Sensory Neuropathy in Parkinson Disease: Electrodiagnostic Evaluation.

The relationship between Parkinson Disease (PD) and peripheral neuropathy (PN) has gained attention in recent years. There is increasing evidence of a-synuclein deposition and pointing to a form of small fiber neuropathy intrinsic to PD, medium-large fiber PN is also a relatively frequent and potentially severe complication in advanced levodopa-treated PD, but degenerative factors and vitamin deficiency were related. Objective: To determine the neurophysiological characteristics of patients with PD and the clinical manifestations of suspected PN. Methods: We performed a cross-sectional study between January 2014 and December 2017, of 36 patients diagnosed with PD who were referred for electrodiagnostic studies (EDX) with suspected clinical PN. We performed electromyography of five muscle or more (brachial biceps, first dorsal interosseous, thumb abductor, anterior tibial, medial gastrocnemius and short finger extensor), and nerve conduction/velocity studies on fibular and tibial nerves (motor) sural and superficial fibular nerves (sensory) and median and ulnar, (both motor and sensory). Results: Twenty-one females (58.3%) with an average age of 69.6 years and fifteen males (41.7%) with an average age of 68.0 years who were submitted for EDX were included in this study. All had a tremor and the average evolution of PD was 5 years. Thirty-two patients were receiving oral levodopa treatment. EDX of twenty-two patients demonstrated neuropathy abnormalities, and in 90.9% of these patients, sensory neuropathy was confirmed. The most common nerve found to be compromised was the superficial fibular nerve (55.0%), followed by the sural (50.0%). Conclusions: Sensory neuropathy was the main finding. Diagnosing PN based on symptom prevalence assessed by checklists and questionnaire has a risk of overestimating the prevalence of PN. The age and the time of disease evolution were factors related to neuropathy. In our study we found that 39% of the patients did not have neuropathic alterations despite clinical suspicion, which opens up new questions about the mechanisms of PD neuropathy and the possibility of fine fiber neuropathy in these patients, motivating further research.

Facial Nerve Palsy Complicated by Masked Tuberculous Mastoiditis in a Recently Transplanted Patient.

Mastoiditis is a complication of the medium otitis characterized by suppuration and destruction of the mastoid cells and the pyramid petrosa; its tuberculous etiology has decreased in the last 40 years. Paralysis resulting from mastoiditis is more common in children. The incidence of mastoiditis has risen, although there are no reports in the literature associated with renal transplants. A 37-year-old man developed paralysis of the seventh cranial nerve associated with tuberculous mastoiditis 71 days after living donor-related renal transplant while on immunosuppressive therapy. The mastoiditis diagnosis was clinical and radiologic, the axial tomography being the election examination. The paralysis of the facial nerve happens for the easy destruction of the bony capsule that involves it. When treated early with tuberculostatic drugs, surgical procedures can be avoided in patients with tuberculous etiology in a mastoiditis, especially in an immunocompromised patient.

Neurology Training Program for the Education of Psychiatry Residents: Experiences Reported from Curitiba, Brazil / Programa de Treinamento em Neurologia para a Educação de Residentes em Psiquiatria: Relato de Experiência em Curitiba, Brasil

Abstract: Introduction: There has been a greater demand for the psychiatry specialty, possibly associated with the paradigm change in asylum care for outpatients and communities; consequently, there is now a greater number of institutions for Medical Training in Psychiatric Residency. As such, we seek to elaborate upon the Neurology Program for Medical Residency in Psychiatry (NPMRP) and present the experience of its application. Methods: We present an observational and descriptive study of the NPMRP experience in Curitiba/Paraná/Brazil. To prepare the NPMRP, reflective theoretical research was carried out via data from the websites of the Brazilian Psychiatric Association, Brazilian Psychiatric Residencies, PubMed and SciELO. Thw keywords used included: program of psychiatry residency; neurology and psychiatry residency; neurology in psychiatry. Results: It is thought that the resident develops clinical skills through the neurology-psychiatry interface, via an in-service training of general neurology (1st year resident) and epilepsy and neurocognitive disorders (3rd year resident), which takes place once a week. Residents receive training in conducting interviews and brief neurological examinations, concerning the types of neurological diagnosis, request for additional tests and interpretation of the reports. The outpatient clinical sessions last 4-5 hours, resulting in one patient/hour per resident who, in turn, prepares the medical record. The cases are reviewed and discussed with the neurologist instructor, promoting patient/family participation in shared decision-making. At the end of the outpatient clinic session, an activity is carried out with the whole team to socialize the visits and review theoretical contents. Assessments are daily, quarterly and annual, covering both quantitative and qualitative aspects. Conclusion: The NPMRP has excellent results in improving resident training and patient care. There is an excellent opinion regarding learning by the residents and a good level of satisfaction of patients/family members. The neurologist instructor becomes part of the residency and the NPMRP integrates academic and assistance training. The authors propose the development of a national, standardized and reproducible NPMRP.

Resumo: Introdução: É necessário que a residência de psiquiatria conste um programa da disciplina de neurologia. No Brasil, como não existe uma padronização dos conteúdos a serem abordados, os residentes realizam estágios em diferentes serviços de neurologia. Neste relato, descreve-se a experiência da aplicação do Programa de Neurologia para Residência Médica de Psiquiatria (PNRMP). Métodos: Trata-se de um estudo observacional e descritivo da experiência do PNRMP em Curitiba, no Paraná. Para a elaboração do PNRMP, realizou-se uma pesquisa teórico-reflexiva nos sites da Associação Brasileira de Psiquiatria, Residências Médicas de Psiquiatria Brasileiras, do PubMed e da SciELO. Na pesquisa, utilizaram-se as seguintes palavras-chave: programa de residência em psiquiatria; residência em neurologia e psiquiatria; neurologia em psiquiatria. Resultados: Em 2011, iniciou-se a elaboração do PNRMP com o objetivo de oferecer aos residentes os subsídios teórico-práticos da interface psiquiatria e neurologia sob supervisão de um preceptor neurologista. O programa, com nove anos de aplicação e 54 residentes formados, ocorre em dois ambulatórios do Sistema Único de Saúde - um de neurologia geral (para residentes do primeiro ano) e outro de epilepsia ou transtornos neurocognitivos do idoso (para residentes do terceiro ano -, com duração de quatro a cinco horas, uma vez por semana. Os residentes realizam um atendimento/hora, e os casos são revisados em parceria com o preceptor que esclarece as dúvidas da entrevista/do exame físico e define o diagnóstico e a conduta colegiada. Procure-se as competências clínicas em treinamento em serviço, discussões de casos, revisões teóricas e seminários. No final do ambulatório, realiza-se uma reunião da equipe para compartilhar os conhecimentos gerados nos atendimentos e orientar atualizações clínicas/terapêuticas. As avaliações são diárias, trimestrais, anuais e quanti-qualitativa, em que se consideram a aquisição de habilidades, o raciocínio clínico, a qualidade nos atendimentos, o profissionalismo e a comunicação com a equipe, os pacientes e os familiares. Conclusão: O PNRMP supera a dicotomia "orgânico versus funcional". Na integração das atividades teóricas e práticas, busca-se um conhecimento abrangente e resolutivo que permita ao futuro psiquiatra prestar um serviço competente e humano. Recomenda-se a participação dos residentes egressos para que eles possam avaliar o PNRMP. Os autores propõem o desenvolvimento de um PNRMP reprodutivo nacional e padronizado.

The Wada test with propofol in a patient with epilepsy

The usual drug used in the Wada test is amobarbital, but it is not available in Brazil. Propofol was already used by Bazin et al. in 1998, and in their report the test resulted good in the absence of any adverse effect. We report the use of propofol as the anesthetic for the Wada test. The test was carried out in a 26 years old woman with temporal medial lobe epilepsy refractory to medical treatment. Language functions and memory were tested after injection in both hemispheres by three procedures (Seattle, Montreal and Interview procedures). Propofol showed to be good to carry on the Wada test.

Orbital myositis and rheumatoid arthritis: case report

Orbital myositis implies orbital inflammation confined to one or more of the extraocular muscles. The acute form responds well to high doses of oral corticosteroids tapered gradually, but it may recur or become chronic. We describe a 38 years old female who has been suffering from rheumatoid arthritis for six years. She developed diplopia as a result of a paralysis of the right and left rectus medialis muscle. MRI showed inflammatory process and thickness of the referred muscles. The patient had a total recovery with oral use of 80 mg methylpredinisolone daily. Two months after the first episode she developed a bilateral ophthalmoplegy. The patient improved with oral use of steroids the second time, but a paresis of the left rectus lateralis muscle remained. From the 156 cases we reviewed only three have been related to rheumatic diseases and none has been previously related to rheumatoid arthritis.

Síndrome de Munchausen e pseudoparaplegia: relato de caso / Syndrome of Munchausen and pseudoparaplegia: case report

Apresentamos uma paciente com "paraplegia" de oito anos de evolução, que se internou para retirada de agulhas em região lombar e apresentava história de insuficiência renal, câncer de esôfago, ovários e mama, suspeita de tubercolose pulmonar e várias internações em hospitais clínicos e psiquiátricos. No exame psiquiátrico encontramos indiferença à sua doença, prolixidade e descrição detalhada de seus problemas, falando mal dos atendimentos anteriores. Não encontramos evidências de processos neoplásicos. Tinha movimento em bloco de membros inferiores, com preservação dos reflexos e sensibilidade. A eletromiografia, a tomografia de crânio, a ultra-sonografia abdominal e o RX de tórax normais. No RX e na tomografia de coluna lombo-sacra observamos 16 agulhas, semelhantes às de costura, em partes moles. Diagnosticada como síndrome de Munchausen, depois de 15 dias de internação com tratamento antidepressivo, psicoterapia e fisioterapia, melhorou. Três meses depois, a paciente encontrava-se assintomática, não voltando mais ao ambulatório.

Torcicolo espasmódico pós-traumático / Post-traumatic spasmodic torcicollis

A distonia pós-traumática (DPT) é sequela rara do traumatismo crânio-encefálico (TCE). Descrevemos um paciente com torcicolo espasmódico e revisamos 31 casos descritos na literatura. O intervalo de tempo entre o TCE e o aparecimento da distonia variou de 2 horas a 9 anos. Em 11 casos o TCE foi de média gravidade e em 20 foi severo. As lesoes na tomografia de crânio (CT) foram: hematomas extra e subdurais e hemorragias talâmicas. Na ressonância magnética a lesao mais frequente estava localizada no gânglio basal contralateral ou no tálamo. Em nosso caso, a CT de crânio evidenciava higroma bilateral e dema cerebral difuso, com reabsorçao 6 dias depois; a RMN encefálica realizada 1 ano após o TCE mostrou discreta atrofia cerebral. Apesar da fisiopatologia da DPT nao estar bem esclarecida, há indícios de disfunçao do circuito lentículo-talâmico e que a variaçao de tempo entre o TCE e o desenvolvimento da DPT, ocorra por presença de neurônios aberrantes.

Efficacy of lamotrigine with add-onn treatment in outpatients with refractory epilepsy

A eficácia da lamotrigina (LTG) foi avaliada em 16 mulheres e 14 homens com epilepsia reistente a tratamentos anteriores, com idade média de 30,2+-7,7 (média +- desvio padräo) anos. A duraçäo da epilepsia foi de 20,9+-9,8 anos e o início da doença ocorreu aos 9,2 anos+-8,3 anos. 26 pacientes tinham epilepsia localizada do lobo tmeporal, 1 do lobo frontal, 1 do lobo parietal, 1 paciente síndrome de Lennox-Gastaut e 1 epilepsia mioclônica juvenil. O eletroencefalograma mostrou alteraçäes em todos os pacientes. No início do estudo 24 pacientes faziam tratamento com carbamazepina, 11 com valproato, 5 com fenobarbital e 4 com fenitoína. Nos três meses do estudo os pacientes tiveram respectivamente 21,6+-28,1; 22,8+-28,4 e 21,1+-27,2 crises. Nos 3 meses de tratamento com doses progressivas de LTG (50 a 400 mg/dia) a frequência de crises foi de 5,2+-7,3; 6,5+-10,2 e 5,4+-9,8. Os resultados indicam uma diminuiçäo estatisticamente significante (p=0,0054). Vertigem, astenia, diplopia e anorexia foram os efeitos adversos observados, aparantemente relacionados com o uso concomitante de LTG e CBZ. Estes resultados mais favoráveis que os reportados eme estudos internacionais refletem a amostragem de populaçäo ambulatorial, com pouco déficit neurológico, tratamento com politerapia racional

Efficacy of lamotrigine with add-on treatment in outpatients with refractory epilepsy / Efficacy of lamotrigine with add-on treatment in outpatients with refractory epilepsy

The efficacy of lamotrigine (LTG) was evaluated in 30 patients with epilepsy resistant to previous treatments. They were 16 females and 14 males, aged 30.2 + or - 7.7 (mean + or - sd) years. They had localization-related epilepsy (26 temporal, 1 frontal, 1 parietal). Lennox-Gastant syndrome (1) and juvenile myoclonic epilepsy (1). Duration of epilepsy was 20.9 + or - 9.8 years. Age at onset of epilepsy was 9.2 + or - 8.3 years. CT showed static lesions in 16 cases. EEGs showed localized abnormalities in 28 cases and a generalized abnormality in two. At the time of the study therapy was carbamazepire (24 cases), valproate (11), phenobarbitone (5) and phentoin (4). In the 3 months before the study they had respectively 21.6 + or - 28.1; 22.8 + or - 28.4 and 21.1 + or -27.2 seizures per month. In the 3 months of the trial on progressive doses of LTG 50-400 mg daily, the seizune frequencies were respectively 5.2 + or - 7.3, 6.5 + or - 10.2 and 5.4 + or - 9.8. These results indicate an improvement or greater than 75 per cent compared to the average of baseline (p=0.0054). Serum antiepileptc drug concentrations, biochemical and hematological measurements were unchanged. We observed the following side-effects of the AEDs: dizziness, asthnia, diplopia, anorexia, insomnia and somnoience. These favorable observations on the efficacy of LTG in refractory epilepsy obtained in open trial, may reflecty our selection of outpatients with little neurological impairment and the rational approach to polytherapy.

Epilepsias refratárias ao tratamento: análise de 63 casos / Epilepsies refractory to therapeutic: analysis of 63 cases

Critérios precisos de diagnóstico, prognóstico e tratamento específico das síndromes epilépticas foram delineadas recentemente. Nesse estudo analisamos 35 homens e 28 mulheres cuja idade variou de 5 a 56 anos, vistos inicialmente por resistência ao tratamento de crises epilépticas durante um período de 5 anos e seguidos por mais de seis meses. Foram excluídos pacientes com patologias progressivas, convulsöes febris e Síndrome de West. Utilizando as classificaçöes de crises e de síndromes epilépticas e critérios de retirada de barbitúricos e benzodiazepínicos, as causas de resistência ao tratamento foram classificadas em: relacionadas com diagnóstico (10 casos), com droga (35), com dose (8) e com prognóstico (10). A epilepsia localizada sintomática foi a mais frequente com 35 pacientes. Foram controlados 49 por cento dos pacientes. Concluímos que as classificaçöes da I.l.A.E. têm implicaçöes diagnósticas, prognósticas e terapêuticas importantes, e que diagnóstico e escolha de drogas foram causas importantes de pseudo-resistência ao tratamento