Low-back pain in HTLV-I-associated myelopathy/tropical spastic paraparesis: nociceptive or neuropathic?

STUDY DESIGN: Cross-sectional. OBJECTIVES: To describe characteristics of low-back pain in human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy/tropical spastic paraparesis (HAM/TSP) patients and to identify its neuropathic and/or non-neuropathic pain components. SETTING: A reference center for the care of patients with HAM/TSP in Rio de Janeiro, Brazil. METHODS: A total of 90 patients with HAM/TSP referred by tertiary care centers were consecutively assessed. The patients were submitted to a clinical protocol that included Visual Analogue Scale (VAS), Timed Up and Go Test, Bodily Pain Domain of the Short Form 36 Health Status Questionnaire, Douleur Neuropathique 4 Questions (Neuropathic Pain 4 Questions) (DN4) and McGill Pain Questionnaire. RESULTS: The prevalence of low-back pain in the studied sample was 75.5%; pain interferes with physical functioning and worsens with movement and physical effort. It can be relieved by analgesics and rest. Average pain intensity was 51.2 mm on VAS and 1.72 on DN4. The most frequent words used to describe low-back pain were throbbing, burning, jumping and aching. Surprisingly, 32.4% patients pointed the lower extremities as the most painful and used different descriptors. The most common drugs used were analgesics, nonsteroidal anti-inflammatory drugs and tricyclic antidepressants. CONCLUSIONS: Low-back pain in HAM/TSP patients has mainly nociceptive characteristics. Conversely, descriptors for lower extremities pain suggest a neuropathic origin.

Disability and determinants of gait performance in tropical spastic paraparesis/HTLV-I associated myelopathy (HAM/TSP).

STUDY DESIGN: Cross-sectional. OBJECTIVES: The aim of this survey is to describe the disability profile in a group of tropical spastic paraparesis/HTLV-I-associated myelopathy patients, identifying the requirements for community ambulation. SETTING: Tertiary care unit, Rio de Janeiro, Brazil. METHODS: Seventy-two patients were assessed (49 female and 23 male), referred by tertiary care centers, when a clinical protocol was applied. RESULTS: The sample had an average age of 40 years and an average of 137 months of duration of the disease. The most prevalent aspects of disability found were in gait and sphincter control areas. A total of 72% of the patients were community ambulators and 17% were restricted to wheel chair. Age, strength and low-back pain interfere in activities of daily living (P<0.05). A positive correlation was found between community ambulation and the knee extensors (r=0.80) and ankle plantar flexors (r=0.74). Strength, age, low-back pain, duration of disease, asymmetric onset of the symptoms and spasticity interfered in the ability to walk (P<0.05). A rehabilitation program was proposed focusing on modifiable factors that affect disability level. CONCLUSION: It was possible to describe the profile of disability in this group of patients, identifying the requirements to the community ambulation.

Disability profile of patients with HTLV-I-associated myelopathy/tropical spastic paraparesis using the Functional Independence Measure (FIM).

STUDY DESIGN: Survey. OBJECTIVE: To determine the disability profile of a group of patients with human T-cell lymphotropic virus type I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), using the Functional Independence Measure (FIM) to identify the most affected functional areas. SETTING: Reference center for HTLV Rio de Janeiro, Brazil. METHODS: A total of 72 patients (49 female and 23 male), consecutively referred by tertiary care centers, were assessed using the FIM. RESULTS: The average FIM score was 108 (+/-12 SD) ranging from 58 to 122. The lowest items scores were obtained in locomotion and bladder management. When divided into two groups (above, and below or equal to the average score), there were significant differences (P<0.05) in age at time of assessment, in the degree of muscular power and in low back pain. There were no significant differences in terms of age of onset and duration of the disease. CONCLUSIONS: The most affected areas in FIM motor items were locomotion (walk and stairs) and bladder management. Age, strength in lower limbs and low back pain interfere with functional activities in patients with HAM/TSP. The duration of the disease is not a significant factor for patient disabilities. The goals of rehabilitation in HAM/TSP patients should target the modifiable factors, such as pain, strength and the neurogenic bladder.

Different perceived foreign accents in one patient after prerolandic hematoma.

Foreign accent syndrome (FAS), a rare disorder characterized by the emergence of a new accent perceived as foreign by listeners, is usually reported with left brain damage. We here report the case of a 28-year-old native Brazilian who appeared, to the examiner, to show a North American accent during recovery from Broca's aphasia. The lesion was due to a frontal hematoma. Without referring specifically to speech, we asked 10 independent observers to comment on a videotape of the patient's interview. Seven reported that the patient had a foreign accent, while 3 simply noted a 'strange' accent. The observers did not agree on the origin of the accent, 5 identifying it as Spanish, 1 as German, and 1 as south Brazilian. These findings suggest that FAS is not due to the acquisition of a specific foreign accent, but to impairment of the suprasegmental linguistic abilities (tone, accent, pauses, rhythm, and vocal stress) that make it possible to distinguish native language.

Neuropsychological assessment in HTLV-1 infection: a comparative study among TSP/HAM, asymptomatic carriers, and healthy controls.

BACKGROUND: Human T cell lymphotropic virus type 1 (HTLV-I) can cause tropical spastic paraparesis/HTLV-1 associated myelopathy (TSP/HAM) and adult T cell leukaemia/lymphoma. More recently other diseases such as isolated peripheral polyneuropathy, myopathy, artropathy, and uveitis have been associated with this retrovirus. Only a few uncontrolled studies, without necessary exclusion criteria, have described mild cognitive deficits among TSP/HAM patients. To further clarify this the authors evaluated, through neuropsychological testing patients with TSP/HAM and asymptomatic infected carriers, comparing both groups with healthy controls. OBJECTIVES: To verify the presence of cognitive deficits among TSP/HAM patients and asymptomatic HTLV-1 infected carriers. In addition, the authors aimed to investigate if these deficits correlated with the degree of motor impairment in TSP/HAM patients. METHODS: From a cohort of 501 HTLV-1 infected people the authors selected, according to predefined inclusion and exclusion criteria, 40 asymptomatic HTLV-1 carriers and 37 TSP/HAM patients. Neuropsychological testing was blindly performed in both groups and their scores were compared with those obtained from controls. RESULTS: Both the HTLV-1 carrier group and the group of patients with TSP/HAM exhibited a lower performance in neuropsychological tests when compared with controls. Asymptomatic infected carriers and TSP/HAM patients did not differ in their cognitive results. Also, there was no relation between the degree of motor disability and cognitive deficits in the TSP/HAM group. Psychomotor slowing and deficits in the some domains characterised the neuropsychological impairment in HTLV-1 infection: verbal and visual memory, attention and visuomotor abilities. CONCLUSIONS: TSP/HAM as well as asymptomatic infection can be associated with mild cognitive deficits. This finding, if confirmed by further studies, will permit the inclusion of cognitive impairment among the neurological manifestations of HTLV-1.

Detection and isolation of human T-cell leukemia/lymphoma virus type I (HTLV-I) from cultured lymphocytes of a Brazilian TSP/HAM patient

Some Brazilian regions are considered to be endemic for human T-cell leukemia/lymphoma virus type I (HTLV-I) infection. Several studies have shown a high prevalence of HTLV-I infection among different groups such as blood donors, hemophiliacs and patients suffering from hematological and neurological diseases. Cases of adult T -cell leukemia/lymphoma as well as tropical spastic paraparesis/HTLV-i-infected T -cell line (ROB) expressing viral antigens was established and reverse transcriptase activity could be detected in the culture supernatant. Ultrastructural analysis showed immature and mature HTLV retrovirus particles. Finally, HTLV-I provirus type I was demonstrated by the plymerase chain reaction. This is the first isolation completely carried out in Latin America. The molecular analysis of viral strains, now in progress, should clarify the molecular epidemiology of HTLV-I in Brazil