Consenso experto sobre el uso clínico de los tratamientos por vía tópica en el manejo del dolor neuropático periférico / No disponible

Objetivo: Proponer a partir del consenso de un panel de expertos de ambito estatal que integre la experiencia clinica y la evidencia disponible mas actual, recomendaciones sobre el uso clinico de los tratamientos por via topica para el manejo del dolor neuropatico periferico (DNP). Métodos: Se proponen, a partir de una revision bibliografica sobre las distintas opciones terapeuticas topicas en DNP, una serie de criterios profesionales y recomendaciones clinicas para la mejora del uso de dichos agentes topicos. Se empleo el metodo Delphi modificado en dos rondas para contrastar las opiniones de un panel nacional de 52 reconocidos expertos, seleccionados mediante una estrategia en “bola de nieve” de entre el colectivo de anestesiologos de unidades del dolor (94 %) y otros especialistas (neurologos y traumatologos). Se evaluaron 61 recomendaciones clinicas agrupadas en 6 areas tematicas: a) DNP: tratamiento topico versus sistemico (11 items); b) dolor neuropatico postquirurgico, postraumatico y munones dolorosos (12 items); c) neuralgia posherpetica, intercostal y del trigemino (9 items); d) DNP por atrapamiento (8 items); e) sindrome de dolor regional complejo (11 items); y f) neuropatia diabetica (ND) y otras polineuropatias (por VIH, alcohol, toxicidad, etc.) (10 items). Se empleo una escala ordinal de tipo Likert de 9 puntos (desacuerdo/ acuerdo) para evaluar cada recomendacion. Tras la primera ronda de encuesta, se facilito al panel informacion del resultado (resultados estadisticos y opiniones libres de los panelistas) y se solicito la reconsideracion del voto sobre los items no consensuados. Resultados: Tras la primera ronda del panel se logró consenso en 37 de las 61 cuestiones planteadas. Al final de la segunda ronda el acuerdo ascendió hasta 46 ítems (75 %). En general, se aprecia consenso entre los expertos sobre la conveniencia de introducir los tratamientos tópicos en primera línea de tratamiento del DNP y sobre su mejor aceptación por los pacientes frente a los sistémicos. Asimismo, fue criterio compartido que la combinación de estos fármacos tópicos con los tratamientos sistémicos es una opción a considerar en el manejo de varios tipos de DNP. También se alcanzó un alto grado de acuerdo en aceptar, desde un punto de vista fisiopatológico, la indicación del tratamiento con parche de capsaicina al 8 % para varios tipos de DNP. Conclusión: Los expertos en el manejo clínico del DNP muestran un elevado nivel de acuerdo profesional con diversas recomendaciones terapéuticas analizadas en el estudio. La difusión de tales recomendaciones puede ayudar a la mejora del manejo rutinario de fármacos tópicos para el dolor neuropático en nuestro sistema sanitario (AU)

Objective: To propose consensus from a panel of state level that integrates clinical experience and the most current evidence, recommendations on the clinical use of topical treatments for the management of peripheral neuropathic pain (PNP). Methods: We propose, based on a literature review on topical therapeutic options in PNP, a series of professional standards and clinical recommendations for improving the use of these topical agents. We used the modified Delphi method in two rounds to contrast the views of a national panel of 52 renowned experts, selected by a “snowball” strategy among the group of anesthesiologists pain units (94 %) and other specialists (neurologist and trauma). We evaluated 61 clinical recommendations grouped into 6 areas: a) PNP systemic versus topical treatment (11 items); b) postsurgical neuropathic pain, post-traumatic and painful stumps (12 items); c) post-herpetic neuralgia, intercostal and trigeminal (9 items); d) PNP entrapment (8 items); e) CRPS (11 items); and f) diabetic neuropathy (DN) and other polyneuropathy (HIV, alcohol, toxicity, etc.) (10 items). We used a Likert- type ordinal scale of 9 points (disagree/agree) to evaluate each recommendation. After the first round of the survey, information was provided requested to reconsider the vote on itemsnot agree. Results: After the first round the panel consensus was achieved in 37 of the 61 issues raised. At the end of the second round of the agreement amounted to 46 (75 %). In general, there was consensus among experts on whether to introduce topical treatment in first line treatment of PNP and its greater acceptance by patients compared with systemic. He was also a shared view consider in the management of various types of PNP. Also reached a high level of agreement to accept, from a physiological point of view, the indication for treatment with capsaicin patch 8 % for various types of PNP. Conclusions: Experts in the clinical management of PNP show a high level of professional agreement with various therapeutic recommendations for study. The dissemination of such recommendations can help improving the routine management of topical drugs for neuropathic pain in our health system (AU)

Versión española del test perfil de síntomas autonómicos / Spanish version of the autonomic symptom profile test

Resumen. Introducción. El perfil de síntomas autonómicos (PSA) es un cuestionario autorrellenable, que ha sido validado en lengua inglesa para valorar los síntomas autonómicos y diferenciar entre pacientes y sujetos sanos según dicha sintomatología. Nuestro grupo ha estudiado su aplicación en lengua castellana. Sujetos y métodos. Después de traducir al castellano la versión inglesa y retrotraducirla, se evaluó la fiabilidad y la validez de criterio de la versión española del test PSA en una muestra de 50 sujetos (27 controles y 23 enfermos). A todos los pacientes con síntomas de disfunción autonómica se les estudió mediante la batería de Ewing y Clarke. Resultados. La fiabilidad de la versión española del PSA fue alta, y se obtuvo un coeficiente de correlación intraclase de 0,93. Con una puntuación en el test de 47 o superior, se obtiene una sensibilidad del 73,9% y una especificidad del 100% para detectar disfunción autonómica. Además, la puntuación de la versión española del test PSA mostró diferencias estadísticamente significativas entre el grupo de pacientes y el grupo control. Conclusiones. La versión española del PSA es fiable y permite distinguir entre pacientes con disfunción autonómica y sujetos control. En nuestro conocimiento, se trata del primer test que valora la sintomatología del sistema nervioso autónomo de forma global y en castellano (AU)

Summary. Introduction. The Autonomic Symptom Profile (ASP) is a self-administered questionnaire that has been validated in English to assess autonomic symptoms and to differentiate between patients and healthy subjects according to said symptoms. Our group has studied its application in Spanish. Subjects and methods. After translating the English version into Spanish and then back-translating it, the reliability and validity of criteria in the Spanish version of the ASP test were evaluated in a sample of 50 subjects (27 controls and 23 patients). All the patients with symptoms of autonomic dysfunction were studied by means of the Ewing and Clarke battery. Results. The reliability of the Spanish version of the ASP was high and an interclass correlation coefficient of 0.93 was obtained. A score of 47 or over in the test yields a sensitivity of 73.9% and a specificity of 100% for the detection of autonomic dysfunction. Furthermore, the score in the Spanish version of the ASP test showed statistically significant differences between the group of patients and the control group. Conclusions. The Spanish version of the ASP is reliable and makes it possible to distinguish between patients with autonomic dysfunction and control subjects. As far as we are aware, this is the first test to evaluate the symptoms of the autonomic nervous system in a global manner and in Spanish (AU)

[Spanish version of the Autonomic Symptom Profile test]. / Versión española del test perfil de síntomas autonómicos.

INTRODUCTION: The Autonomic Symptom Profile (ASP) is a self-administered questionnaire that has been validated in English to assess autonomic symptoms and to differentiate between patients and healthy subjects according to said symptoms. Our group has studied its application in Spanish. SUBJECTS AND METHODS: After translating the English version into Spanish and then back-translating it, the reliability and validity of criteria in the Spanish version of the ASP test were evaluated in a sample of 50 subjects (27 controls and 23 patients). All the patients with symptoms of autonomic dysfunction were studied by means of the Ewing and Clarke battery. RESULTS: The reliability of the Spanish version of the ASP was high and an interclass correlation coefficient of 0.93 was obtained. A score of 47 or over in the test yields a sensitivity of 73.9% and a specificity of 100% for the detection of autonomic dysfunction. Furthermore, the score in the Spanish version of the ASP test showed statistically significant differences between the group of patients and the control group. CONCLUSIONS: The Spanish version of the ASP is reliable and makes it possible to distinguish between patients with autonomic dysfunction and control subjects. As far as we are aware, this is the first test to evaluate the symptoms of the autonomic nervous system in a global manner and in Spanish.

Ataxia espinocerebelosa tipo 17. Descripción del primer caso en población española / No disponible

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[Lepra: an uncommon cause of infectious neuropathy]. / Lepra: causa infrecuente de neuropatía potencialmente tratable.

INTRODUCTION: Lepra is an uncommon disease within our setting. However, it was considered the most frequent cause of polyneuropathy only 50 years ago. CASE REPORT: We present the case of a 37 year-old woman who consulted due to paresthesias in both hands and feet, livedo reticularis and complaints of frequent hand lesions. Examination of the skin detected nodular lesions and the neurophysiological study confirmed distal symmetric sensitive polyneuropathy with axonal predominance. The skin biopsy also showed histocytic infiltrate and mycobacterium lepra type intracytoplasmatic bacilli. This led to the diagnosis of Multibacillary lepromatous leprosy. Multiple treatment was begun, according to the World Health Organization recommendations, with good evolution. In spite of the attempts to eradicate lepra, its incidence continues to be elevated, especially in endemic areas, among which the south of Spain is included. It is generally associated to overcrowding and low social-economic level. CONCLUSIONS: This is the last endemic case in the Valencian Community. The possibility of lepra should be considered among the possible causes of sensitive polyneuropathy, above all in patients in endemic areas.

Lepra: causa infrecuente de neuropatía potencialmente tratable / Lepra: an uncommon cause of infectious neuropathy

Introducción. La lepra es una enfermedad poco frecuente en nuestro entorno; sin embargo, hace tan sólo 50 años era considerada la causa más frecuente de polineuropatía. Caso clínico. Presentamos el caso de una mujer de 37 años que consulta por parestesias en manos y pies, livedo reticularis y quejas de frecuentes ulceraciones en las manos. En la exploración cútanea se detectaron lesiones nodulares y el estudio neurofisiológico puso de manifiesto una polineuropatía sensitiva simétrica distal de predominio axonal. La biopsia cutánea mostró un infiltrado histocitario y bacilos intracitoplasmáticos de tipo Mycobacterium leprae, lo que condujo al diagnóstico de lepra lepromatosa multibacilar. Se instauró tratamiento con politerapia, según recomendaciones de la Organización Mundial de la Salud, con buena evolución. A pesar de los intentos de erradicación de la lepra, su incidencia continúa siendo elevada, especialmente en áreas endémicas, entre las que se incluye el sur de España y, generalmente, asociada a hacinamiento y bajo nivel socioeconómico. Conclusiones. Éste es el último caso autóctono comunicado en la Comunidad Valenciana. Entre las posibles causas de polineuropatía sensitiva debe tenerse en cuenta todavía la posibilidad de la lepra, sobre todo en pacientes procedentes de áreas endémicas (AU)

Introduction: Lepra is an uncommon disease within our setting. However, it was considered the most frequent cause of polyneuropathy only 50 years ago. Case Report: We present the case of a 37 year-old woman who consulted due to paresthesias in both hands and feet, livedo reticularis and complaints of frequent hand lesions. Examination of the skin detected nodular lesions and the neurophysiological study confirmed distal symmetric sensitive polyneuropathy with axonal predominance. The skin biopsy also showed histocytic infiltrate and mycobacterium lepra type intracytoplasmatic bacilli. This led to the diagnosis of Multibacillary lepromatous leprosy. Multiple treatment was begun, according to the World Health Organization recommendations, with good evolution. In spite of the attempts to eradicate lepra, its incidence continues to be elevated, especially in endemic areas, among which the south of Spain is included. It is generally associated to overcrowding and low social-economic level. Conclusions: This is the last endemic case in the Valencian Community. The possibility of lepra should be considered among the possible causes of sensitive polyneuropathy, above all in patients in endemic areas (AU)

Síndrome de taquicardia postural / No disponible

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[Statins and neuromuscular pathology]. / Estatinas y patología neuromuscular.

INTRODUCTION: Statins represent a group of pharmaceutical agents with proven effectiveness and scarce side effects; however, their widespread use increases the probability of the appearance of such adverse effects. DEVELOPMENT: We reviewed the articles that have been published on myotoxicity, neurotoxicity and other cases of disorders affecting the peripheral nervous system, both in reviews and in clinical trials and isolated cases. The frequency of appearance, clinical repercussion, proposed physiopathogenetic mechanisms were analysed in order to draw conclusions regarding the therapeutic attitude that should be adopted. CONCLUSIONS: Generally speaking they are safe pharmaceuticals, but the physician must pay attention to the appearance of possible side effects, given their potential reversibility and lower degree of severity if they are diagnosed at an early stage.

Estatinas y patología neuromuscular / Statins and neuromuscular pathology

Introducción. Las estatinas representan un grupo de fármacos con eficacia probada y escasos efectos secundarios; sin embargo, su amplia difusión aumenta la probabilidad de su aparición. Desarrollo. Revisamos los artículos publicados sobre miotoxicidad, neurotoxicidad y otros casos de afectación del sistema nervioso periférico, tanto en revisiones como en ensayos clínicos y casos aislados, analizando la frecuencia de aparición, la repercusión clínica, los mecanismos fisiopatogénicos propuestos y extrayendo la actitud terapéutica que debe tomarse.Conclusiones. En general son fármacos seguros, pero el facultativo debe prestar atención a la aparición de posibles efectos adversos dada su potencial reversibilidad y menor gravedad si se diagnostican de forma precoz

Introduction. Statins represent a group of pharmaceutical agents with proven effectiveness and scarce side effects; however, their widespread use increases the probability of the appearance of such adverse effects. Development. We reviewed the articles that have been published on myotoxicity, neurotoxicity and other cases of disorders affecting the peripheral nervous system, both in reviews and in clinical trials and isolated cases. The frequency of appearance, clinical repercussion, proposed physiopathogenetic mechanisms were analysed in order to draw conclusions regarding the therapeutic attitude that should be adopted. Conclusions. Generally speaking they are safe pharmaceuticals, but the physician must pay attention tothe appearance of possible side effects, given their potential reversibility and lower degree of severity if they are diagnosed at an early stage

Edema de papila bilateral como manifestación inicial de un síndrome de POEMS / Bilateral papilloedema as the initial symptom of POEMS syndrome

Introducción. El edema de papila suele ser secundario a hipertensión intracraneal, pero en ocasiones puede ser la manifestación inicial de enfermedades sistémicas como síndrome de Guillain-Barré, neurosarcoidosis, enfermedad de Leber, enfermedad de Lyme, síndrome de POEMS y otros. Presentamos un caso ocurrido en el Hospital General Universitario de Alicante, en el que el edema de papila fue la manifestación inicial de un síndrome de POEMS. Caso clínico. Mujer de 36 años, sin antecedentes de interés, que consulta por cefalea opresiva frontal izquierda, de cinco días de evolución, de inicio brusco, sin náusea ni vómitos acompañantes, sin exacerbación con las maniobras de Valsalva y sin otra sintomatología acompañante. En la exploración destaca borramiento nasal del ojo derecho y papiledema en el ojo izquierdo, hiperpigmentación cutánea en cara y escote que respetaba pliegues, hipoestesia táctil dolorosa distal en miembros inferiores y arreflexia aquílea e hiporreflexia rotuliana bilateral. Tras realizar distintas pruebas complementarias se descartó lesión ocupante de espacio intracraneal e hipertensión intracraneal, y se llegó al diagnóstico de polineuropatía crónica sensitivomotora de tipo mixto en miembros superiores e inferiores con afectación predominantemente proximal, edema de papila bilateral y fotosensibilidad cutánea a estudio. Tras dos años, la paciente presentó hepatomegalia, hipotiroidismo subclínico y alteraciones cutáneas esclerodermiformes, con lo que se diagnosticó como probable síndrome de POEMS, confirmado por la presencia de componente monoclonal en sangre y orina. Conclusión. El edema de papila como manifestación inicial de un síndrome de POEMS es infrecuente, pero debe estar presente en el diagnóstico diferencial de esta patología por las implicaciones diagnósticas y terapéuticas que conlleva

INTRODUCTION. Oedema of the papilla, or papilloedema, is usually due to intracranial hypertension, but can sometimes be the initial symptom of systemic diseases like Guillain-Barre syndrome, neurosarcoidosis, Leber’s disease, Lyme disease or POEMS syndrome, among others. We report on a case that occurred at the Hospital General Universitario in Alicante, in which papilloedema was the initial symptom of POEMS syndrome. CASE REPORT. A 36-year-old female, with no relevant past history, who visited after suffering a left-side frontal oppressive headache for five days; onset was sudden, there was no concomitant nausea or vomiting, it did not get worse when Valsalva manoeuvres were performed and there were no other accompanying symptoms. The examination revealed nasal blurring in the visual field of the right eye and papilloedema in the left eye, hyperpigmentation of the skin on the face and upper chest area that respected creases in the skin, painful distal tactile hypaesthesia in the lower limbs and bilateral areflexia of Achilles’ tendons and patellar hyperreflexia. After conducting a number of different complementary tests intracranial space-occupying lesions and intracranial hypotension were both ruled out and the patient was diagnosed with mixed-type sensory-motor chronic polyneuropathy in the upper limbs, and in the lower extremities with predominantly distal involvement, bilateral oedema of the papilla and skin photosensitivity. Two years later the patient had hepatomegaly, subclinical hypothyroidism and sclerodermiform alterations of the skin, which suggested a probable diagnosis of POEMS syndrome that was later confirmed by the presence of monoclonal component in blood and urine. CONCLUSIONS. Papilloedema is rarely seen as the initial symptom of POEMS syndrome, but it must be included in the differential diagnosis of this pathology due to the diagnostic and therapeutic implications it entails

[Bilateral papilloedema as the initial symptom of POEMS syndrome]. / Edema de papila bilateral como manifestación inicial de un síndrome de POEMS.

INTRODUCTION: Oedema of the papilla, or papilloedema, is usually due to intracranial hypertension, but can sometimes be the initial symptom of systemic diseases like Guillain-Barre syndrome, neurosarcoidosis, Leber's disease, Lyme disease or POEMS syndrome, among others. We report on a case that occurred at the Hospital General Universitario in Alicante, in which papilloedema was the initial symptom of POEMS syndrome. CASE REPORT: A 36-year-old female, with no relevant past history, who visited after suffering a left-side frontal oppressive headache for five days; onset was sudden, there was no concomitant nausea or vomiting, it did not get worse when Valsalva manoeuvres were performed and there were no other accompanying symptoms. The examination revealed nasal blurring in the visual field of the right eye and papilloedema in the left eye, hyperpigmentation of the skin on the face and upper chest area that respected creases in the skin, painful distal tactile hypaesthesia in the lower limbs and bilateral areflexia of Achilles' tendons and patellar hyperreflexia. After conducting a number of different complementary tests intracranial space-occupying lesions and intracranial hypotension were both ruled out and the patient was diagnosed with mixed-type sensory-motor chronic polyneuropathy in the upper limbs, and in the lower extremities with predominantly distal involvement, bilateral oedema of the papilla and skin photosensitivity. Two years later the patient had hepatomegaly, subclinical hypothyroidism and sclerodermiform alterations of the skin, which suggested a probable diagnosis of POEMS syndrome that was later confirmed by the presence of monoclonal component in blood and urine. CONCLUSIONS: Papilloedema is rarely seen as the initial symptom of POEMS syndrome, but it must be included in the differential diagnosis of this pathology due to the diagnostic and therapeutic implications it entails.

Meningitis por Escherichia coli como complicación tardía de bomba intratecal de baclofeno / Meningitis due to Escherichia coli as a delayed complication of intrathecal de baclofeno

No disponible

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Síndrome de Collet-Sicard como presentación de schawannoma del nervio hipogloso / Schwannoma of the hypoglossal nerve presenting as a syndrome of Collet-Sicard

El síndrome de Collet-Sicard consiste en la lesión unilateral de los cuatro últimos pares craneales. Describimos este síndrome en relación con un schwannoma del nervio hipogloso. Presentamos el caso de un paciente varón de 45 años, asintomático previamente, que consulta por presentar de forma progresiva en las dos últimas semanas ronquera y disfagia. A la exploración presenta paresia ipsolateral de los pares craneales: nueve, diez, once y doce. El cuadro clínico constituye un síndrome de Collet-Sicard. La resonancia magnética (RM) encefálica mostró un tumor de la base de cráneo dependiente del nervio hipogloso, con captación de contraste. Aunque la RM permite una aproximación al diagnóstico, así como de sus relaciones anatómicas, es imprescindible el estudio anatomopatológico. Tras la resección quirúrgica, el estudio histológico permitió el diagnóstico definitivo de schwannoma del nervio hipogloso. Describimos un caso de Collet-Sicard de presentación atípica en su clínica, así como una revisión de la literatura al respecto. Revisamos además la etiología de este síndrome, así como una descripción de los schwannomas del nervio hipogloso. Aunque se trata de una patología rara consideramos que debería ser incluida en el diagnóstico diferencial del síndrome de Collet-Sicard

Collet-Sicard is a rare syndrome that consists of the palsy of all the lower four cranial nerves. We describe this entity in relation with a schwannoma of the hypoglossal nerve. A 45 year-old-patient was admitted to the hospital referring hoarseness and difficulty in swallowing for two weeks. On neurological examination, the patient exhibited palsy of the ninth, tenth, eleventh and twelfth nerves. This is a syndrome of Collet-Sicard. The cranial MRI revealed a small intracranial and extracranial tumor adjacent to the hypoglossal foramen. The tumor involved the jugular foramen and was moderately enhanced with gadolinium The patient underwent surgical removal. The pathologic examination of the surgical specimen confirmed the diagnosis of a schwannoma of the hypoglossal nerve. We have carried out a research of the Collet-Sicard syndrome and of its aetiology. Although schwannoma of the hypoglossal nerve is a rare disorder we consider that this entity should be included in the differential diagnosis of the Collet -Sicard syndrome

[Schwannoma of the hypoglossal nerve presenting as a syndrome of Collet-Sicard]. / Síndrome de Collet-Sicard como presentación de schwannoma del nervio hipogloso.

Collet-Sicard is a rare syndrome that consists of the palsy of all the lower four cranial nerves. We describe this entity in relation with a schwannoma of the hypoglossal nerve. A 45 year-old-patient was admitted to the hospital referring hoarseness and difficulty in swallowing for two weeks. On neurological examination, the patient exhibited palsy of the ninth, tenth, eleventh and twelfth nerves. This is a syndrome of Collet-Sicard. The cranial MRI revealed a small intracranial and extracranial tumor adjacent to the hypoglossal foramen. The tumor involved the jugular foramen and was moderately enhanced with gadolinium The patient underwent surgical removal. The pathologic examination of the surgical specimen confirmed the diagnosis of a schwannoma of the hypoglossal nerve. We have carried out a research of the Collet-Sicard syndrome and of its aetiology. Although schwannoma the hypoglossal nerve is a rare disorder we consider that this entity should be included in the differential diagnosis of the Collet-Sicard syndrome.

Intoxicación accidental por alcohol metílico: secuelas neurológicas agudas y crónicas / Accidental methyl alcohol poisoning: acute and chronic neurological sequelae

No disponible

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