A Case Report of NMO Transverse Myelitis.

BACKGROUND: Transverse myelitis is considered one of the cardinal features of neuromyelitis optica spectrum disorder (NMOSD), an immune-mediated inflammatory condition of the CNS characterized by severe, immune-mediated demyelination and axonal damage predominantly targeting optic nerves and spinal cord. We describe a case in which a diagnosis of NMOSD was established, associated with West Nile Virus (WNV) infection. CASE PRESENTATION: A healthy 18-year-old female presented with intractable hiccups and rapidly progressing paraparesis. MRI demonstrated T2 edema extending from the medulla to the conus, consistent with longitudinally extensive transverse myelitis. Serum and CSF Aquaporin-4 IgG (AQP4) were both positive with high titers. In conjunction with antiviral therapy, immunomodulatory treatment was initiated using pulse methylprednisolone, plasmapheresis and Rituximab. A month and a half after admission, the patient was fully ambulatory with no residual symptoms. On her rheumatology follow-up visit, West Nile Virus-specific IgM in CSF was found to be positive from the patient's initial presentation. CONCLUSION: We propose that West Nile Virus may have been the autoimmune trigger to the patient's development of NMOSD, highlighting the importance of evaluating viral triggers in autoimmune diseases.

Leprosy, the Great Imitator of Rheumatic Diseases: A Case Study.

A 68-year-old Hispanic man was referred to our center for cutaneous vasculitis of the lower extremities, diagnosed via skin biopsy. He had a 10-year history of erythematous plaques complicated by persistent, non-healing ulcers previously treated with prednisone and hydroxychloroquine. Laboratory testing was significant for positive U1-ribonucleoprotein antibody, antinuclear antibody human epithelial-2, and an elevated erythrocyte sedimentation rate. A repeat skin biopsy revealed nonspecific ulcerations. The patient was diagnosed with a mixed connective tissue disease with features of scleroderma. Mycophenolate was initiated, and prednisone was tapered. After two years of relapsing ulcerations on his lower extremities, a third skin punch biopsy showed dermal granulomas with numerous acid-fast organisms, and a polymerase chain reaction identified Mycobacterium lepromatosis, indicating polar lepromatous leprosy with an erythema nodosum leprosum reaction. After three months of minocycline and rifampin therapy, his lower extremity ulcerations and erythema resolved. Our case highlights the variable and elusive nature of this disease, which can mimic many systemic rheumatologic conditions.

Adalimumab-Induced Lupus Serositis: A Case Report and Review of the Literature.

Tumor necrosis factor-alpha (TNF-alpha) antagonist use is prevalent for the treatment of autoimmune diseases, including psoriasis, ankylosing spondylitis, and rheumatoid arthritis. Since the onset of its use over the last couple of decades, there have been increasing reports of drug-induced antibodies and antitumor necrosis factor-alpha-induced lupus (ATIL). Herein, we present a case of pericarditis induced by tumor necrosis factor-alpha antagonist, adalimumab. A 61-year-old male with psoriatic arthritis treated with adalimumab injections for five years presented with dyspnea, chest tightness, and three-pillow orthopnea. Echocardiogram showed moderate pericardial effusion with early signs of tamponade. Adalimumab was discontinued. He was started on colchicine and steroids for a high suspicion of drug-induced serositis. With the increased use of tumor necrosis factor-alpha antagonists, adverse reactions such as ATIL will become more common. Such cases need to be reported to spread awareness of this possible complication and avoid any delay in treatment and care.

Anodal Stimulation Latency Response Differences Between Ipsilateral and Contralateral Motor Evoked Potentials in Hand Muscles.

PURPOSE: Purpose of this study was to analyze the latency and amplitude of transcranial motor evoked potentials responses from the contralateral and ipsilateral muscle groups to the same stimulus. If responses are because of activation of deeper structures, the latency of both the ipsilateral and the contralateral responses should have no difference. However, a difference in latency would suggest that activation might be occurring at different subcortical levels. METHODS: Data regarding demographics, medical history, and neurophysiological parameters were collected retrospectively on patients undergoing lumbar spine surgeries. Each side transcranial MEPs was considered as an independent data. Latency and amplitude of motor responses were recorded from the hand muscles of the ipsilateral and contralateral side from the same transcranial stimulus at preincision baseline. Statistical data analysis was performed using SAS 9.4. Paired t test was used to identify mean of differences in latency and amplitude between contralateral and ipsilateral intrinsic hand muscle. RESULTS: Data on 54 patients (104 MEPs) were obtained. Using paired t test, mean of differences in latency between ipsilateral (crossover) and contralateral (desired) intrinsic hand muscle was 0.8967 milliseconds ( P < 0.0001) while median was 0.71 milliseconds. Using paired t test, mean of differences in amplitude between ipsilateral and contralateral hand muscles was -1,071 µV ( P = <0.0001). CONCLUSIONS: Significant latency differences were seen between the contralateral and the ipsilateral hand MEP responses using the same transcranial stimulus, suggesting a different subcortical activation. Understanding of this difference might help better in the selection of baselines, and whether to favor responses obtained under the anode or under the cathode.