Jerks of the latissimus dorsi muscle and intercostal neuralgia after posterolateral thoracotomy.

INTRODUCTION: Post-thoracotomy pain syndrome (PTPS) is a common complication related to intercostal nerve injury. During this type of surgery, although less frequently, thoracodorsal and long thoracic nerves can also be injured, and jerks of peripheral origins may appear. We report a case with intercostal neuralgia and latissimus dorsi muscle jerks after posterolateral thoracotomy. CASE REPORT: A 55-year-old woman with Ehlers-Danlos Syndrome presented with a typical picture of PTPS along the right T5 dermatome following posterolateral thoracotomy at the level of the fifth intercostal space. Approximately six months after the surgery she developed frequent jerk-like involuntary movements of the right latissimus dorsi muscle. Neuropathic pain along the T5 dermatome was partially relieved with thoracic epidural block. No special attention was paid to the jerks until three years later. A neurophysiological study demonstrated a peripheral origin of these movements and the patient was then treated with periodic injections of botulinum toxin. In response, involuntary movements of the latissimus dorsi muscle disappeared. SIGNIFICANCE: To our knowledge, this is the first case with PTPS and post-thoracotomy latissimus dorsi muscle jerks in a patient with Ehlers-Danlos Syndrome. A correct diagnosis together with identification of iatrogenic neuropathic disorders allow the delivery of targeted treatments. In such cases clinical neurophysiology helps to determine a correct diagnosis.

Functional and structural changes in the visual pathway in multiple sclerosis.

INTRODUCTION: Multiple sclerosis (MS) is a heterogeneous disease with an unpredictable course. Visual pathway is a target of the disease and may reflect mechanisms that lead to disability. Structural and functional changes in the visual pathway may be studied by noninvasive techniques such as optical coherence tomography (OCT), visual evoked potentials (VEP), or B-mode transorbital sonography (TOS). OBJECTIVES: The aim is to assess changes in the visual pathway in eyes of MS patients with and without a history of optic neuritis over a 3-year period and to explore their relationship with disability. MATERIALS AND METHODS: In total, 112 eyes from 56 patients with relapsing MS were recruited: 29 with, and 83 without a history of ON (hON and nhON, respectively). Several parameters were measured by OCT, VEP, and TOS. Baseline measurements were also compared to 29 healthy controls. At 36 months, measurements were repeated in all eyes. RESULTS: At baseline, all tests showed significant differences in optic nerve structure and function in both patient cohorts in all the parameters studied, suggestive of more impairment of the visual pathway among the hON cohort. OCT showed significant differences between healthy controls and the nhON cohort. At 36 months, the nhON cohort showed significant changes by OCT, VEP, and TOS suggestive of further visual pathway impairment. OCT measurements also correlated with baseline EDSS among the nhON cohort. CONCLUSIONS: OCT is the most suitable technique and outperforms VEP and TOS to detect subclinical damage in the visual pathway. It discriminated MS patients from healthy controls and showed a progressive decline in optic nerve thickness over time among these patients.

Prevalence of sensitization to inhaled and food allergens in a group of children with primary renal tubular acidosis.

OBJECTIVE: Some reports associate certain illnesses of the urinary system with allergies. Thus, we decided to examine the prevalence of sensitization to allergens in a group of children with primary renal tubular acidosis (RTA). METHODS: Children with primary RTA who attended the nephrology department at a third level pediatric hospital during a four-month period, were included. With informed parental consent, a questionnaire and skin prick test, total IgE, specific IgE and milk precipitins were performed. RESULTS: Forty-three children were included, aged 5 months to 9 years (mean, 3.4 ± 1.8 years), and a male/female ratio of 1.7:1. The age of onset of ATR ranged from 2 to 18 months. The most common symptoms at the beginning of disease were: failure to thrive and lack of appetite. Twenty-one parents (48.8%) noticed an association between the introduction of cow´s milk and the beginning of symptoms. Skin tests were positive in 27.9%. Total IgE levels were elevated in 34.9%, ranged from 5.9 to 324 IU/mL. Allergen-specific IgE was positive in 25.6%, mainly for milk, wheat and egg white. The milk precipitins test was positive in 9 patients (21%). CONCLUSIONS: Although this study demonstrated the existence of allergen sensitization in a group of children with RTA, it is necessary to look for this association in studies with larger sample size and to use tests with higher specificity and sensitivity.

[Seronegative myasthenia gravis associated with other autoimmune diseases]. / Miastenia gravis seronegativa asociada a otras enfermedades autoinmunes.

INTRODUCTION: The presence of muscle-specific receptor tyrosine kinase (MuSK) defines a subset of patients with generalized myasthenia gravis. The diagnosis of this disease, due to its clinical distribution and negativity of the acetylcholine receptor (AchR) antibodies, is mo re complicated, especially when linked to other autoimmune diseases. CASE REPORT: A 41 year woman with 3 month long symptoms consisting in diplopia, dysarthria and gait instability. On examination, only mild paresis of the right external rectus without fatigability. The complementary tests performed were evoked potentials were normal including multimodal except for the brain magnetic resonance imaging that detected six-eight hyperintense periventricular nodular lesions in both semioval centers, with impairment of corona radiata and corpus callosum without contrast uptake. Given these findings, she was diagnosed of demyelinating disease and treated with megadoses of methylprednisolone for 5 days with mild clinical improvement. At one month, her condition deteriorated, presenting dysphagia and respiratory failure. The neurophysiological study was extended, and very pathological Jitter was detected in the frontal muscle. Despite the negative AchR antibodies, treatment was initiated with pyridostigmine bromide with poor response, admission to the intensive care unit and plasmapheresis due to a new respiratory episode being required. The torpid course and positive outcome of the MuSK antibodies have confirmed the diagnosis. CONCLUSIONS: The detection of these antibodies and performance of neurophysiological tests in clinically deficient muscles are required for the diagnosis of these clinical forms, especially when the neuroimaging-based pathological findings do not justify the clinical course of the patient.

Prostate planning treatment volume margin calculation based on the ExacTrac X-Ray 6D image-guided system: margins for various clinical implementations.

PURPOSE: To assess the prostate motion from day-to-day setup, as well as during irradiation time, to calculate planning target volume (PTV) margins. PTV margins differ depending on the clinical implementation of an image-guided system. Three cases were considered in this study: daily bony anatomy match, center of gravity of the implanted marker seeds calculated with a limited number of imaged days, and daily online correction based on implanted marker seeds. METHODS AND MATERIALS: A cohort of 30 nonrandomized patients and 1,330 pairs of stereoscopic kV images have been used to determine the prostate movement. The commercial image guided positioning tool employed was ExacTrac X-Ray 6D (BrainLAB AG, Feldkirchen, Germany). RESULTS: Planning target volume margins such that a minimum of 95% of the prescribed dose covers the clinical target volume for 90% of the population are presented. PTV margins based on daily bony anatomy match, including intrafraction correction, would be 11.5, 13.5, and 4.5 mm in the anterior-posterior, superior-inferior, and right-left directions, respectively. This margin can be further reduced to 8.1, 8.6, and 4.8 mm (including intrafraction motion) if implanted marker seeds are used. Finally, daily on line correction based on marker seeds would result in the smallest of the studied margins: 4.7, 6.2, and 1.9 mm. CONCLUSION: Planning target volume margins are dependent on the local clinical use of the image-guided RT system available in any radiotherapy department.