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29. Mononeuritis multiplex in leprosy
Society Proceedings / Clinical Neurophysiology 123 (2012) e17–e68
28. The role of ultrasound imaging in carpal tunnel syndrome— J.D.P. Bland (Canterbury, UK) Introduction: High resolution ultrasound (US) imaging has been widely advocated as a substitute for electrodiagnosis in the evaluation of carpal tunnel syndrome (CTS) but most studies have been carried out in highly selected patient populations. Objectives: To assess the diagnostic performance of US imaging of the median nerve in comparison to electrodiagnosis in unselected patients. Methods: The clinical probability of CTS based on the patient history was quantified using a previously validated symptom questionnaire in 565 patients attending a neurophysiology laboratory for assessment of possible CTS. Subjects had not previously been treated for CTS but no other exclusions were applied. Subjects had conventional electrodiagnostic (EDX) studies for CTS conforming to the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) standards, and high resolution US imaging in both wrists using a Sonosite M-turbo portable US system with a 30 mm linear array 8–14 MHz transducer. Median nerve cross sectional areas just proximal to the carpal tunnel were measured using the method of manual tracing just inside the hyperechoic nerve border. The proportion of normal and abnormal EDX and imaging findings was compared across a range of clinical probabilities of CTS using two alternate cutoff criteria for abnormality in each case. Results: Where the clinical likelihood of CTS was low US imaging was more likely to produce an abnormal result (76%) than nerve conduction studies (NCSs) (54%). As the clinical probability of CTS increased, the likelihood of an abnormal NCS result increased, eventually reaching 98%. A less marked increase in the sensitivity of US was seen, reaching 85%. Conclusion: In unselected patients NCSs have better diagnostic performance than US. Acknowledgement Jeremy DP Bland, MBChB, President’s Research Initiative Award Recipient. doi:10.1016/j.clinph.2011.11.111
29. Mononeuritis multiplex in leprosy—J.A. Diaz-Ruiz, F. OrtizCorredor, C. Mendoza-Pulido (Bogota, Colombia) Introduction: Leprosy (Hansen’s disease) has different neurologic manifestations that may appear many years after the onset of the clinical picture. Case report: A 44-year-old woman with tuberculoid leprosy that was treated 15 years ago, was referred with a 1-month severe neuropathic pain in her left foot. She had paresthesia in her hands and right foot. She denied weakness. On physical examination she had hypoesthesia, alodynia, and arreflexia in her left foot. She also had tender and enlarged ulnar and tibial nerves. Her strength was normal, and she had no skin lesions. Autoimmune, infectious, and metabolic diseases were ruled out. Electrodiagnostic (EDX) examination showed mild axonal disease in ulnar nerves and severe axonal loss in the tibial, peroneal, and sural nerves of the left foot. Needle electromyography showed denervation in abductor hallucis, abductor digiti minimi, and extensor digitorum brevis of the left foot. Leg muscles were normal. Sural biopsy indicated perivascular and endoneural inflammatory infiltrates with axonal loss. No foamy macrophages or acid-fast bacilli were observed. Pure neuritic leprosy was diagnosed and was treated with prednisolone, dapsone, rifampicin and
e25
minocyclin. One year after treatment, she did not have pain or paresthesia. On physical examination, hypoesthesia without alodynia was found on the sole of the left foot. EDX assessment was normal for the ulnar nerve with improvement of amplitude of the peroneal and posterior tibial nerves. Some denervation was found in the abductor hallucis. Conclusion: This is a mononeuritis multiplex in a patient with leprosy. The pure neuritic form exhibits no skin lesions and, unlike this particular case, is more frequent in males. doi:10.1016/j.clinph.2011.11.112
30. Prevalence of low vitamin D in sensory neuropathy— P. Thaisetthawatkul, J.A.M. Fernandes Filho, S.A. Ansari (Omaha, NE, USA) Introduction: The role of low vitamin D in patients with chronic pain has been proposed. Its role in painful sensory neuropathy is unknown. The frequency of low vitamin D in this group of patients remains uncertain. Objectives: To determine the frequency of low vitamin D in a group of patients with painful sensory neuropathy. Methods: A retrospective review was undertaken of medical records of patients with painful sensory neuropathy seen in the neuromuscular clinic at the University of Nebraska Medical Center from July 2008 to October 2010. Exclusion criteria included other neuromuscular disorders or peripheral neuropathy with significant weakness. Data reviewed included demographic data, clinical data of neuropathy, vitamin D, and common causes of neuropathy. Vitamin D insufficiency/deficiency was defined as total vitamin D 20–30 and <20 ng/mL, respectively. An unpaired t-test was used to compare means and a Fischer Exact test for proportions. Results: Of the 287 patients reviewed, 214 were included (115 females, mean age 58). Of those, 118 had large and 96 had small fiber neuropathy. Vitamin D testing was performed on 104 (49%) and 59 (57%) showed low vitamin D. Median vitamin D was 29 ng/mL. Fasting glucose and HgA1c was performed on 147 (69%) and 83 (39%), respectively, but abnormal levels were seen in only 45 (31%) and 36 (43%). Vitamin D was tested less frequently than fasting glucose (p < 0.0001) but yielded higher abnormal results (p < 0.0001) while HgA1C had comparable diagnostic results. Conclusion: Low vitamin D was found in high frequency in a group of patients with painful sensory neuropathy. A control study is needed to determine the role of vitamin D deficiency in sensory neuropathy. Acknowledgement Study sponsored by the University of Nebraska Medical Center, Neurologic Services Departmental Resources. doi:10.1016/j.clinph.2011.11.113
31. Evidence based computer program for electrodiagnostic evaluation of patients with the carpal tunnel syndrome— S. Podnar (Ljubljana, Slovenia) Introduction: Median nerve entrapment at the wrist is the most common neuropathy, presenting clinically as carpal tunnel syndrome (CTS). Nerve conduction studies (NCSs) are very useful to confirm CTS.
28. The role of ultrasound imaging in carpal tunnel syndrome— J.D.P. Bland (Canterbury, UK) Introduction: High resolution ultrasound (US) imaging has been widely advocated as a substitute for electrodiagnosis in the evaluation of carpal tunnel syndrome (CTS) but most studies have been carried out in highly selected patient populations. Objectives: To assess the diagnostic performance of US imaging of the median nerve in comparison to electrodiagnosis in unselected patients. Methods: The clinical probability of CTS based on the patient history was quantified using a previously validated symptom questionnaire in 565 patients attending a neurophysiology laboratory for assessment of possible CTS. Subjects had not previously been treated for CTS but no other exclusions were applied. Subjects had conventional electrodiagnostic (EDX) studies for CTS conforming to the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) standards, and high resolution US imaging in both wrists using a Sonosite M-turbo portable US system with a 30 mm linear array 8–14 MHz transducer. Median nerve cross sectional areas just proximal to the carpal tunnel were measured using the method of manual tracing just inside the hyperechoic nerve border. The proportion of normal and abnormal EDX and imaging findings was compared across a range of clinical probabilities of CTS using two alternate cutoff criteria for abnormality in each case. Results: Where the clinical likelihood of CTS was low US imaging was more likely to produce an abnormal result (76%) than nerve conduction studies (NCSs) (54%). As the clinical probability of CTS increased, the likelihood of an abnormal NCS result increased, eventually reaching 98%. A less marked increase in the sensitivity of US was seen, reaching 85%. Conclusion: In unselected patients NCSs have better diagnostic performance than US. Acknowledgement Jeremy DP Bland, MBChB, President’s Research Initiative Award Recipient. doi:10.1016/j.clinph.2011.11.111
29. Mononeuritis multiplex in leprosy—J.A. Diaz-Ruiz, F. OrtizCorredor, C. Mendoza-Pulido (Bogota, Colombia) Introduction: Leprosy (Hansen’s disease) has different neurologic manifestations that may appear many years after the onset of the clinical picture. Case report: A 44-year-old woman with tuberculoid leprosy that was treated 15 years ago, was referred with a 1-month severe neuropathic pain in her left foot. She had paresthesia in her hands and right foot. She denied weakness. On physical examination she had hypoesthesia, alodynia, and arreflexia in her left foot. She also had tender and enlarged ulnar and tibial nerves. Her strength was normal, and she had no skin lesions. Autoimmune, infectious, and metabolic diseases were ruled out. Electrodiagnostic (EDX) examination showed mild axonal disease in ulnar nerves and severe axonal loss in the tibial, peroneal, and sural nerves of the left foot. Needle electromyography showed denervation in abductor hallucis, abductor digiti minimi, and extensor digitorum brevis of the left foot. Leg muscles were normal. Sural biopsy indicated perivascular and endoneural inflammatory infiltrates with axonal loss. No foamy macrophages or acid-fast bacilli were observed. Pure neuritic leprosy was diagnosed and was treated with prednisolone, dapsone, rifampicin and
e25
minocyclin. One year after treatment, she did not have pain or paresthesia. On physical examination, hypoesthesia without alodynia was found on the sole of the left foot. EDX assessment was normal for the ulnar nerve with improvement of amplitude of the peroneal and posterior tibial nerves. Some denervation was found in the abductor hallucis. Conclusion: This is a mononeuritis multiplex in a patient with leprosy. The pure neuritic form exhibits no skin lesions and, unlike this particular case, is more frequent in males. doi:10.1016/j.clinph.2011.11.112
30. Prevalence of low vitamin D in sensory neuropathy— P. Thaisetthawatkul, J.A.M. Fernandes Filho, S.A. Ansari (Omaha, NE, USA) Introduction: The role of low vitamin D in patients with chronic pain has been proposed. Its role in painful sensory neuropathy is unknown. The frequency of low vitamin D in this group of patients remains uncertain. Objectives: To determine the frequency of low vitamin D in a group of patients with painful sensory neuropathy. Methods: A retrospective review was undertaken of medical records of patients with painful sensory neuropathy seen in the neuromuscular clinic at the University of Nebraska Medical Center from July 2008 to October 2010. Exclusion criteria included other neuromuscular disorders or peripheral neuropathy with significant weakness. Data reviewed included demographic data, clinical data of neuropathy, vitamin D, and common causes of neuropathy. Vitamin D insufficiency/deficiency was defined as total vitamin D 20–30 and <20 ng/mL, respectively. An unpaired t-test was used to compare means and a Fischer Exact test for proportions. Results: Of the 287 patients reviewed, 214 were included (115 females, mean age 58). Of those, 118 had large and 96 had small fiber neuropathy. Vitamin D testing was performed on 104 (49%) and 59 (57%) showed low vitamin D. Median vitamin D was 29 ng/mL. Fasting glucose and HgA1c was performed on 147 (69%) and 83 (39%), respectively, but abnormal levels were seen in only 45 (31%) and 36 (43%). Vitamin D was tested less frequently than fasting glucose (p < 0.0001) but yielded higher abnormal results (p < 0.0001) while HgA1C had comparable diagnostic results. Conclusion: Low vitamin D was found in high frequency in a group of patients with painful sensory neuropathy. A control study is needed to determine the role of vitamin D deficiency in sensory neuropathy. Acknowledgement Study sponsored by the University of Nebraska Medical Center, Neurologic Services Departmental Resources. doi:10.1016/j.clinph.2011.11.113
31. Evidence based computer program for electrodiagnostic evaluation of patients with the carpal tunnel syndrome— S. Podnar (Ljubljana, Slovenia) Introduction: Median nerve entrapment at the wrist is the most common neuropathy, presenting clinically as carpal tunnel syndrome (CTS). Nerve conduction studies (NCSs) are very useful to confirm CTS.