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Letters 363 Rological Abnormalities Were Found at That Psychological J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.3.363 on 1 March 1987. Downloaded from Letters 363 6 Wood BA. Anatomy of anal sphincters and pelvic floor. In: Henry MM, Swash M, eds. Coloproctologv and the Pelvic Floor. London: Butterworths, 1985:3-21. 7 Swash M, Snooks SJ. Electromyography in Pelvic Floor Disorders. In: Henry MM, Swash M, eds. Coloproctologi and the Pelvic Floor. London: Butterworths, 1985:88-103. 8 La Fuente DJ, Andrew J, Joy A. Sacral sparing with cauda equina compression from central lumbar intervertebral disc prolapse. J Neurol Neurosurg Psychiatry 1985;48:579-81. 9 Henry MM, Swash M. Faecal incontinence. B. Pathogenesis and Clinical Features: In: Henry MM, Swash M, eds. Coloproctology and the Pelvic Floor. London: Butterworths, 1985:222-8. Accepted I August 1986 Argyll Robertson pupils in lymphocytic meningoradiculitis (Bannwarth's syndrome) Sir: Lymphocytic meningoradiculitis or Bannwarth's syndrome is clinically charac- terised by severe radicular pains with sen- sory and motor impairment and cranial nerve palsies, especially unilateral or bilat-Protected by copyright. eral facial weakness.'`4 The syndrome is probably a European variety of Lyme dis- ease,5 which is caused by a spirochete, Borrelia burgdorferi,6 and transmitted by the bite of a tick. In Bannwarth's syndrome antibodies to the same7 or to closely related8 spirochetes are found. CSF findings such as elevated protein and pleocytosis' - 3 are con- Fig lohexol myelogram showing narrowing of the subarachnoid space at L 4/5 and L 3/4. sistent with aseptic meningitis. The disease is often self-limiting, but the course of the dis- ease and the duration of pain may be short- model that lumbar disc prolapse causes less Department of Neurological Studies, ened by high doses of penicillin given intra- stretch in the sacral roots than in their lum- The Middlesex Hospital MUedical School, venously.9 In some cases it may be difficult bar counterparts. The lower tension in the Mortimer Street, to distinguish Bannwarth's syndrome from sacral roots may cause relative sparing London WIN 8AA, UK neurosyphilis. We present such a case. from the exercise induced ischaemic neuritis A 65 year old man was admitted to the which Blau and Logue2 thought caused department of neurology because of burning "neurogenic claudication", and this explains pains in both legs and transient periods of http://jnnp.bmj.com/ the rarity of sphincter movement in this References low-grade fever for ten days. The patient condition. had noticed slight weakness and numbness Most causes of faecal incontinence are I Verbiest H. A radicular syndrome from devel- of both legs. He had twice experienced "idiopathic" and are not associated with opmental narrowing of the lumbar vertebral cramping abdominal pains. He did not canal. J Bone Joint Surg 1954;36:B230-7. more generalised neurological disturbance. recall the bite of a tick or any skin lesion. 2 Blau JN, Logue V. Intermittent claudication of Three before he had Electromyography and histological studies the cauda equina. Lancel 196 li: 1081-6. years visited our out- suggest that injury to the distal nerve supply, 3 Sharr MM, Garfield JS, Jenkins JD. Lumbar patient clinic after a car accident. No neu- perhaps due to stretch injury during strain- spondylosis and neuropathic bladder: rological abnormalities were found at that on September 28, 2021 by guest. ing at stool or childbirth, causes partial investigation of 73 patients with chronic time, and the pupils had been recorded as denervation of the muscles of the pelvic urinary symptoms. Br Med J 1976;i:695-7. normal. floor.9 It may be that in our patient an 4 Hawkes CH, Roberts GM. Neurogenic and On admission the patient was extremely mechanism vascular claudication. J Neurol Sci 1978;38: loquacious. He appeared well orientated, already compromised sphincter 337-45. an but his were incoherent. was rendered incompetent by exercise 5 Henry MM, Swash M. Physiology of faecal thoughts Neuro- induced alteration in sacral outflow. incontinence and defaecation. In: Henry psychological testing, which was performed OJF FOSTER MM, Swash M, eds. Coloproctologi and the later, showed normal intelligence and intact MJG HARRISON Pelv,ic Floor. London: Butterworths, 1985: memory. A cerebellar dysarthria was noted. HA CROCKARD 42-7. There was no neck stiffness. Both pupils J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.3.363 on 1 March 1987. Downloaded from 364 Letters were very small and irregular in shape and myokymia'0 as well as the CSF findings9 are infections. Unfortunately, how such a lesion there was slight anisocoria. The light reac- compatible with the diagnosis of Bann- is produced is poorly understood at the tion was almost absent, whereas the warth's syndrome. Unusual findings were present time.21 response to near-effort was normal and the prominent cerebellar ataxia, which has In conclusion, our findings indicate that brisk. In darkness the miosis remained rarely been described in Lyme disease11 and Bannwarth's syndrome should be consid- unchanged. Visual acuity was normal. The Bannwarth's syndrome, 2 and the small ered in seronegative patients with the eye straight leg raising test was positive in both number of white cells in the CSF, which is signs of neurosyphilis. legs. There was a slight weakness of uncommon in the acute stage of the dis- dorsiflexors and extensors of both feet and ease.13 The most strikingly unusual finding, The authors thank Dr Willy Burgdorfer, cerebellar ataxia of both legs. All tendon however, was the Argyll Robertson syn- Rocky Mountain Laboratories, Hamilton, jerks in the legs were absent. The patient was drome. All criteria for this syndrome were Montana, who performed the immuno- 4 unable to walk because of severe ataxia. fulfilled namely small and irregular pupils, a fluorescence assay for antibodies against CSF analysis showed 13 white cells/mm3 more extensive reaction to near-effort than Borrelia burgdorferi, Prof Dr J van Gijn and and a total protein of 1-01 g/l on admission to light, and intact visual function.'4 Since Prof Dr A Staal for the valuable comments, and after one week 9 white cells, a protein of these abnormalities were not noted when the and Mrs J Doornbosch-Konijn for typing 1 60 g/l and a normal IgG index and agarose patient visited our out-patient clinic after a the manuscript. gel electrophoresis. Laboratory analysis car accident some years before, it seems very showed negative Treponema pallidum hae- likely that the Argyll Robertson pupils are PJ KOUDSTAAL* maglutination assay (TPHA), fluorescent indeed related to the present disease. M VERMEULEN* treponemal antibody absorption (FTA-BS), The abnormalities of the pupils must be JHJ WOKKEt venereal disease research laboratory test differentiated from Adie's syndrome,'4 *Department of Neurology, (VDRL) and Reiter-CIE reaction on two which may appear later in life, sometimes University Hospital Dijkzigt, occasions in both blood and CSF. Com- following a viral infection.'" However, this Rotterdam, puted tomography of the brain, ECG and abnormality is unilateral in 90% ofall cases, The Netherlands chest radiographs were all normal. Pharma- the pupil is mydriatic instead of miotic, at tDepartment of Neurology, cological tests showed no pupillary response least in the acute stage, and the narrowing University Hospital Utrecht, following pilocarpine 0 125% or adrenaline and redilation during and after convergence The NetherlandsProtected by copyright. 010%, but brisk dilatation after cocaine is tonic instead of brisk as in our patient.'4 4%. Furthermore, the patient showed no super- Initially, a diagnosis of neurosyphilis was sensitivity reaction to pilocarpine, which is made and the patient received high doses of present in 80% of patients with Adie's References penicillin intravenously. After three days syndrome.'6 Other diseases which may right-sided facial weakness developed, cause Argyll-Robertson-like pupils such as I WulffCH, Hansen K, Strange P, Trojaborg W. Multiple mononeuritis and radiculitis with together with left-sided facial A diabetes mellitus and von Economo's myokymia. erythema, pain, elevated CSF protein and prominent cerebellar ataxia was now present encephalitis were all easily excluded. pleocytosis (Bannwarth's syndrome). J Neu- in both arms as well as in the legs. At that The site of the causative lesion in the rol Neurosurg P.scychiatry 1983;46:485-90. time the results of the diagnostic tests for Argyll Robertson syndrome is the subject of 2 Bomholt A. Facial palsy in lymphocytic menin- syphilis proved negative and a diagnosis of longstanding controversy. Pupillary light- goradiculitis (Bannwarth's syndrome). Arch Bannwarth's syndrome was considered. near dissociation has been documented in a Ololaryngol 1984;110:763-4. This diagnosis was later confirmed by the number of peripheral neuropathies, 18 in 3 Hindfelt B, Jeppsson PG, Nilsson B, Olsson presence of serum antibodies (IgG) against which the abnormalities were attributed to J-E, Ryberg B, S6rnas R. Clinical and Borrelia burgdorferi in a titre of 1:128, para-sympathetic denervation of the pupil- cerebrospinal fluid findings in lympho- cytic meningo-radiculitis (Bannwarth's determined by indirect immunofluorescence lary sphincter.'8 Most of these cases, how- syndrome). Ahta Neurol Sc-and 1982; assay. During and after the penicillin treat- ever, lacked typical features of the Argyll 66:444-53. ment the patient completely recovered and Robertson syndrome, such as miosis or 4 Schmutzhard E, Stanek G, Pohl P. Polyneuritishttp://jnnp.bmj.com/ the CSF findings normalised. Only the irregular pupils. At present, most evidence cranialis associated with Borrelia burg- pupillary abnormalities remained. supports a central rather than a peripheral dorferi. J Neurol Neurosurg P.scyhiatrv This patient demonstrates that lympho- origin of the Argyll Robertson syn- 1985;48: 1182-4. cytic meningoradiculitis or Bannwarth's drome. 17 19 20 Loewenfeld concluded that 5 Ryberg B, Wilson B, Hindfelt B, Jeppsson PG, syndrome may closely resemble neuro- the site of the lesion is probably rostral to Olsson JE, Sorntis R.
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