P < 0.001). Also, the FOG-Q and facial nerve to IAC ratio were negatively correlated (P = 0.049, rho = −0.335). ConclusionsOur study provides new information about the facial nerve and its neighborhoods and clinical relationships in individuals with PD. In studies investigating hypomimia and FOG in Parkinson's, neuroimaging of the facial nerve can also be used. These results need to be proven with more comprehensive studies.

Relationship between 25-Hydroxy Vitamin D Levels and Type of Morbus Hansen

Background: Morbus Hansen is a chronic granulomatous infection of Mycobacterium leprae (M. leprae) which is characterized by cardinal signs in the form of numbness of the skin, thickening of peripheral nerves and acid-fast bacteria (AFB) were found on bacterioscopic examination. WHO has classified MH into paucibasilar MH (MH-PB) and multibasilar MH (MH-MB) based on the number of skin lesions or bacterial index (IB). Vitamin D in MH is known to act as an immunomodulator. This study aims to determine the relationship between serum 25(OH)D levels with Morbus Hansen type at RSUP Dr. Mohammad Hoesin and Leprosy Hospital Dr. Rivai Abdullah Palembang.&#x0D; Methods: A laboratory observational study with a case series design was undertaken at the Dermatology and Venereology (DV) Polyclinic of Infectious Dermatology (DI) Mohammad Hoesin Hospital Palembang since December 2019 to January 2020. A sample of 33 patient MH met the inclusion criteria, consisting of 22 patients with Morbus Hansen (MH) type MB and 11 patients with Morbus Hansen (MH) type PB. Comparison of serum 25(OH)D levels between MB and PB type MH patients was analyzed using the Independent T Test, the relationship between serum 25(OH)D levels and MH type was analyzed using the Fisher Exact Test and the correlation between serum 25(OH)D levels with type of MH was analyzed using Spearman Rho's test. Data analysis using SPSS version 22.0.&#x0D; Results: In this study, there were no differences in demographic characteristics of gender, age, age category, body mass index, education and occupation between MB and PB type MH patients (p &gt; 0.05). There were no difference in duration of therapy (p = 0.155), ENL reaction (p = 0.276) and patient status (p = 0.304) between MB and PB type MH patients, but there were differences in bacterial index (p = 0.000) and clinical spectrum (p = 0.000) between MB and PB type MH patients. There is a difference in the mean level of 25(OH)D between MB and PB type MH patients (p = 0.006), there is a significant relationship between 25 (OH)D levels and MH type patients, (OR = 9.643 ; p = 0.010) and there is a significant moderate positive correlation between levels of 25 (OH)D and the type of MH (r = 0.467; p = 0.006).&#x0D; Conclusion: It can be concluded that there are differences in serum 25(OH)D levels among Morbus Hansen type. In addition, there is a significant relationship between serum 25(OH)D levels with Morbus Hansen type.

Relationship between 25-Hydroxy Vitamin D Levels and Type of Morbus Hansen

Background: Morbus Hansen is a chronic granulomatous infection of Mycobacterium leprae (M. leprae) which is characterized by cardinal signs in the form of numbness of the skin, thickening of peripheral nerves and acid-fast bacteria (AFB) were found on bacterioscopic examination. WHO has classified MH into paucibasilar MH (MH-PB) and multibasilar MH (MH-MB) based on the number of skin lesions or bacterial index (IB). Vitamin D in MH is known to act as an immunomodulator. This study aims to determine the relationship between serum 25(OH)D levels with Morbus Hansen type at RSUP Dr. Mohammad Hoesin and Leprosy Hospital Dr. Rivai Abdullah Palembang.&#x0D; Methods: A laboratory observational study with a case series design was undertaken at the Dermatology and Venereology (DV) Polyclinic of Infectious Dermatology (DI) Mohammad Hoesin Hospital Palembang since December 2019 to January 2020. A sample of 33 patient MH met the inclusion criteria, consisting of 22 patients with Morbus Hansen (MH) type MB and 11 patients with Morbus Hansen (MH) type PB. Comparison of serum 25(OH)D levels between MB and PB type MH patients was analyzed using the Independent T Test, the relationship between serum 25(OH)D levels and MH type was analyzed using the Fisher Exact Test and the correlation between serum 25(OH)D levels with type of MH was analyzed using Spearman Rho's test. Data analysis using SPSS version 22.0.&#x0D; Results: In this study, there were no differences in demographic characteristics of gender, age, age category, body mass index, education and occupation between MB and PB type MH patients (p &gt; 0.05). There were no difference in duration of therapy (p = 0.155), ENL reaction (p = 0.276) and patient status (p = 0.304) between MB and PB type MH patients, but there were differences in bacterial index (p = 0.000) and clinical spectrum (p = 0.000) between MB and PB type MH patients. There is a difference in the mean level of 25(OH)D between MB and PB type MH patients (p = 0.006), there is a significant relationship between 25 (OH)D levels and MH type patients, (OR = 9.643 ; p = 0.010) and there is a significant moderate positive correlation between levels of 25 (OH)D and the type of MH (r = 0.467; p = 0.006).&#x0D; Conclusion: It can be concluded that there are differences in serum 25(OH)D levels among Morbus Hansen type. In addition, there is a significant relationship between serum 25(OH)D levels with Morbus Hansen type.

High-Resolution Ultrasonography in the Assessment of Lumbar Radiculoplexus Neuropathy in Diabetics: Preliminary Results of a Case-Control Study.

Background The traditional diagnosis of lumbar radiculoplexus neuropathy (LRN) is based on a classical sequence of symptoms and targeted electrodiagnostic examination by means of electromyography. Ultrasonography reliably indicates the level of lumbar radiculopathy by assessing edema mesial to the site of compression. Materials and Methods This case–control study was undertaken at a tertiary care hospital between July 2017 and June 2019 on 15 diabetic patients with symptoms of LRN. Fifteen healthy volunteers with no symptoms or clinical signs of LRN were included in the control group. The diameter (D) and transverse diameter (TD) of L1 nerve root (L1NR), L2NR, L3NR, and L4NR were measured, and their cross-sectional areas (CSAs) were calculated based on location in the lateral zone, where the NRs were visualized. On high-resolution ultrasonography, femoral nerve was localized lateral to the femoral artery in the femoral triangle beneath the inguinal ligament. Additionally, the CSA (calculated as CSA [mm 2 ] = D × TD × π/4), the diameter (mm), and transverse diameter (mm) of bilateral femoral nerves at the level of L3-L4 were calculated. Results The difference attributed to CSAs between affected NRs in LRN group and unaffected NRs in controls at levels L1-L4 was considered statistically significant ( p < 0.05). Receiver operating characteristic analysis revealed mean values to be 8 mm 2 (CSA) for L1NR, 11.2 mm 2 (CSA) for L2NR, 13.6 mm2 (CSA) for L3NR, and 17.8 mm 2 (CSA) for L4NR. There was significant difference between ΔCSA of LRN patients and controls at L1 to L4 levels ( p < 0.05). CSA measurements of lateral femoral cutaneous nerve (8 mm 2 ) and femoral nerve (58 mm 2 ) performed on high-resolution ultrasonography were significantly larger on the affected side as compared with the unaffected side. Conclusion Radiculoplexus neuropathy of the lumbar plexus can be reliably diagnosed on high-resolution ultrasonography that can reveal nerve thickening. The laterality of affected NRs was significantly greater in LRN group when compared with controls.

Acute unilateral decrease in vision on initial presentation of an adolescent female in the emergency department

Background: Optic neuritis is an acute demyelinating inflammation of the optic nerve that leads to acute loss of vision and eye pain worsened with eye movement. It is a relatively rare condition in the pediatric population. Pediatric optic neuritis usually arises following a viral illness. It can present as an initial feature of a systemic demyelinating disease such as multiple sclerosis or neuromyelitis optica, but can also occur as an isolated syndrome. We report a classic presentation of optic neuritis presented to our Emergency Department in Doha, Qatar. Case presentation: A 16-year-old female adolescent, of Asian descent, with no past medical history, presented with acute decrease in vision in her left eye associated with eye pain and mild headache for the past week. There were no other associated symptoms. Vital signs, systemic and neurologic examinations were normal. Pertinent ophthalmologic findings on her left eye examination were as follows: visual acuity: counting fingers at 3 meters aided, color vision 0/15; normal intra-ocular pressure, slight ptosis; sluggish pupil with relative afferent pupillary defect and funduscopy showing hyperemic optic disc with blurring of the nasal margin, normal macula and retinal vessels. Laboratory reports were unremarkable. Head computed tomography (CT) scan showed asymmetric thickening of the left optic nerve with subtle surrounding fat stranding. Brain and spinal cord magnetic resonance imaging (MRI) showed left optic nerve increased signal and thickness in the proximal segment and contrast enhancement in the optic nerve and optic nerve sheet . Lumbar puncture was done. Cerebrospinal fluid (CSF) analysis and culture showed unremarkable results. The patient was admitted with a working diagnosis of optic neuritis for further investigations. Conclusion: The patient fully recovered after receiving steroid treatment for 5 days and was discharged subsequently. Optic neuritis can be seen among young patients, often female, with classic presentation of acute loss of vision and eye pain. It can be the primary manifestation of a chronic demyelinating process.

Retrospective study of the ultrasound characteristics of the tibial nerve in patients with type 2 diabetic peripheral neuropathy.

Ultrasound is a promising imaging examination for type 2 diabetic peripheral neuropathy (DPN). This study aimed to explore the risk factors of ultrasound diagnostic characteristics in the tibial nerves of patients with type 2 DPN. The Michigan Neuropathy Screening Instrument (MNSI) was used for neuropathy evaluation, and 520 patients with type 2 diabetes were divided into a DPN group and non-DPN (NDPN) group with 2 points as the cut-off value. The two groups were matched at a ratio of 1:1 according to age, BMI, calf circumference, and gender, resulting in 44 matched pairs. The dependent variable was type 2 DPN and the concomitant variables were the width, thickness, cross-sectional area, and unclear honeycomb-like structure of the tibial nerve. A 1:1 matched conditional logistic regression model was established to analyze which ultrasound diagnostic characteristics of the tibial nerve were risk factors for type 2 DPN. The thickness (OR =5.176, P=0.043) and cross-sectional area (OR =1.659, P=0.030) of the tibial nerve were risk factors for the diagnosis of DPN, while the width and unclear honeycomb-like structure of the nerve were not (P>0.05). In the diagnosis of DPN, the area under the receiver operating characteristic (ROC) curve of the cross-sectional area of the tibial nerve was 0.747, and the sensitivity, specificity, positive predictive value, and negative predictive value were 61.36%, 95.45%, 93.10%, and 71.20%, respectively. The area under the ROC curve of tibial nerve thickness was 0.867, and the sensitivity, specificity, positive predictive value, and negative predictive value were 81.82%, 90.91%, 90.00%, and 83.30%, respectively. The area under the ROC curve of thickness was larger than that of cross-sectional area of the tibial nerve (z statistic =1.800, P=0.07). The thickness and cross-sectional area of the tibial nerve measured by ultrasound are risk factors for type 2 DPN. The diagnostic sensitivity of the thickness is higher than the cross-sectional area, while the diagnostic specificity of the cross-sectional area is higher than the thickness.

Does Presurgical Magnetic Resonance Neurography Predict Surgical Gap Size in Trigeminal Class IV and V Injuries?

The accuracy of magnetic resonance neurography (MRN) for quantitative assessment of nerve injury gap is unknown. We tested the hypothesis that presurgical MRN predicts the final surgical gap size after neuroma resection at the time of surgery. This was a retrospective, single-blinded, nonrandomized cohort study on 43 patients with Sunderland Class IV and V injuries of the inferior alveolar (IAN) or the lingual nerve (LN). The MRN maxillofacial protocol was performed on a 3T scanner and was read by 2 musculoskeletal radiologists to determine the maximum size of neuroma and the abnormal nerve segment. Two independent variables were recorded during surgery: 1) the length of neuroma from histologic specimens since only 9 of the 43 neuroma size measurements were accurately measureable at the time of surgery; and 2) the length of nerve gap size after the neuroma was removed and normal fascicles were identified. There were 7 IAN and 36 LN cases analyzed. The mean time in months from injury to MRN was 6.97 ± 9.18 and MRN to surgery was 1.21 ± 1.4. The mean length of the neuroma at surgery was 7.22 ± 2.78 mm and mean nerve gap size was 12.02 ± 4.41 mm. Intraclass coefficient (ICC) agreement was fair for abnormal nerve thickness and neuroma length (ICC=0.28, 0.39) while it was moderate for neuroma thickness and abnormal nerve length (0.50, 0.59). There was no significant correlation between MRN based measurements and surgical gap size for both readers (P > .05). Abnormal nerve and neuromas of the peripheral trigeminal nerve as identified on MRN imaging demonstrates no correlation of the assessed MRN findings with the final surgical gap after neuroma removal.

Nerve ultrasound findings in Sjögren's syndrome-associated neuropathy.

The phenotype of Sjögren's syndrome-associated neuropathy has been better characterized in recent years. However, Sjögren's syndrome-associated neuropathy remains an underdiagnosed entity with only few insights considering the pathomechanisms of nerve damage. Nerve ultrasound has proven to be a useful and efficient tool in detecting nerve damage of autoimmune origin. We, therefore, aimed to evaluate this method for Sjögren's syndrome-associated neuropathy. Patients with Sjögren's syndrome and clinical signs of neuropathy underwent sonographic examination of both median and ulnar nerves. Nerve thickening was classified for cross-sectional areas of >12 mm² at the median nerve and for >10 mm² at the ulnar nerve. Fascicle thickening was documented for cross-sectional areas ≥5 mm² at the median and ≥3 mm² at the ulnar nerve. Forty-three patients were included in the analysis (median age 60 years [interquartile range 53-73 years], female rate 60%). 31/43 patients (72%) showed abnormalities on nerve ultrasound, while nerve thickening was found more frequently than fascicle thickening (90% vs. 52% of patients with sonographic abnormalities, respectively). Abnormal findings were observed more frequently at the median nerve and in proximal localization. Abnormal findings on nerve conduction studies were evident in 36/43 patients (84%). Nerve conduction studies revealed a tendency of demyelinating nerve damage patterns being associated with abnormal findings on nerve ultrasound. In addition to nerve conduction studies, nerve ultrasound may have a supporting role in the diagnosis of Sjögren's syndrome-associated neuropathy. Also, our data support an immune-mediated inflammatory demyelinating pathogenesis of Sjögren's syndrome-associated neuropathy.

Effects of Venoconstrictive Thigh Cuffs on Dry Immersion-Induced Ophthalmological Changes.

Neuro-ophthalmological changes named spaceflight associated neuro-ocular syndrome (SANS) reported after spaceflights are important medical issues. Dry immersion (DI), an analog to microgravity, rapidly induces a centralization of body fluids, immobilization, and hypokinesia similar to that observed during spaceflight. The main objectives of the present study were 2-fold: (1) to assess the neuro-ophthalmological impact during 5 days of DI and (2) to determine the effects of venoconstrictive thigh cuffs (VTC), used as a countermeasure to limit headward fluid shift, on DI-induced ophthalmological adaptations. Eighteen healthy male subjects underwent 5 days of DI with or without VTC countermeasures. The subjects were randomly assigned into two groups of 9: a control and cuffs group. Retinal and optic nerve thickness were assessed with spectral-domain optical coherence tomography (OCT). Optic nerve sheath diameter (ONSD) was measured by ocular ultrasonography and used to assess indirect changes in intracranial pressure (ICP). Intraocular pressure (IOP) was assessed by applanation tonometry. A higher thickness of the retinal nerve fiber layer (RNFL) in the temporal quadrant was observed after DI. ONSD increased significantly during DI and remained higher during the recovery phase. IOP did not significantly change during and after DI. VTC tended to limit the ONSD enlargement but not the higher thickness of an RNFL induced by DI. These findings suggest that 5 days of DI induced significant ophthalmological changes. VTC were found to dampen the ONSD enlargement induced by DI.

Leprous Neuropathy: Observational Study Highlighting the Role of Electrophysiology in Early Diagnosis.

Background Worldwide leprosy is a common cause of peripheral neuropathy. Electrophysiology is underutilized in its diagnosis. Objective This study aims to evaluate the usefulness of electrophysiological study in the diagnosis of leprous neuropathy. Materials and Methods Clinical and electrophysiological abnormalities of 36 histopathology proven leprosy patients from January 2015 to January 2017 were studied. Statistical Analysis Proportions were compared by Chi-square test. Results Total patients were 36. Thirty-four patients had abnormal electrophysiology and 34 had neurological deficits like weakness, sensory changes, and thickening. By clinical examination, multiple nerve involvement (motor weakness, sensory changes, and nerve thickening) occurred in 29, single nerve in 5, and no nerve involvement in 2. With electrophysiology, multiple nerve involvement (mononeuritis multiplex) was present in 32, single nerve in 2, and normal conduction parameters in 2. From the 36 patients, a total of 1,008 nerves were subjected to clinical examination and 132 were picked up clinically as affected, (13.1%). Electrophysiological study was done in 504 nerves, and 215 were found to be involved, (43%). Nerve abnormality detected by electrophysiology is significantly higher than clinical detection. (Chi-square =164.4054; p = 0.0000). Clinically, the most commonly affected nerve was unar (27) and the least affected was median (2) nerve. Electrophysiology detected 69% of nerves with demyelination and 35% of nerves with axonal features (mosaic pattern). Discussion There was subclinical neuropathy with electroclinical dissociation, as evidenced by more abnormality in electrophysiology than clinical examination. The nerve involvement was mononeuritis or mononeuritis multiplex pattern, both clinically and electrophysiologically. Electrophysiology showed both axonal and demyelinating nerve involvement (mosaic pattern). All the three features are present in leprous neuropathy. In corollary, if a patient has these electrophysiological features, he should be thoroughly investigated for leprosy. Conclusion Triple findings, such as subclinical neuropathy with electroclinical dissociation, mononeuritis multiplex, and mosaic pattern of demyelination and axonopathy, suggest leprous neuropathy

Challenging diagnosis of leprosy in a psychotic homeless patient with atypical clinical manifestations: an interesting case report

BackgroundA decision to diagnose certain skin diseases in patient undergoing psychotic break is challenging; this includes establishing the diagnosis of leprosy. Diagnosis of leprosy is established if there is at least one of the three cardinal signs of leprosy. Histopathological examination is not a gold standard, but remains useful in atypical or clinically suspicious cases.Case presentationWe report for the first time, an interesting case of leprosy with atypical clinical manifestations in a psychotic homeless male with unknown history of present illness. Upon examination, hypopigmented macules, hyperpigmented macules, and plaques were observed, with unclear sensation impairment. Peripheral nerve thickening and acid-fast bacilli from slit-skin smear were not found. Histopathological examination from hypopigmented macule on the upper right limb showed no granulomatous reaction and other histopathological features of leprosy. Although the condition did not fulfill the cardinal signs of leprosy, we found lagophthalmos, claw hands, pseudomutilation of fingers and toes. Therefore, the diagnosis of suspected leprosy was established. The patient was hospitalized and attempts to administer oral rifampicin and clofazimine were made. Several days after treatment, annular erythematous macules appeared on the patient’s face, abdomen, and back. Histopathological examination results on sample taken from erythematous macule and right sural nerve were consistent with the diagnosis of leprosy with reversal reaction.ConclusionIn certain conditions, histopathological examination of the skin and nerves are a highly rewarding test in establishing a diagnosis of leprosy.

ИННЕРВАЦИЯ КРОВЕНОСНЫХ СОСУДОВ ПОЧКИ У БЕЛОЙ ЛАБОРАТОРНОЙ КРЫСЫ

In the adventitia, there are mainly thick and medium-sized pulp fibers, the diameter of the thick nerve fibers is 0.3±0.2 mm. From the adventitia, nerve fibers penetrate into the muscle membrane, where the nerves have a large length, their diameter is 0.1±0.2 mm. There are quite a lot of soft nerve fibers lying in adventitia, in intima and media, with the presence of nuclei. The diameter of the thin nerve fibers is – 0.03±0.2 mm.

Diabetic Oculomotor Nerve Palsy Displaying Enhancement of the Oculomotor Nerve in the Orbit and Cavernous Sinus on MRI

Introduction: Imaging data were scarce on diabetic oculomotor nerve palsy (ONP). Our study explored the MRI features and their clinical implications for diabetic ONP. Methods: Fifty-nine patients with a clinical diagnosis of diabetic ONP were recruited from our department between January 2015 and December 2019. Orbital MRI was retrospectively analyzed, and follow-up scans were obtained for 5 patients. Based on the ocular motor nerve palsy scale, the difference in the scores on the first and last hospital days was defined as the improvement score and was used to assess the treatment effects in all. Results: Thirty-eight (64.41%) patients presented thickening and enhancement of the cavernous segment and inferior division of the intraorbital segment of the ipsilateral oculomotor nerve, with the cisternal segment spared in all. After complete resolution of symptoms, follow-up MRI in 5 patients revealed that the enhancement was less obvious compared with the previous images. 6 patients in the enhancement group and 4 patients in the nonenhancement group were treated with 80 mg of methylprednisolone. Significant differences were not detected in the median improvement scores between patients with and those without corticosteroid use (p = 0.240). Conclusion: Thickening and enhancement of the unilateral oculomotor nerve were common imaging findings in diabetic ONP, and they persisted after complete resolution of symptoms in some patients. The cavernous segment and the inferior division of the intraorbital segment were simultaneously involved, and the cisternal segment was often spared. Refraining from corticosteroids was recommended even with nerve enhancement.

Neurosarcoidosis and the Pituitary

Abstract Background: Sarcoidosis involves the nervous system in 3-10% of cases. Neurosarcoidosis (NS) can mimic other diseases, leading to delay in diagnosis and management. We present 2 cases of hypothalmo-pituitary (HP) NS with widely differing initial presentations. Case Presentations: Case 1: A 58 year old African American (AA) male presented with decreased libido and hot flashes of 8-10 months duration. He also reported headaches, pain in the face and behind the eyes and dyspnea on exertion. On evaluation, he had central hypogonadism. MRI brain showed thickening and enhancement of pituitary infundibulum (PI). CT chest showed lung lesions and bilateral hilar adenopathies. EBUS with biopsies of lung and hilar lymph node showed non caseating granulomas (NCG). He was started on Prednisone and testosterone leading to symptomatic relief. However, he stopped prednisone after 3 months due to weight gain. He was then started on azathioprine. 9 months later, he presented with recurrence of neurologic symptoms and weight loss of 30 lbs. Labs showed new findings of low prolactin, low IGF-1, central hypothyroidism and central adrenal insufficiency (AI). MRI pituitary showed diffuse thickening of 3rd and 5th cranial nerves and of PI. He was re-started on Prednisone and levothyroxine (LT4) was started with improvement of symptoms. Plan was to start him on Infliximab instead of Azathioprine. Case 2: A 26 year old AA female presented with near syncope and visual impairment in the left eye that started a few weeks prior. Testing showed superior visual field loss and evidence of optic neuropathy, disc edema with mild dyschromatopsia in the left eye. She had had polyuria and polydipsia for the preceding 2-3 months and amenorrhea for 2 years. Lab testing revealed hyperprolactinemia and central DI, hypothyroidism, AI and hypogonadism. Pituitary MRI revealed a suprasellar mass measuring 20 x 19 x 11 mm, displacing the optic chiasm. CT scan showed bilateral hilar lymphadenopathy and lesions in liver and spleen. EBUS and biopsy of mediastinal lymph nodes showed NCG. Patient was treated with IV steroids leading to improved vision. She was started on DDAVP and LT4 and initiated on methotrexate and prednisone on discharge. Discussion: Pituitary hormone abnormalities due to HP NS include anterior hypopituitarism, hyperprolactinemia and DI. The most common (MC) presentation is of DI. Among anterior pituitary hormone deficits, central hypogonadism is the MC. Systemic high dose glucocorticoids (GC) are the mainstay of initial treatment. Optic atrophy is the MC neuro-ophthalmologic manifestation of NS. Only 10 - 20 % of patients have been found to have biochemical improvement of HP axis in response to high-dose GC treatment. Since pituitary involvement commonly leads to permanent endocrine deficits, it is essential to recognize it early and to treat it aggressively to prevent further permanent hormonal and neurologic deficits.

Retinal Thickness Analysis in Progressive Multiple Sclerosis Patients Treated With Epigallocatechin Gallate: Optical Coherence Tomography Results From the SUPREMES Study.

Background: Epigallocatechin gallate (EGCG) is an anti-inflammatory agent and has proven neuroprotective properties in animal models of multiple sclerosis (MS). Optical coherence tomography (OCT) assessed retinal thickness analysis can reflect treatment responses in MS.Objective: To analyze the influence of EGCG treatment on retinal thickness analysis as secondary and exploratory outcomes of the randomized controlled Sunphenon in Progressive Forms of MS trial (SUPREMES, NCT00799890).Methods: SUPREMES patients underwent OCT with the Heidelberg Spectralis device at a subset of visits. We determined peripapillary retinal nerve fiber layer (pRNFL) thickness from a 12° ring scan around the optic nerve head and thickness of the ganglion cell/inner plexiform layer (GCIP) and inner nuclear layer (INL) within a 6 mm diameter grid centered on the fovea from a macular volume scan. Longitudinal OCT data were available for exploratory analysis from 31 SUPREMES participants (12/19 primary/secondary progressive MS (PPMS/SPMS); mean age 51 ± 7 years; 12 female; mean time since disease onset 16 ± 11 years). We tested the null hypothesis of no treatment*time interaction using nonparametric analysis of longitudinal data in factorial experiments.Results: After 2 years, there were no significant differences in longitudinal retinal thickness changes between EGCG treated and placebo arms in any OCT parameter (Mean change [confidence interval] ECGC vs. Placebo: pRNFL: −0.83 [1.29] μm vs. −0.64 [1.56] μm, p = 0.156; GCIP: −0.67 [0.67] μm vs. −0.14 [0.47] μm, p = 0.476; INL: −0.06 [0.58] μm vs. 0.22 [0.41] μm, p = 0.455).Conclusion: Retinal thickness analysis did not reveal a neuroprotective effect of EGCG. While this is in line with the results of the main SUPREMES trial, our study was probably underpowered to detect an effect.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT00799890.