Case report: Chronic inflammatory demyelinating polyneuropathy superimposed on Charcot-Marie-tooth type 1A disease after SARS-CoV-2 vaccination and COVID-19 infection.

Background: There is growing evidence that severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) or COVID-19 infection is associated with the development of immune mediated neuropathies like chronic inflammatory demyelinating polyneuropathy (CIDP), but the impact of SARS-CoV-2 vaccination and COVID-19 infection on genetic disorders such as Charcot-MarieTooth (CMT) remains unclear. Case presentation: A 42-year-old male with occulted CMT neuropathy type lA (CMT1A) who developed limb numbness and weakness after the second SARS-CoV-2-vaccination was confirmed by identifying characteristic repeats in the p11.2 region of chromosome 17. Due to the progressive deterioration of muscle strength over 8 weeks, limb atrophy, moderately elevated protein counts in the cerebrospinal fluid, and significant improvement with intravenous human immunoglobulin, which were characteristic of acquired inflammatory neuropathies, he was eventually diagnosed with CIDP superimposed on CMT1A. However, after a three-month plateau, the patient contracted COVID-19, which led to repeated and worsening symptoms of limb weakness and atrophy, thus was diagnosed with a recurrence of CIDP and treated with Intravenous immunoglobulin and methylprednisolone 500 mg/d for 5 consecutive days, followed by oral prednisone and mycophenolate mofetil tablets. On 2 month follow-up, he exhibited remarkable clinical improvement and could walk independently with rocking gait. After 1 year of follow-up, the patient's condition was stable without further change. Conclusion: Our case indicates that CMT1A can deteriorate after SARS-CoV-2 vaccination. Thus, SARS-CoV-2 vaccination should be considered a potential predisposing factor for CMT1A worsening. The possible superposition of CMTIA and CIDP in the context of SARS-CoV-2 infection or immunity suggests that any clinical exacerbation in patients with CMT1A should be carefully evaluated to rule out treatable superposition inflammation. In addition, electrophysiological and imaging examination of the proximal nerves, such as the axillary nerve, is helpful for the diagnosis of CIDP.

The impact of anxiety on gait impairments in Parkinson's disease: insights from sensor-based gait analysis.

BACKGROUND: Sensor-based gait analysis provides a robust quantitative tool for assessing gait impairments and their associated factors in Parkinson's disease (PD). Anxiety is observed to interfere with gait clinically, but this has been poorly investigated. Our purpose is to utilize gait analysis to uncover the effect of anxiety on gait in patients with PD. METHODS: We enrolled 38 and 106 PD patients with and without anxiety, respectively. Gait parameters were quantitively examined and compared between two groups both in single-task (ST) and dual-task (DT) walking tests. Multiple linear regression was applied to evaluate whether anxiety independently contributed to gait impairments. RESULTS: During ST, PD patients with anxiety presented significantly shorter stride length, lower gait velocity, longer stride time and stance time, longer stance phase, smaller toe-off (TO) and heel-strike (HS) angles than those without anxiety. While under DT status, the differences were diminished. Multiple linear regression analysis demonstrated that anxiety was an independent factor to a serials of gait parameters, particularly ST-TO (B = -2.599, (-4.82, -0.38)), ST-HS (B = -2.532, (-4.71, -0.35)), ST-TO-CV (B = 4.627, (1.71, 7.64)), ST-HS-CV(B = 4.597, (1.66, 7.53)), ST stance phase (B = 1.4, (0.22, 2.58)), and DT stance phase (B = 1.749, (0.56, 2.94)). CONCLUSION: Our study discovered that anxiety has a significant impact on gait impairments in PD patients, especially exacerbating shuffling steps and prolonging stance phase. These findings highlight the importance of addressing anxiety in PD precision therapy to achieve better treatment outcomes.

Serum Olink Proteomics-Based Identification of Protein Biomarkers Associated with the Immune Response in Ischemic Stroke.

The immune response is considered essential for pathology of ischemic stroke (IS), but it remains unclear which immune response-related proteins exhibit altered expression in IS patients. Here, we used Olink proteomics to examine the expression levels of 92 immune response-related proteins in the sera of IS patients (n = 88) and controls (n = 88), and we found that 59 of these proteins were differentially expressed. Feature variables were screened from the differentially expressed proteins by the least absolute shrinkage and selection operator (LASSO) and the random forest and by determining whether their proteins had an area under the curve (AUC) greater than 0.8. Ultimately, we identified six potential protein biomarkers of IS, namely, MASP1, STC1, HCLS1, CLEC4D, PTH1R, and PIK3AP1, and established a logistic regression model that used these proteins to diagnose IS. The AUCs of the models in the internal validation and the test set were 0.962 (95% confidence interval (CI): 0.895-1.000) and 0.954 (95% CI: 0.884-1.000), respectively, and the same protein detection method was performed in an external independent validation set (AUC: 0.857 (95% CI: 0.801-0.913)). These proteins may play a role in immune regulation via the C-type lectin receptor signaling pathway, the PI3K-AKT signaling pathway, and the B-cell receptor signaling pathway.

Corrigendum: Single- and dual-task gait performance and their diagnostic value in early-stage Parkinson's disease.

[This corrects the article DOI: 10.3389/fneur.2022.974985.].

Single- and dual-task gait performance and their diagnostic value in early-stage Parkinson's disease.

Background: Gait parameters are considered potential diagnostic markers of Parkinson's disease (PD). We aimed to 1) assess the gait impairment in early-stage PD and its related factors in the single-task (ST) and dual-task (DT) walking tests and 2) evaluate and compare the diagnostic value of gait parameters for early-stage PD under ST and DT conditions. Methods: A total of 97 early-stage PD patients and 41 healthy controls (HC) were enrolled at Hwa Mei hospital. Gait parameters were gathered and compared between the two groups in the ST and DT walking test, controlling for covariates. Utilizing the receiver operating characteristic curve, diagnostic parameters were investigated. Results: In the ST walking test, significantly altered gait patterns could be observed in early-stage PD patients in all domains of gait, except for asymmetry (P < 0.05). Compared to the ST walking test, the early-stage PD group performed poorly in the DT walking test in the pace, rhythm, variability and postural control domain (P < 0.05). Older, heavier subjects, as well as those with lower height, lower level of education and lower gait velocity, were found to have a poorer gait performance (P < 0.05). Stride length (AUC = 0.823, sensitivity, 68.0%; specificity, 85.4%; P < 0.001) and heel strike angle (AUC = 0.796, sensitivity, 71.1%; specificity, 80.5%; P < 0.001) could distinguish early-stage PD patients from HCs with moderate accuracy, independent of covariates. The diagnostic accuracy of gait parameters under ST conditions were statistically noninferior to those under DT conditions(P>0.05). Combining all gait parameters with diagnostic values under ST and DT walking test, the predictive power significantly increased with an AUC of 0.924 (sensitivity, 85.4%; specificity, 92.7%; P < 0.001). Conclusion: Gait patterns altered in patients with early-stage PD but the gait symmetry remained preserved. Stride length and heel strike angle were the two most prominent gait parameters of altered gait in early-stage of PD that could serve as diagnostic markers of early-stage PD. Our findings are helpful to understand the gait pattern of early-stage PD and its related factors and can be conducive to the development of new diagnostic tools for early-stage PD.

Educational level differences in the primary and secondary prevention of stroke.

The aim of this study is to estimate the educational level differences in the primary and secondary prevention of stroke among the Chinese population. Data were obtained from the China Kadoorie Biobank (CKB) survey of 512,891 people aged 30-79 years in 10 geographic regions of China, which was conducted from 2002 to 2008. The Prediction for Atherosclerotic Cardiovascular Disease Risk in China model was used to identify individuals with a high estimated 10-year stroke risk. A total of 8884 participants (1.7%) had established stroke and 218,972 (42.7%) had a high stroke risk. In both primary and secondary prevention, the participants' educational level was positively associated with the control of smoking, blood pressure, consuming a healthy diet, and the use of antiplatelet, BP-lowering medications but negatively associated with higher physical activity levels (all Ptrend < 0.001). In addition, the positive associations were observed with the control of drinking and use of anti-hyperglycaemia medication for primary prevention (all Ptrend < 0.001) and with the use of lipid-lowering medication for secondary prevention (Ptrend = 0.019). The results of the interaction between education level and prevention level showed that, compared with participants in primary prevention, educational level disparities in those with secondary prevention had significantly higher use of antiplatelets and lipid-lowering drugs, achieving the physical activity goal and non-current drinker (all Pfor interaction < 0.05). A higher education level was associated with an increased acceptance of primary and secondary prevention strategies (not smoking or drinking, consuming a healthier diet) except for engaging in a suitable level of physical activity.

Characteristics of bone metabolism in postmenopausal female patients with different types of idiopathic benign paroxysmal positional vertigo: A single-centre retrospective study.

OBJECTIVE: The association between benign paroxysmal positional vertigo (BPPV) and impaired calcium metabolism has attracted widespread interest. Several studies have suggested that decreased bone mineral density (BMD) and serum 25-hydroxyvitamin D (25(OH)D) level are related to the occurrence and/or recurrence of BPPV; however, the characteristics of bone metabolism in patients with BPPV subtypes have not been fully investigated, and conclusions have been controversial. This study aimed to evaluate BMD and serum levels of 25(OH)D and bone turnover markers to clarify the characteristics of bone metabolism in patients with different types of BPPV. METHOD: We retrospectively analysed the data of new-onset idiopathic postmenopausal female patients with BPPV at our institution from January 2016 to January 2020. The patients' demographic data including age, medication history, concomitant diseases, onset time, clinical form, laboratory indicators, such as serum levels of 25(OH)D, bone formation markers, namely, amino-terminal propeptide of type I procollagen (PINP) and osteocalcin (OC), bone resorption marker, namely, ß-isomerized carboxy-terminal telopeptide of type I collagen (ß-CTX), and BMD were collected and analysed. RESULTS: This study included 201 consecutive postmenopausal female patients with BPPV. Among them, 138 were diagnosed with posterior semicircular canal BPPV, 42 were diagnosed with lateral semicircular canal canalolithiasis, and 21 were diagnosed with lateral semicircular canal cupulolithiasis. There were no significant differences in age distribution, body mass index, clinical history, levels of albumin, globulin, uric acid, creatinine, or blood urea nitrogen, lipid profiles (except high-density lipoprotein cholesterol) and routine blood parameters among these groups (P > 0.05). There were no significant differences in the mean T-score and BMD values of different sites or in the serum levels of 25(OH)D and bone turnover markers (PINP, OC and ß-CTX) among the subgroups (P > 0.05). The proportion of reduction in BMD (T-score < -1 SD) and decreased serum vitamin D level (< 20 ng/ml) were not significantly different between the subgroups (P > 0.05). CONCLUSION: There were no significant differences in bone metabolism in postmenopausal female patients with different types of idiopathic BPPV.

Psychological and occupational impact on healthcare workers and its associated factors during the COVID-19 outbreak in China.

PURPOSE: China was affected by an outbreak of coronavirus disease 2019 (COVID-19) in 2019-2020. Research data are needed to develop evidence-driven strategies to reduce the adverse psychological and occupational impacts on healthcare workers (HCWs). METHODS: From March 1, 2020, to March 8, 2020, 946 HCWs in China completed a survey consist of sociodemographic data, precautionary measures against COVID-19, and concerns about COVID-19. Self-administered questionnaire were collected to assess psychological and occupational adverse outcomes of HCWs. Multivariable logistic regression analysis was performed to identify factors associated with the outcomes. RESULTS: A total of 55.0%, 56.0% and 48.3% of the HCWs experienced burnout, psychological distress and posttraumatic stress, respectively. A total of seven factors were independently associated with burnout: good health status (OR 0.51, 95% CI 0.36-0.71), fear of contagion (OR 1.31, 95% CI 1.003-1.79), avoiding contact with children (OR 1.40, 95% CI 1.03-1.91), enough staff support at the workplace (OR 0.59, 95% CI 0.38-0.92), having to work overtime (OR 1.37, 95% CI 1.03-1.83), maladaptive coping (OR 3.28, 95% CI 2.42-4.45) and adaptive coping (OR 0.47, 95% CI 0.35-0.62). A total of 11 factors were independently associated with high psychological distress: having one child (OR 0.54, 95% CI 0.38-0.77), good health status (OR 0.57, 95% CI 0.39-0.83), alcohol abuse (OR 1.51, 95% CI 1.02-2.25), thinking the epidemic would continue for quite a long time (OR 1.59, 95% CI 1.08-2.34), wearing extra-work clothes (OR 1.51, 95% CI 1.06-2.15),effective protective equipment (OR 0.45, 95% CI 0.22-0.90), enough staff support at the workplace (OR 0.55, 95% CI 0.34-0.89), unable to take care of families (OR 1.99, 95% CI 1.42-2.78), economic losses (OR 1.62, 95% CI 1.14-2.31), maladaptive coping (OR 6.88, 95% CI 4.75-9.97),and adaptive coping (OR 0.29, 95% CI 0.21-0.41). These factors were independently associated with posttraumatic stress: living with the elderly (OR 1.46, 95% CI 1.04-2.05), alcohol abuse (OR 1.41, 95% CI 1.002-1.98), working at a 3A hospital(OR 0.66, 95% CI 0.49-0.88), acquaintances confirmed COVID-19 (OR 2.14, 95% CI 1.20-3.84), fear of contagion (OR 1.87, 95% CI 1.40-2.50), believing they would survive if infected (OR 0.63, 95% CI 0.46-0.86), self-disinfected after arriving home (OR 1.43, 95% CI 1.01-2.02), interpersonal isolation (OR 1.65, 95% CI 1.21-2.26), unable to take care of families (OR 1.41, 95% CI 1.05-1.88) and maladaptive coping (OR 3.09, 95% CI 2.32-4.11). CONCLUSION: The variance in adverse outcomes was explained by the effect of various factors, which will help policymakers better prepare for subsequent potential outbreaks of COVID-19.

Increased Otolin-1 in Serum as a Potential Biomarker for Idiopathic Benign Paroxysmal Positional Vertigo Episodes.

Objective: Otolin-1, a main specific otoconia matrix protein, passes through the labyrinth-blood barrier and is detectable in peripheral blood. Serum otolin-1 levels differ between patients with benign paroxysmal positional vertigo (BPPV) and healthy controls and are significantly age-related, increasing in healthy controls with age, suggesting that serum otolin-1 levels reflect otolith status. The aim of this study was to determine whether otolin-1 levels change during vertigo episodes in patients with BPPV and whether any change is specific and sensitive enough for BPPV episodes. Method: Patients diagnosed with de novo idiopathic BPPV during an acute episode were included in the study from May 2017 to May 2018. Blood samples were drawn before patients were treated with canalith-repositioning maneuvers. Serum otolin-1 levels were compared between 78 patients and 121 age- and sex-matched healthy individuals. Results: There were no significant differences between the groups in the age distribution, sex ratio, body mass index, clinical history, routine blood parameters, or total protein, albumin, uric acid, creatinine, blood urea nitrogen and lipid profiles (P > 0.05). Serum levels of otolin-1 were significantly higher in BPPV patients than in healthy controls (P < 0.001). Receiver operating characteristic analysis revealed that a serum otolin-1 value of 299.45 pg/ml was the optimal cut-off value to discriminate patients with BPPV from healthy controls (area under the curve 0.757, 95% CI 0.687~0.826) with a sensitivity of 67.9% and a specificity of 72.7%. Conclusion: Serum levels of otolin-1 may be a potential biomarker for BPPV episodes.

Decreased 25-Hydroxyvitamin D Levels in Patients With Vestibular Neuritis.

Objective: Vestibular neuritis (VN) is characterized by acute onset of vertigo, nausea, and vomiting, without auditory or other neurological symptoms. Although the pathogenesis of VN is not yet clear, many studies have shown that a pro-inflammatory environment can lead to the induction and progression of the disease. Considering the importance of vitamin D in modulating the activation, proliferation, and differentiation of inflammatory physiological processes, we hypothesized that decreased serum vitamin D may be associated with the development of VN. In this study, we evaluated serum levels of 25-hydroxyvitamin D [25(OH)D] in patients presenting acutely with VN and healthy controls and investigated the possible correlation of serum 25(OH)D levels with VN. Methods: A total of 59 consecutive patients diagnosed with VN within 7 days of symptom onset and 112 age- and sex-matched healthy controls referred to Hwa Mei Hospital, University of Chinese Academy of Science, between March 2017 and March 2019 were recruited. Demographic and clinical data, such as age, sex, height, weight, living habits, ongoing health problems, and medication history, for all subjects were recorded, and levels of 25(OH)D were measured and compared. Results: Serum levels of 25(OH)D were lower in patients with VN than in controls (19.01 ± 6.53 vs. 22.94 ± 6.74 ng/ml, p < 0.001). Patients with VN had a higher frequency of vitamin D deficiency (61.0 vs. 34.8%, P = 0.001) than did controls. Regression analyses demonstrated that vitamin D deficiency was associated with VN, with an odds ratio of 4.53 (95% CI = 1.342-15.279, P = 0.015). Conclusion: This prospective study is the first to evaluate serum 25(OH)D levels in patients with VN and found that decreased serum 25(OH)D may be associated with VN occurrence.

Assessment of Bone Metabolism in Male Patients With Benign Paroxysmal Positional Vertigo.

Objective: Several studies have suggested a probable association between benign paroxysmal positional vertigo (BPPV) and both reduction of bone mineral density (BMD) and serum vitamin D levels, but none of these studies have explored their findings by examining bone turnover markers (BTM) in male idiopathic BPPV patients. This study aimed to evaluate the relationship between BMD and serum 25-hydroxyvitamin D (25(OH) D), with the occurrence of BPPV along with the characteristics of bone metabolism in male idiopathic BPPV patients. Methods: This retrospective study comprised 60 male idiopathic BPPV patients and 92 age-matched healthy controls referred to Ningbo No.2 Hospital during the period of February 2016 to February 2018. All subjects' serum levels of 25(OH) D, bone formation marker amino-terminal propeptide of type I procollagen (PINP), and bone resorption marker ß-isomerized carboxy-terminal telopeptide of type I collagen (ß-CTX) were measured. BMD was determined by dual energy X-ray absorption at the lumbar spine and hip. Results: Among male patients with BPPV, the prevalence of BMD reduction was 35.0%, which was similar to that of 27.2% in healthy controls. There were significant differences in the mean serum 25(OH) D level and prevalence of vitamin D deficiency between the two groups, with p-values of 0.049 and 0.009, respectively. The bone turnover markers of PINP and ß-CTX in BPPV patients were lower than those in healthy controls. Logistic regression showed that vitamin D deficiency were associated with BPPV with an odds ratio of 3.8 (95% confidence interval = 1.25-11.73). Conclusion: Our study found that decreased serum vitamin D may be a risk factor for BPPV in male patients. The level of bone turnover among male patients with BPPV was lower than that among healthy controls.

Correlation between vestibular neuritis and cerebrovascular risk factors.

PURPOSE: To investigate the relationship between cerebrovascular risk factors, including carotid plaques, and vestibular neuritis (VN). MATERIALS AND METHODS: According to the inclusion and exclusion criteria, this retrospective study included 90 VN patients and 74 age- and sex-matched healthy controls from January 2016 to December 2017. All subjects' records of cerebrovascular risk factors, such as age, sex, height, weight, history of hypertension and diabetes mellitus, living habits, serum levels of glucose, lipids, glycosylated haemoglobin (HbA1c), creatinine (CR), albumin (ALB), haemoglobin (HGB); and results of carotid colour Doppler ultrasound, were obtained and compared. RESULTS: No significant differences in age; sex ratio; body mass index; history of hypertension or diabetes mellitus; or mean serum lipids, glucose, creatinine, haemoglobin or HbA1c were found between patients with VN and healthy controls (all P > 0.05). The mean serum ALB level was significantly lower in VN patients than in healthy controls (40.65 ±â€¯3.77 vs 42.84 ±â€¯4.32, P = 0.001).The prevalence of carotid plaques was significantly higher in VN patients than in healthy controls (36.67% vs. 16.22%, P = 0.003). Regression analyses demonstrated that a high frequency of carotid plaques was associated with VN with an odds ratio of 2.252 (95% CI 1.165-5.458, P = 0.019). CONCLUSION: A high frequency of carotid plaques may be a risk factor for VN.

Video Head Impulse Test for Early Diagnosis of Vestibular Neuritis Among Acute Vertigo.

BACKGROUND: This study assesses the value of the video head impulse test (vHIT) for early diagnosis of vestibular neuritis (VN) among acute vertigo. METHODS: Thirty-three cases of vestibular neuritis (VN), 96 patients with other acute vertigo (AV), and 50 cases of normal controls used vHIT to quantitatively test a pair of horizontal vestibulo-ocular reflection (VOR) gains, two pairs of vertical VOR gains, and the corresponding three pairs of VOR gain asymmetry. The peculiarity of VOR gains in VN and the differences between VN and other AV, normal controls by vHIT, were collected and analyzed. RESULTS: There were statistically significant differences in the three pairs of VOR gains asymmetry between VN and other AV, and normal controls (P<0.01). The sensitivity was 87.9% and specificity was 94.3% in differentiating VN from normal and other acute vertigo by vHIT. CONCLUSIONS: This study shows vHIT has advantages in the diagnosis of VN in acute vertigo with good sensitivity and specificity and indicates a widespread clinical application.

Vestibulo-ocular reflex abnormality in Parkinson's disease detected by video head impulse test.

BACKGROUND: Parkinson's disease (PD) is a common neurodegenerative disease characterized by dopaminergic neuronal loss. The underlying cause of PD is unknown. OBJECTIVE: To assess the clinical relevance of vestibular-ocular reflex (VOR) gain in patients with PD, especially those in the early stages. METHODS: Sixty-three PD patients and 56 control healthy individuals were enrolled in this study between Mar 2015 and Aug 2015. VOR gains were determined by video head impulse test (vHIT) device. Statistical analysis was performed to assess the difference in VOR gains between PD patients and normal people. The relationship of VOR gain with age, duration and severity of disease was also assessed. RESULTS: In the control group, average VOR gain was 0.98±0.09 on the left side and 0.99±0.16 on the right side. No statistically significant difference was observed between the two sides in the control group (P>0.05). In the PD group, average VOR gain was 1.20±0.22 on the left side and 1.23±0.23 on the right side. No statistically significant difference was observed between the two sides in the PD group (P>0.05). There was a significant difference in VOR gain between the PD (both in early and mid-late stages) and the control group (P<0.05). A weak correlation was observed between VOR gain and the motor Unified Parkinson Disease Rating Scale score. No correlation of VOR gain with age, duration of disease or the Hoehn and Yahr Scale score was observed. VOR gains in PD patients were found to be higher than normal, especially in the early stages of the disease. CONCLUSION: vHIT is a potential tool to determine the VOR gain in PD patients and may help detect PD at an early stage.

[Video head impulse test for evaluation of vestibular function in patients with vestibular neuritis and benign paroxysmal positional vertigo].

Objective: To assess the clinical application of video head impulse test (vHIT) for vestibular function in vestibular neuritis (VN) and benign paroxysmal positional vertigo (BPPV) patients. Methods: Thirty-three patients with VN and 43 patients with BPPV were enrolled from Sir Run Run Shaw Hospital and Ningbo Second Hospital from March 15 to September 10, 2015; and 50 healthy controls were also enrolled in the study. vHIT was used to quantitatively test the vestibulo-ocular reflex (VOR) gains of a pair of horizontal semicircular canals. VOR gains two pairs of vertical semicircular canals, and the corresponding asymmetrical value of three VOR gains. The saccades information was also recorded. Results: Compared with the healthy control group and BPPV patients, the affected horizontal and vertical VOR gains were declined and the corresponding asymmetries were increased in VN patients (all P<0.01). BPPV group also showed higher vertical VOR gain asymmetries compared with the healthy control group (all P<0.01), but no significant difference was observed in VOR gains and horizontal VOR gain asymmetry (all P>0.05). The sensibility of vHIT in diagnosis of VN was 87.9%. Among 33 VN patients, 22 were diagnosed with superior vestibular nerve dysfunction, 7 were found with inferior vestibular nerve dysfunction and 3 were with both dysfunction; and 1 case was not distinguished. Conclusion: Video head impulse test can quantitatively evaluate the vestibular dysfunction of VN and can help early diagnosis of VN, which may be widely used in clinic.

Cervical spinal epidural abscess following acupuncture and wet-cupping therapy: A case report.

OBJECTIVE: Report of an uncommon complication of acupuncture and wet cupping. METHODS: A 54-year-old man presented with neck pain and fever. Magnetic resonance imaging of the cervical spine revealed an epidural abscess at C4 to T2. RESULTS: The symptoms related to epidural abscess resolved partially after treatment with antibiotics. CONCLUSION: Acupuncture and wet-cupping therapy should be taken into consideration as a cause of spinal epidural abscesses in patients who present with neck pain and fever. Furthermore, acupuncture and wet-cupping practitioners should pay attention to hygienic measures.