An unusual complication of quadriparesis after trigger point injection: a case report.

ABSTRACT: Quadriparesis after intramuscular trigger point injections for myofascial pain syndrome has been rarely reported in the literature. A 37-year-old male patient presented with myofascial pain syndrome and was given trigger point injections in trapezius muscles under ultrasound guidance. The patient noticed weakness in all the 4 limbs at approximately 12 hours after the procedure, which gradually progressed to functional quadriplegia at the time of presentation to the emergency department. On examination, he had quadriparesis with no sensory involvement and superficial reflexes were normal. MRI screening of the whole spine was unremarkable, and MRI brain suggested an incidental granuloma, which could not explain his symptoms. Blood tests revealed severe hypokalemia (2.2 mEq/L) and deranged thyroid function tests. Immediate potassium correction with intravenous and oral potassium chloride was initiated, and the patient showed improvement within 6 hours of initiating correction. Stress of the procedure, use of steroids with mineralocorticoid effects such as methylprednisolone, or deranged thyroid function tests may have acted as triggers to precipitate hypokalemic paralysis in the patient. Knowledge of this complication is essential as prompt diagnosis and timely management of hypokalemia can result in complete resolution of the symptoms.

Spastic quadriplegia following intradermal use of hydrogen peroxide in the tardive curettage procedure for the treatment of a giant congenital nevus.

The possible transformation of a giant congenital melanocytic nevi (GCMN) in malignant melanoma estimated from 0.05% to 40% depend on the size of the lesions. Many are the surgical procedures proposed, including: full or partial-thickness excisions, dermabrasion, curettage in the first weeks of life and laser treatment. The curettage technique has been proposed in the literature for the treatment of GCMN in the first few weeks of life and defined as a relatively atraumatic surgery procedure without general complications. The authors report the first case in the literature of embolization due to use of subcutaneous peroxide infiltration before a tardive curettage procedure in a newborn case of GCMN resulting in spastic quadriplegia with dystonic reaction. Consequently, a lawsuit, due to this medical malpractice, has been opened.

Permanent lesion to the corticospinal tract after therapy with capecitabine.

Capecitabine is an oral fluoropyrimidine used to treat solid tumours such as colorectal and breast cancer. A rare but severe side effect is capecitabine-induced leukoencephalopathy, including bilateral lesion to the corticospinal tract. However, neurological symptoms due to capecitabine treatment are usually reported to be reversible after discontinuation of capecitabine. Here, we present the case of a patient with bilateral degeneration of the corticospinal tract and progressive spastic tetraplegia after chemotherapy with capecitabine mimicking primary lateral sclerosis. Although therapy with capecitabine was ended, symptoms substantially worsened over the following years and the patient finally died from aspiration pneumonia almost 3 years after the application of capecitabine.

[Toxic myopathy associated with concomitant treatment with atorvastatin and colchicine]. / Miopatia toxica asociada al tratamiento concomitante con atorvastatina y colchicina.

TITLE: Miopatia toxica asociada al tratamiento concomitante con atorvastatina y colchicina.

Antimalarial myopathy in a systemic lupus erythematosus patient with quadriparesis and seizures: a case-based review.

Weakness, seizures, and encephalopathy have a broad differential diagnosis in patients with systemic lupus erythematosus (SLE). We present a case of a 26-year-old female with a recent diagnosis of SLE who experienced a clinical deterioration with quadriparesis, seizures, and encephalopathy. Her quadriparesis was found to be secondary to biopsy-proven hydroxychloroquine-induced myopathy with concomitant inflammatory myopathy. Her seizures and encephalopathy were suspected to be multifactorial in the setting of sepsis and critical illness with possible contributions from neuropsychiatric manifestations of SLE and macrophage activation syndrome. She experienced a dramatic clinical recovery with discontinuation of hydroxychloroquine, treatment of lupus disease activity with mycophenolate mofetil and prednisone, and antibiotic treatment for methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. This case-based review provides a systematic approach to quadriparesis, seizures, and encephalopathy in patients with SLE and an evidence-based discussion of antimalarial myopathy, which is of critical importance given the widespread use of antimalarial medications for rheumatologic diseases.

Autoimmune/autoinflammatory syndrome induced by adjuvants (ASIA syndrome) in commercial sheep.

We describe a form of the autoimmune/autoinflammatory syndrome induced by adjuvants (ASIA syndrome) in commercial sheep, linked to the repetitive inoculation of aluminum-containing adjuvants through vaccination. The syndrome shows an acute phase that affects less than 0.5% of animals in a given herd, it appears 2-6 days after an adjuvant-containing inoculation and it is characterized by an acute neurological episode with low response to external stimuli and acute meningoencephalitis, most animals apparently recovering afterward. The chronic phase is seen in a higher proportion of flocks, it can follow the acute phase, and it is triggered by external stimuli, mostly low temperatures. The chronic phase begins with an excitatory phase, followed by weakness, extreme cachexia, tetraplegia and death. Gross lesions are related to a cachectic process with muscular atrophy, and microscopic lesions are mostly linked to a neurodegenerative process in both dorsal and ventral column of the gray matter of the spinal cord. Experimental reproduction of ovine ASIA in a small group of repeatedly vaccinated animals was successful. Detection of Al(III) in tissues indicated the presence of aluminum in the nervous tissue of experimental animals. The present report is the first description of a new sheep syndrome (ovine ASIA syndrome) linked to multiple, repetitive vaccination and that can have devastating consequences as it happened after the compulsory vaccination against bluetongue in 2008. The ovine ASIA syndrome can be used as a model of other similar diseases affecting both human and animals. A major research effort is needed in order to understand its complex pathogenesis.

Temporary quadriplegia following continuous thoracic paravertebral block.

A case of temporary quadriplegia following a continuous thoracic paravertebral block in an adult patient scheduled for video-assisted thoracoscopy is presented. An 18-gauge Tuohy needle was inserted under direct vision by the surgeon but the tip of the catheter was not localized. Postoperatively, the patient developed temporary quadriplegia 90 minutes after the start of a continuous infusion of ropivacaine 0.2%. Imaging studies showed that the catheter was localized in the intrathecal space.

An unusual complication of immunosuppression in myasthenia gravis: progressive multifocal leukoencephalopathy.

We present a 44-year-old female patient with generalised myasthenia gravis who developed progressive multifocal leukoencephalopathy. She was receiving high dose corticosteroids, azathioprine 200mg daily and high dose intravenous immunoglobulin during relapses. Two months after thymectomy she presented with progressive cognitive decline, asymmetric quadriparesis and ataxia. Two months later she was bedridden. Cranial MRI showed large asymmetric T2 and FLAIR hyperintense lesions in cortical and subcortical structures. Positive CSF PCR of JC virus confirmed the diagnosis. The patient survives with severe sequela which confirms slow progression as typical in nonAIDS cases. This is the second case of progressive multifocal leukoencephalopathy in a myasthenic patient.

[Ethylene glycol intoxication. Important differential diagnosis in comatose patients with metabolic acidosis]. / Athylenglykolintoxikation. Wichtige Differenzialdiagnose beim komatösen Patienten mit metabolischer Acidose.

Ethylene glycol is an alcohol, which is mainly used as antifreeze. Intoxication with ethylene glycol can cause neurological and cardiopulmonary symptoms, metabolic acidosis and acute renal failure. Therapeutic options include reversal of metabolic acidosis, inhibition of alcohol dehydrogenase and early hemodialysis. In survivors of the acute phase, lasting damage is rare. The case of a 49-year-old patient with ethylene glycol intoxication is reported which was characterized by progressive impairment of consciousness, tetraparesis, hyperventilation and metabolic acidosis.

Levofloxacin-associated hypoglycaemia complicated by pontine myelinolysis and quadriplegia.

BACKGROUND: Central pontine myelinolysis (CPM) usually presents in chronic alcoholics and in patients in whom hyponatraemia has been corrected rapidly. However, CPM may occur in other clinical circumstances, including patients with severe hypoglycaemia. We describe the occurrence of CPM and quadriplegia in a patient who experienced fluoroquinolone-associated severe hypoglycaemia. CASE REPORT: A 63-year-old man with Type 2 diabetes mellitus was admitted to hospital for resection of a large liposarcoma. Renal-dose levofloxacin was utilized as part of an antimicrobial regimen to treat post-operative peritonitis. On days 6-8 of levofloxacin therapy, the patient experienced recurrent hypoglycaemia despite total parenteral nutrition, 10% dextrose containing fluids and cessation of insulin therapy 3 days prior to the first hypoglycaemic episode. Hypoglycaemia resolved within 24 h of stopping levofloxacin. After a final and severe hypoglycaemic event, the patient developed quadriplegia and tonic left deviation of gaze. Magnetic resonance imaging revealed a high-intensity lesion in the central pons consistent with CPM. CONCLUSIONS: Fluoroquinolones should be considered as a potential cause of hypoglycaemia. Severe hypoglycaemia has the potential to cause white matter lesions in the pons. Putative mechanisms include failure of membrane ion channels, oligodendrocyte apoptosis and oxidative stress of glucose reperfusion. Fluoroquinolone-associated hypoglycaemia and hypoglycaemia-induced quadriplegia are both rare and we believe this is the first case report linking the two events.

Acute motor and sensory axonal neuropathy in Burkitt-like lymphoma.

Immune-mediated neuropathies associated with non-Hodgkin's lymphoma are rare and can be difficult to delineate from neuropathies of other etiologies. We report the clinical and pathological findings of a 36-year-old patient with fulminant quadriplegic neuropathy, left facial nerve palsy, and Burkitt-like lymphoma. Features of the neuropathy, which occurred during induction chemotherapy with a total cumulative dose of 4 mg vincristine, suggested axonal Guillain-Barré syndrome. There was no evidence of direct malignant infiltration of the peripheral nervous system. We hypothesize that immune mechanisms triggered by the lymphoma initiated damage to the peripheral nervous system and enhanced its vulnerability to the toxic effects of vincristine.

Steroid-induced myopathy in patients intubated due to exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: To determine incidence, risk factors and impact on various outcome parameters of the development of acute quadriplegic myopathy in a selected population of critically ill patients. SETTING: A prospective cohort study carried out in the intensive care unit of a tertiary-level university hospital. PATIENTS: All patients admitted due to acute exacerbation of chronic obstructive pulmonary disease who required intubation and mechanical ventilation, and received high doses of intravenous corticosteroids. INTERVENTIONS: A neurophysiological study was performed in all cases at the onset of weaning. Muscular biopsy was taken when the neurophysiological study revealed a myopathic pattern. MEASUREMENTS AND RESULTS: Twenty-six patients were enrolled in the study. Nine patients (34.6%) developed myopathy. Only seven patients were treated with muscle relaxants. Histology confirmed the diagnosis in the three patients who underwent muscle biopsy. APACHE II score at admission, the rate of sepsis and the total doses of corticosteroids were significantly higher in patients with myopathy compared with those patients that did not develop it. Myopathy is associated with an increase in the duration of mechanical ventilation [15.4 (9.2) versus 5.7 (3.9) days; p<0.006], the length of ICU stay [23.6 (10.7) versus 11.4 (7.05) days; p<0.003] and hospital stay [33.3 (19.2) versus 21.2 (16.1) days; p<0.034)]. Myopathy was not associated with increased mortality. CONCLUSIONS: In the population under study, severity of illness at admission, the development of sepsis and the total dose of corticosteroids are factors associated with the occurrence of myopathy after the administration of corticosteroids. Myopathy was associated with prolonged mechanical ventilation and in-hospital stay.

Hyperkalaemic paralysis.

BACKGROUND: hyperkalaemic paralysis is a rare, treatable, and potentially fatal entity presenting with flaccid motor weakness. CASE REPORT: a patient with acute hyperkalaemic paralysis caused by erroneous oral potassium supplementation in the context of chronic renal failure. The clinical picture of quadriplegia was initially interpreted as spinal cord injury due to a pathological cervical fracture. DISCUSSION: the diagnosis of hyperkalaemic paralysis requires a high index of suspicion. Instructions for over-the-counter supplements must be clear and concise to prevent life-threatening medication errors.

Magnetic resonance imaging findings in a case of cytarabine-induced myelopathy.

A 44-year-old white male with an isolated central nervous system relapse of acute lymphoblastic leukemia was treated with intrathecal cytarabine. He developed Staphylococcus epidermidis meningitis, which was treated successfully with intrathecal vancomycin. Four weeks after the initiation of intrathecal cytarabine, the patient developed progressive ascending paralysis to the upper cervical level. Initial magnetic resonance imaging of the brain and spine were normal, and cerebrospinal fluid evaluation showed no evidence of ongoing infection and clearance of lymphoblasts. Three weeks later, magnetic resonance imaging demonstrated marked edema and peripheral enhancement of the spinal cord, consistent with cytarabine toxicity.

Fulminant peripheral neuropathy with severe quadriparesis associated with vincristine therapy.

OBJECTIVE: To report a case of fulminant neuropathy with severe quadriparesis associated with vincristine chemotherapy. CASE SUMMARY: A 48-year-old white man with acute lymphoblastic leukemia was started on an induction chemotherapeutic regimen that included intravenous vincristine. He received a total of 6 mg of vincristine over two weeks during induction chemotherapy. Over the next two weeks, he developed a fulminant peripheral neuropathy with severe quadriparesis. DISCUSSION: Although commonly associated with peripheral neuropathy, vincristine neurotoxicity only rarely involves instances of fulminant peripheral neuropathy with severe quadriparesis. Guillain-Barré syndrome is also associated with leukemia and may present as a fulminant peripheral neuropathy with severe quadriparesis. CONCLUSIONS: Fulminant neuropathy with severe quadriparesis occurring in patients with leukemia being treated with vincristine (and who do not have coexistent Charcot-Marie-Tooth disease) is more likely due to Guillain-Barré syndrome than to vincristine neurotoxicity.