Selective cranial multineuritis in severe COVID-19 pneumonia: two cases and literature review.

OBJECTIVE: To report two cases of cranial multineuritis after severe acute respiratory syndrome caused by coronavirus-2. METHODS: Patients' data were obtained from medical records of the clinical chart of dell'Angelo Hospital, Venice, Italy. RESULTS: The first patient is a 42-year-old male patient who developed, 10 days after the resolution of coronavirus-2 pneumonia and intensive care unit hospitalization with hyperactive delirium, a cranial multineuritis with asymmetric distribution (bilateral hypoglossus involvement and right Claude Bernard Horner syndrome). No albumin-cytologic dissociation was found in cerebrospinal fluid; severe bilateral denervation was detected in hypoglossus nerve, with normal EMG of other cranial muscles, blink reflex, and cerebral magnetic resonance with gadolinium. He presented a striking improvement after intravenous human immunoglobulin therapy. The second case is a 67-year-old male patient who developed a cranial neuritis (left hypoglossus paresis), with dyslalia and deglutition difficulties. He had cerebrospinal fluid abnormalities (albumin-cytologic dissociation), no involvement of ninth and 10th cranial nerves, diffuse hyporeflexia, and brachial diparesis. DISCUSSION: Cranial neuritis is a possible neurological manifestation of coronavirus-2 pneumonia. Etiology is not clear: it is possible a direct injury of the nervous structures by the virus through olfactory nasopharyngeal terminations. However, the presence of albumin-cytological dissociation in one patient, the sparing of the sense of smell, and the response to human immunoglobulin therapy suggests an immune-mediated genesis of the disorder.

Recovery cycle of the masseter inhibitory reflex after magnetic stimulation in normal subjects.

OBJECTIVE: To evaluate the differences in the recovery cycle of the masseter inhibitory reflex (MIR) obtained with electrical and magnetic stimulation. METHODS: In 31 healthy subjects we studied the MIR evoked by electrical or magnetic stimulation of the mental territory and the recovery cycle of this reflex with the paired stimuli technique at different interstimulus intervals (ISI), between 100 and 600 ms. RESULTS: Latency and area of the early and late silent periods (SPs) of the MIR were similar after electrical and magnetic stimulation. The recovery cycle of the test late SP was similar with the two kinds of stimulation, except for short ISIs. The main difference between the two kinds of stimulation was in the painful quality of the stimulus: the magnetic stimuli were always below pain threshold. CONCLUSIONS: As with electrical stimulation, it is possible to obtain a MIR with magnetic peripheral stimulation. The magnetic paired stimuli are equally effective in the evaluation of the recovery cycle of the MIR. The results demonstrate that magnetic stimulation is a useful tool in the evaluation of excitability of the trigeminal motoneuronal system, with little discomfort for the patient. They also confirm the unlikelihood of nociceptive afferences involvement.

Neurophysiological study of corticomotor pathways in restless legs syndrome.

OBJECTIVE: To test the variations in cerebral motor excitability in patients with primary restless legs syndrome (RLS) by using electrophysiological techniques. In RLS patients periodic legs movements (PLMs) in sleep and wake have been described and it is hypothesised that PLMs result from a sleep-related disinhibition of descending central motor inhibitory pathways. Moreover, in primary RLS, these modifications are still debated. METHODS: In 15 patients with primary RLS, transcranial magnetic stimulation (TMS) was carried out using several paradigms, particularly paired pulse TMS with short interstimulus intervals (ISI) in abductor digiti minimi (ADM) and tibialis anterior (TA) muscles. RESULTS: Short ISI paired TMS showed a significant decrease in inhibition and increase in facilitation in ADM muscles. This result was even more evident in TA muscles of patients as compared to the controls and these modifications were more evident in the limbs which were more affected by PLM. Moreover, intracortical (corticocortical) inhibition (ICI) and intracortical facilitation (ICF) unchanged their biphasic time course. CONCLUSIONS: In our study the changes in short paired-pulse ICI and ICF revealed the presence of an altered excitability of central motor pathways, with good correlation with asymmetric distribution of symptoms.

Risk factors predicting exertional heat illness in male Marine Corps recruits.

A matched population-based case-control study was conducted on exertional heat illness (EHI) in male Marine Corps recruits in basic training at Parris Island, SC. Physical fitness and anthropometric measurements were obtained for 391 of 528 cases of EHI identified in this population during 1988-1992, and 1467 of 1725 controls matched to cases by initial training platoon. The risk for developing EHI increased with increase in body mass index (BMI = weight.height-2) as measured on arrival and with increase in time to complete a 1.5-mile run conducted during the first week. Recruits at highest risk for developing exertional heat illness had a BMI of 22 or more kg.m-2 and a 1.5-mile run-time for 12 of more minutes. These recruits had an eightfold higher risk for developing exertional heat illness during basic training when compared with those with BMI less than 22 kg.m-2 and 1.5-mile run-time under 10 min (P < 10(-6). Only one-fifth (18%) of male recruits met these criteria for high risk, but they accounted for nearly half (47%) of the exertional heat illness cases occurring during the 12-wk basic training course.

Exertional heat illness in Marine Corps recruit training.

BACKGROUND: Exertional heat illness (EHI) is a recurring problem in military training resulting in loss of manpower and training effectiveness. A scientific approach to this problem requires quantitative analysis of factors related to its occurrence. METHODS: Review of clinic and hospital records identified all cases of EHI occurring among 217,000 Marine Corps recruits (90% male, 80% age 18-20 yr) entering 12-week basic training at Parris Island, SC during 1982-1991. RESULTS: There were 1454 cases, 89% males and 11% females; 11% of male and no female cases were hospitalized. The majority (88%) of cases occurred during May-September, with a peak rate of 2% of recruits in summer. Most of the cases occurred during the cooler early morning hours when recruits performed strenuous exercise. During 0700-0900 hours the rate of heat casualties increased substantially as the Wet Bulb Globe Temperature Index (WBGT) increased, beginning at levels as low as 65 degrees F. EHI rates increased 26- and 39-fold at WBGT 75- < 80 degrees F (over baseline rates at < 65 degrees F) for immediate and prior day exposures, respectively. Exposure to WBGT of 80 + degrees F was infrequent (25%) among the early morning cases at the time of illness, while it was common (87%) on the day prior to illness, suggesting a lasting effect of heat exposure. CONCLUSIONS: Risk for EHI in military training increases markedly as WBGT levels rise above 65 degrees F; cases occur primarily with strenuous exercise (e.g., running); and heat stress exposure on prior days may be important.

Effect of slow rTMS of motor cortex on the excitability of the blink reflex: a study in healthy humans.

OBJECTIVE: To evaluate the after-effects of low frequency, sub-threshold repetitive Transcranial Magnetic Stimulation (rTMS) of primary motor cortex, on the excitability of Blink Reflex (BR) in healthy subjects. METHODS: The BR recovery cycle was carried out in 10 healthy volunteers in basal conditions, immediately after rTMS (30s), 15 and 60min later. A paired electric supraorbital stimulus paradigm with inter-stimulus intervals (ISI) of 100-600-1000-1500ms was used. The "real" rTMS consisted of a 200 stimuli long train delivered at 1Hz and intensity 80% of rest Motor Threshold of the FDI muscle, using a focal coil applied over the primary motor cortex region. The basal BR recovery cycle was also compared with that obtained after a "sham" rTMS. RESULTS: The recovery of the R2 component of the BR was significantly suppressed 30s after rTMS. This effect was also observed at 15min, though of lower magnitude and only at long ISIs (1000-1500ms). No significant effect on R2 recovery was observed 60min after real rTMS as well as after sham rTMS. CONCLUSIONS: rTMS of motor cortex modulates the excitability of BR through its action on cortical excitability and on the cortical facilitatory drive to the brainstem reflex pathways. SIGNIFICANCE: Slow (1Hz), sub-threshold rTMS of motor cortex determines a long-lasting reduction of excitability of BR.

The majority of cases of neonatal diabetes in Spain can be explained by known genetic abnormalities.

BACKGROUND: Neonatal diabetes is a rare disease characterized by hyperglycaemia within the first 3 months of life and requiring insulin treatment; it can either be transient (TNDM) or permanent (PNDM). Alterations at band 6q24 and heterozygous activating mutations in KCNJ11, the gene encoding the pore-forming subunit of the KATP channel, can cause neonatal diabetes. Aims We screened the 6q24 region, KCNJ11, GCK, FOXP3 and IPF1 genes for mutations in families with PNDM or TNDM to establish a phenotype-genotype correlation. METHODS: Twenty-two patients with neonatal diabetes were recruited. Inclusion criteria were insulin-treated diabetes diagnosed within the first 3 months and insulin treatment for at least 15 days. Clinical data were recorded in a questionnaire. RESULTS: We identified 17 genetic alterations in our patients: six alterations at the 6q24 band associated with TNDM and nine mutations in KCNJ11, five of which were novel. The analysis for a phenotype-genotype correlation showed that patients with 6q24 alterations had a lower birth weight and were diagnosed earlier than patients with KCNJ11 mutations. At follow-up of the TNDM patients with genetic alterations, 43% developed diabetes or impaired glucose tolerance in later life (one with 6q24 duplication and two with N48D and E227K mutations at KCNJ11 gene). Furthermore, half the first-degree relatives who carried a genetic alteration but who had not suffered from neonatal diabetes were diagnosed with diabetes or impaired glucose tolerance before the age of 30 years. CONCLUSIONS: KCNJ11 mutations are common in both TNDM and PNDM and are associated with a higher birth weight compared with patients with 6q24 abnormalities. Patients with TNDM should be screened for abnormalities in glucose metabolism in adult life.

[Hemorrhage caused by vitamin K deficiency in the post-natal period]. / L'emorragia da deficit di vitamina K in epoca post-neonatale.

The paper describes 8 cases of delayed haemorrhagic disease caused by vitamin K deficiency, occurring from 16 days to 3 months after birth and observed in 1982-87. All these infants were breast fed and had received no vitamin K prophylaxis. On the basis of these findings, the preventive role of vitamin K in breast fed infants is emphasised.

Nocturnal hypoglycaemia in IDDM patients younger than 18 years.

The present multicentre study was undertaken to assess the prevalence of nocturnal hypoglycaemia and its determining factors in 117 diabetic children and adolescents, aged 2-18 years and diabetes duration > 1 year in Spain. Each child made 3 measurements of blood glucose (BG) at home at night (between 0000 h and 0600 h) on nine separate nights. A hypoglycaemic event occurred in 12-14% of children in any one night. This is lower than rates for nocturnal hypoglycaemia reported in literature, perhaps because of relatively late mealtimes and different meal content, in Spanish children. Children aged < 7 years were at higher risk of nocturnal hypoglycaemia than older children (p < 0.05). Mean HbA1c from the year before the study and mean HbA1c measured during the closest time to the study were significantly lower in those with nocturnal hypoglycaemia (p < 0.0001). Blood glucose concentrations 2 h before hypoglycaemia did not predict nocturnal hypoglycaemia. The occurrence of low or very low blood glucose concentrations before breakfast was related to a higher risk for nocturnal hypoglycaemia (chi 2 22.97; p < 0.001). No previous symptoms were detectable in 89% of cases.