Macrophage Activation in the Dorsal Root Ganglion in Rats Developing Autotomy after Peripheral Nerve Injury.

Autotomy, self-mutilation of a denervated limb, is common in animals after peripheral nerve injury (PNI) and is a reliable proxy for neuropathic pain in humans. Understanding the occurrence and treatment of autotomy remains challenging. The objective of this study was to investigate the occurrence of autotomy in nude and Wistar rats and evaluate the differences in macrophage activation and fiber sensitization contributing to the understanding of autotomy behavior. Autotomy in nude and Wistar rats was observed and evaluated 6 and 12 weeks after sciatic nerve repair surgery. The numbers of macrophages and the types of neurons in the dorsal root ganglion (DRG) between the two groups were compared by immunofluorescence studies. Immunostaining of T cells in the DRG was also assessed. Nude rats engaged in autotomy with less frequency than Wistar rats. Autotomy symptoms were also relatively less severe in nude rats. Immunofluorescence studies revealed increased macrophage accumulation and activation in the DRG of Wistar rats. The percentage of NF200+ neurons was higher at 6 and 12 weeks in Wistar rats compared to nude rats, but the percentage of CGRP+ neurons did not differ between two groups. Additionally, macrophages were concentrated around NF200-labeled A fibers. At 6 and 12 weeks following PNI, CD4+ T cells were not found in the DRG of the two groups. The accumulation and activation of macrophages in the DRG may account for the increased frequency and severity of autotomy in Wistar rats. Our results also suggest that A fiber neurons in the DRG play an important role in autotomy.

Post-surgical evisceration with or without autocannibalism in 333 dogs-a survey of veterinarians.

Background: Few reports of post-surgical evisceration, with or without autocannibalism, in dogs exist. Aims: To collect a large case series of dogs experiencing post-surgical evisceration, with or without autocannibalism. Methods: We surveyed practicing veterinarians who were members of the Veterinary Information Network about their experiences with post-surgical evisceration in dogs, variably accompanied by autocannibalism (ingestion of eviscerated organs or tissues). Responses were analyzed using descriptive statistics. Results: We identified 333 cases with sufficient information for analysis: 221 with evisceration and autocannibalism, and 112 with just evisceration. Most cases occurred following surgery for reproductive reasons (desexing, cesarean section, and pyometra). Most occurred in young adult or adult dogs. Most dogs received analgesia perioperatively had routine closure (simple interrupted or simple continuous muscle layer closure) and most did not wear an E-collar post-surgically. Most dogs eviscerated within 3 days of the initial surgery. Approximately 64% underwent surgical repair and survived long-term without complications, more frequently if the evisceration was not accompanied by autocannibalism. Conclusion: Our study suggests that post-surgical evisceration and autocannibalism can generally be successfully managed by practitioners and do not confer a uniformly poor outcome for the dog.

Self-insertion of foreign bodies into the orbit and periocular tissue.

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Joubert Plus Syndrome with Self-Mutilation: A Case report.

BACKGROUND: Joubert syndrome is a very rare condition with dismal prognosis. It is characterized by several abnormalities including molar tooth sign on MRI. When coupled with mega cisterna magna- a feature of the Dandy Walker syndrome- it is categorized as Joubert plus syndrome. CASE REPORT: A 16 month old male child with Joubert syndrome was referred to the Pediatric Dentistry Department Clinic, Faculty of Dentistry Alexandria University, complaining of severe tongue and lower lip injury due to self-mutilation. He required multiple teeth extractions under general anesthesia to prevent further tongue and lip mutilation. CONCLUSION: Joubert plus syndrome is a very rare occurring condition. Because self-mutilation is sometimes fatal, a treatment plan tailored to each patient's need is mandatory. A multidisciplinary approach is recommended.

Self-mutilation of the tongue in a patient with schizophrenia.

Attempts at tongue replantation are rare, possibly because of the friable nature of the tongue vasculature. We describe the successful replantation of the tongue in a patient with schizophrenia who attempted self-mutilation. Anastomosis of the right deep lingual artery and vein was performed under microscopy. To ensure that the patient did not make another mutilation attempt, he was kept under sedation in the intensive care unit, and a Denhardt mouth gag was placed for 5 days. Currently, his pronunciation is close to normal, and he has recovered some degree of somatic and gustatory sensation. It may be argued that the amputated tongue should be discarded; however, successful replantation can be achieved with high satisfaction for the patient and family, especially in a psychiatric patient.

An open-label pilot study of N-acetylcysteine for skin-picking in Prader-Willi syndrome.

Prader-Willi syndrome (PWS) is a complex neurodevelopmental disorder caused by an abnormality on the long arm of chromosome 15 (q11-q13) that results in a host of behavioral characteristics including excessive interest in food, skin picking, difficulty with a change in routine, and obsessive and compulsive behaviors. Skin-picking can result in serious and potentially life-threatening infections. Recent evidence suggests that the excitatory neurotransmitter glutamate is dysregulated in obsessive-compulsive behaviors, and modulation of the glutaminergic pathway may decrease compulsive behaviors, such as recurrent hair pulling or skin-picking behaviors. N-acetylcysteine (NAC), a derivative of the amino acid cysteine, is thought to act either via modulation of NMDA glutamate receptors or by increasing glutathione in pilot studies. Thirty-five individuals with confirmed PWS (ages 5-39 years, 23 females/12 males) and skin-picking behavior for more than 1 year were treated with N-acetylcysteine (Pharma-NAC®) at a dose of 450-1,200 mg/day. Skin-picking symptoms and open lesions were assessed after 12 weeks of treatment by counting and measuring lesions before and after the medication. All 35 individuals had improvement in skin-picking behaviors. Ten (29%) individuals (six males and four females) did not have complete resolution of skin-picking behavior, but had significant reduction in the number of active lesions. Longer-term, placebo-controlled trials are needed to further assess the potential benefit of this treatment.

Self-inflicted testicular amputation in first lysergic acid diethylamide use.

BACKGROUND: Genital self-mutilation is a well-known phenomenon in patients with schizophrenia and has occasionally been described in patients with personality disorders or transsexuality. However, literature just provides few cases of genital self-mutilation related to the use of psychotropic substances. CASE DESCRIPTION: A previously mentally healthy man (age, 32 years) performed manual amputation of both testes after first use of lysergic acid diethylamide in combination with alcohol consumption. Follow-up examination 6 month after the event did not reveal the development of a psychiatric disorder. CONCLUSIONS: This report shows that a first and single use of lysergic acid diethylamide in combination with alcohol can cause intoxication with dramatic consequences.

Self-inflicted lesions of the mouth and lips in mentally retarded young subjects.

OBJECTIVE: To evaluate the type and frequency of self-mutilation lesions of the mouth and lips in a large group of institutionalized mentally retarded subjects. SUBJECTS AND METHODS: Two hundred and forty-five institutionalized mentally retarded patients were evaluated clinically by a systematic inspection of the perioral cutis, lips, tongue, oral mucosa, palate, gingivae and teeth. Moreover, the drug therapy taken by each patient was carefully reviewed. RESULTS: Numerous lesions were found involving the tongue, lips, oral mucosa, perioral skin, gingivae and teeth, prevalently supported by a self-mutilation mechanism (such as cheek and tongue biting and nodular traumatic lesions), which were differentially expressed in patients with different degrees of mental retardation. A possible effect of anti-epileptic or neuroleptic drugs was also detected. CONCLUSIONS: These findings indicate that inspection of the oral cavity should always and carefully be performed in all patients with mental retardation and in those with neuroleptic and anti-epileptic drug therapy, in order to avoid or even extinguish self-mutilation of the oral cavity by means of an accurate hydration of the mucosa which might counterbalance some iatrogenic undesired effects.

Automutilación en Trastorno Borderline de Personalidad. ¿El dolor como auto tratamiento? Un caso clínico / [Self mutilation in borderline personality disorder. Pain as a self-treatment? A case report].

The objective of this article is to highlight the complexity of the phenomenon of self-mutilation, or self-injury, among individuals with Borderline Personality Disorder. The practice of self-mutilation in this population is strikingly common, with some authors estimating the prevalence to be up to 75

. Particularly noteworthy is the high percentage of patients with Borderline Personality Disorder who state that the act of self-injury has an analgesic effect. This article lays out a few theories that support this finding. Frequently, patients who self-mutilate do not aim to commit suicide but rather, to relieve internal tension. However, clinical interventions are often largely centered on interpreting the self-injurious act as a suicide attempt, with complex therapeutic consequences. A clinical vignette is presented to highlight the aforementioned issues.

Self-enucleation: forget Freud and Oedipus, it's all about untreated psychosis.

Self-enucleation is a rare but serious ophthalmological and psychiatric emergency. It has traditionally been considered to be the result of psycho-sexual conflicts, including those arising from Freud's Oedipal complex and Christian religious teaching. However, an analysis of published case reports suggests that self-enucleation is a result of psychotic illnesses such as schizophrenia. Early treatment with antipsychotic medication in the case of unilateral or threatened self-enucleation might prevent some cases of blindness.

A review of the oro-dento-facial characteristics of hereditary sensory and autonomic neuropathy type III (familial dysautonomia).

The oro-dento-facial features and dysfunction of children with hereditary sensory and autonomic neuropathy type III, known as familial dysautonomia or Riley-Day syndrome, was first described in the scientific literature in 1949. They include dental trauma; dental and soft tissue self-mutilation; normal dental age; normal sequence and timing of eruption and exfoliation of teeth; smaller tooth size; different and disproportional tooth components; normal alveolar bone height; small jaws, mild crowding, and malocclusions. These persons have craniofacial morphology that is different from accepted norms but they resemble norms of their ethnic origin. The subjects can have gray, pale, shiny faces with an asymmetric suffering expression; frontal bossing, with eventual hypertelorism and narrow lips; a low-caries rate; drooling, and hypersalivation. They can have changes in salivary composition and content, which influences plaque and calculus and increases the risk of gingival and periodontal diseases. They also have difficulty in controlling oral muscles; a progressive decrease in number of tongue fungiform papillae, accompanied by lack of taste buds; and specific dysgeusia, but a normal sense of smell.

Surgical reconstruction of penile stump in a patient with Klingsor syndrome.

Self-mutilation of genitalia is an extremely rare entity, usually found in psychotic patients. Klingsor syndrome is a condition in which such an act is based upon religious delusions. The extent of genital mutilation can vary from superficial cuts to partial or total amputation of penis to total emasculation. The management of these patients is challenging. The aim of the treatment is restoration of the genital functionality. Microvascular reanastomosis of the phallus is ideal but it is often not possible due to the delay in seeking medical attention, non viability of the excised phallus or lack of surgical expertise. Hence, it is not unusual for these patients to end up with complete loss of the phallus and a perineal urethrostomy. We describe a patient with Klingsor syndrome who presented to us with near total penile amputation. The excised phallus was not viable and could not be used. The patient was managed with surgical reconstruction of the penile stump which was covered with loco-regional flaps. The case highlights that a functional penile reconstruction is possible in such patients even when microvascular reanastomosis is not feasible. This technique should be attempted before embarking upon perineal urethrostomy.

A case of autoenucleation associated with a contralateral field defect.

PURPOSE: To report a case of autoenucleation associated with contralateral field defect. DESIGN: Observational case report. METHODS: A 36-year-old man was referred to the emergency ward with his right eye attached to a fork. His history revealed drug abuse with ecstasy. RESULTS: Visual field examination revealed a temporal hemianopia on the left eye. There was no change in the visual field defect after intravenous steroid, two months after initial presentation. CONCLUSIONS: Contralateral visual field defect may be associated with autoenucleation. A visual field test is recommended in all cases with traumatic enucleation.

Congenital insensitivity to pain with anhydrosis: report of a family case.

Congenital Insensitivity to pain with anhydrosis (CIPA) is a rare inherited disease. It is classified as hereditary sensory and autonomic neuropathy type IV. Pain insensitivity and autonomic deficits are present, but touch and pressure sensitivity are unimpaired. Mental retardation is usually present. We report a family case of a 5 years old girl and 2 years old boy with congenital insensitivity to pain, while discussing the clinical features and the anesthetic strategy of such patients. Patients with Congenital Insensitivity to Pain with anhydrosis may undergo surgery because of susceptibility to trauma due to absence of pain. The clinical features may intrinsically possess anesthetic challenges.

Gradually increasing predominance of self-mutilation in upper extremity arterial injuries: less morbidity but with high threat to society.

BACKGROUND: Although vascular trauma of the upper extremity is increasingly more common, mortality and morbidity rates remain low, at between 0-8%. Self-mutilation has become evident in recent years. We planned this study to compare the results of self-mutilation with other penetrating trauma in upper extremity vascular injuries and also to emphasize the dangers of self-mutilation for society. METHODS: Data of 249 patients with penetrating vascular injury of the upper extremity were retrospectively analyzed. There were 214 male (86%) and 35 female (14%) patients, with a mean age of 24.76 ± 11.28 years (range: 2-69 years). Of these, 129 (52%) were self-mutilators. RESULTS: The ulnar artery was the most frequently affected (n=140, 56%). There was no mortality or limb loss. However, eight (3.21%) patients, who had penetrating trauma, had restriction in finger motions. Male predominance, substance abuse and associated nerve injury were significantly more common among self-mutilators (p values <0.001, <0.001 and 0.005, respectively), whereas brachial artery injury, vein graft interposition and fasciotomy rates were higher among the penetrating trauma group (p<0.001 for all). CONCLUSION: The form of and reason for injuries and presence of substance abuse in case of self-mutilation must be investigated cautiously, and the immediate commencement of psychiatric treatment must be provided to the self-mutilators.

Serial stellate ganglion blocks for intractable postherpetic itching in a pediatric patient: a case report.

BACKGROUND: While intractable itching may be rarely associated with postherpetic neuralgia, it can have catastrophic complications if present. METHOD: We highlight a severe case of postherpetic itching in a 10-year-old male with Fanconi's and aplastic anemia, refractory to conventional treatments and requiring intravenous sedation. RESULTS: Our use of 3 sequential stellate ganglion blocks with 5.5 mL of 0.25% bupivacaine provided significant improvement of the symptoms for 4 months after the last procedure. CONCLUSION: Although further evaluation is needed, we feel that novel use of sympathetic blockade may provide treatment for intractable itching. Highlighted is the possible influence of the sympathetic system in the pathophysiology of postherpetic itch. IMPLICATION: The use of serial stellate ganglion blocks may be a treatment option for patients with intractable itching and postherpertic neuralgia of the neck and arm region. This technique may lead to more permanent solutions such as pulse radiofrequency lesion or chemical neurolysis of sympathetic ganglions for postherpetic itch.

Lens reabsorption following self-induced needling and subsequent intracapsular secondary intraocular lens placement.

We present the case of a young man who inadvertently penetrated his cornea and lens with a needle used for injecting heroin. Three years later, the lens had completely reabsorbed leaving a fibrosed capsular bag. We describe the surgical techniques used to insert a secondary intraocular lens into the capsular bag with excellent visual outcome.

[Case of self mutilation of urethra in a Munchausen's syndrome patient].

A 33-year-old man presented with urethral bleeding and syncope. Urethroscopy revealed erosive lesion with bleeding at bulbar urethra. Magnetic resonance imaging, biopsy, and blood examination were performed, but the cause of urethral bleeding was not identified. By accident, chopsticks with blood ware detected in his ward. It was revealed that urethral bleeding was caused by self-mutilation with chopsticks. He consulted a psychiatrist, and was diagnosed with 'munchausen's syndrome'.

Spontaneous pain following spinal nerve injury in mice.

Autotomy behavior is frequently observed in rats and mice in which the nerves of the hindlimb are severed, denervating the paw. This is the neuroma model of neuropathic pain. A large body of evidence suggests that this behavior reflects the presence of spontaneous dysesthesia and pain. In contrast, autotomy typically does not develop in partial nerve injury pain models, leading to the belief that these animals develop hypersensibility to applied stimuli (allodynia and hyperalgesia), but not spontaneous pain. We have modified the widely used Chung (spinal nerve ligation [SNL]) model of neuropathic pain in a way that retains the fundamental neural lesion, but eliminates nociceptive sensory cover of the paw. These animals performed autotomy. Moreover, the heritable across strains predisposition to spontaneous pain behavior in this new proximal denervation model (SNN) was highly correlated with pain phenotype in the neuroma model suggesting that the pain mechanism in the two models is the same. Relative reproducibility of strain predispositions across laboratories was verified. These data indicate that the neural substrate for spontaneous pain is present in the Chung-SNL model, and perhaps in the other partial nerve injury models as well, but that spontaneous pain is not expressed as autotomy in these models because there is protective nociceptive sensory cover.