Ultrasound reference values for peripheral nerve cross-sectional areas and indices in a sample of healthy individuals in Brazil / Valores de referência ultrassonográficos para áreas e índices de secção transversa de nervos periféricos em uma amostra de indivíduos brasileiros saudáveis

Abstract Objective: To establish peripheral nerve cross-sectional area (CSA) reference values (absolute values, measures of asymmetry, and measures of focality) for healthy individuals in Brazil. Materials and Methods: Sixty-six healthy volunteers underwent high-resolution ultrasound of the peripheral nerves. We obtained CSA measurements for three peripheral nerves, at specific locations: the median nerve, in the carpal tunnel (MT); the ulnar nerve, at the cubital tunnel site (UT) and at the pre-tunnel site (UPT); and the common fibular nerve, near the fibular head (FH). We calculated the CSA indices between the same sites on different sides (∆CSAs) and between the ulnar nerve tunnel and pre-tunnel sites on the same side (∆TPT). Results: A total of 132 neural sites were analyzed, and the following CSA values (mean ± SD, median) were obtained: MT (6.3 ± 1.9 mm2, 6.0 mm2); UT (6.2 ± 1.6 mm2, 6.1 mm2); UPT (5.6 ± 1.7 mm2, 5.4 mm2); and FH (10.0 ± 3.7 mm2, 9.9 mm2). The ∆CSA values (mean ± SD, median) were as follows: MT (0.85 ± 0.7 mm2, 0.95); UT (0.81 ± 0.62 mm2, 0.95); UPT (0.61 ± 0.51 mm2, 0.5); and FH (1.0 ± 0.77 mm2, 1.0). The ∆TPT (mean ± SD, median) was (1.0 ± 0.8 mm2, 1.0). Conclusion: Among individuals in Brazil, peripheral nerve CSA values tend to be higher among males and to increase with aging. However, the same does not appear to hold true for the ∆CSA or the ∆TPT, the exception being the difference between the right and left UT. Differences in CSA values greater than 2.5 mm2 between sides or between sites along the same nerve can indicate asymmetry or focal thickening in neuropathy, respectively.

Resumo Objetivo: Estabelecer valores de referência da área de secção transversa (AST) dos nervos periféricos (valores absolutos e medidas de assimetria e de espessamento focal) para amostra de indivíduos brasileiros saudáveis. Materiais e Métodos: Sessenta e seis voluntários brasileiros saudáveis foram submetidos a ultrassonografia de alta resolução de nervos periféricos. As medidas da AST dos seguintes nervos periféricos foram obtidas em: mediano no túnel do carpo (MT), ulnar no túnel cubital (UT), pré-túnel ulnar (UPT) e fibular comum na cabeça da fíbula (FH). Os índices CSA foram obtidos entre os mesmos sítios em lados diferentes (∆CSA) e entre os sítios distal e proximal do nervo ulnar (∆TPT). Resultados: As seguintes médias ± desvio-padrão e mediana da AST foram obtidas para os 132 sítios dos nervos periféricos analisados: MT (6,3 ± 1,9 mm2; 6,0 mm2), UT (6,2 ± 1,6 mm2; 6,1 mm2), UPT (5,6 ± 1,7 mm2; 5,4 mm2) e FH (10,0 ± 3,7 mm2; 9,9 mm2). A média ± desvio-padrão e as respectivas medianas do ∆CSA em mm2 foram: 0,85 ± 0,7 [0,95] para MT, 0,81 ± 0,62 [0,95] para UT, 0,61 ± 0,51 [0,5] para UPT, 1,0 ± 0,77 [1] para FH, e 1,0 ± 0,8 [1,0] para ∆TPT. Conclusão: Os valores de AST tendem a ser maiores no sexo masculino, aumentando os valores absolutos das medianas das ASTs com o envelhecimento, mas não nos seus índices, ∆CSA e ∆TPT, exceto a diferença entre a AST dos nervos ulnares nos lados direito e esquerdo. Diferenças de valores de AST entre lados ou pontos no mesmo nervo maior que 2,5 mm2 podem significar neuropatia com assimetria e espessamento focal.

Leprosy case series in the emergency room: A warning sign for a challenging diagnosis

ABSTRACT Leprosy can be considered a dissimulated disease, mainly when presented as atypical cases leading to mistaken diagnosis at the emergency setting. Herein we report six patients referred to the emergence room with hypotheses of acute myocardial infarction and arterial and venous thrombosis, although with chronic neurological symptoms; the seventh patient was referred with a wrong suspicion of infected skin ulcer. Positive findings included hypo-anesthetic skin lesions and thickened nerves; 100% were negative for IgM anti-phenolic glycolipid-I, while 71.4%, 100% and 42.8% were positive for IgA, IgM and IgG Mce1A. RLEP-PCR was positive in all patients. Ultrasound of peripheral nerves showed asymmetric and focal multiple mononeuropathy for all patients. Unfortunately, in many patients leprosy is often misdiagnosed as other medical conditions for long periods thus delaying initiation of specific treatment. This paper is intended to increase physicians' awareness to recognize leprosy cases presented as both classical and unusual forms, including in emergency department.