DOCSLIB.ORG

Polyneuropathy Following COVID-19 Infection: the Rehabilitation Approach Ahmad Saif ‍ ‍ ,1,2 Anton Pick2

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Polyneuropathy Following COVID-19 Infection: the Rehabilitation Approach Ahmad Saif ‍ ‍ ,1,2 Anton Pick2 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-242330 on 24 May 2021. Downloaded from Polyneuropathy following COVID-19 infection: the rehabilitation approach Ahmad Saif ,1,2 Anton Pick2 1Rehabilitation Medicine, SUMMARY Throughout his intensive care admission, he had Buckinghamshire Healthcare A range of neurological manifestations associated with multiple SARS- CoV-2 RNA PCR tests from nasal NHS Trust, Aylesbury, UK and throat swabs and broncheoalveolar lavage 2 COVID-19 have been reported in the literature, but the Rehabilitation Medicine, Oxford pathogenesis of these have yet to be fully explained. The samples that were negative but was treated as Centre for Enablement, Oxford, majority of cases of peripheral nervous system disease suspected COVID-19 based on what was deemed UK published thus far have shown a symmetrical pattern. to be a typical clinical presentation. He developed several complications including Correspondence to In contrast, we describe the case of a patient with Dr Ahmad Saif; asymmetrical predominantly upper-limb sensorimotor ventilator- associated pneumonia, gastrointestinal ahmad. saif2@ nhs. net polyneuropathy following COVID-19 infection, likely due bleed, acute kidney injury requiring a period of to a multifactorial pathological process involving critical haemodialysis and bilateral pulmonary embolisms. Accepted 22 April 2021 illness neuropathy, mechanical injury and inflammatory Nerve conduction studies (NCS) were carried out on disease. His presentation, management and recovery day 29 of his intensive care unit admission showing contribute to the understanding of this complex evidence of widespread and severe sensory and motor condition and informs rehabilitation approaches. axonal dysfunction, in keeping with critical care polyneuropathy. The patient was extubated and discharged from intensive care after 55 days. He was found to have BACKGROUND generalised weakness most prominently in the upper As the coronavirus pandemic progresses, so does our limbs and associated neuropathic pain. He was then understanding of the natural history, transmission transferred to a specialist multidisciplinary neurore- and clinical presentation.1 Although patients most habilitation unit for ongoing treatment. Examination commonly present with respiratory and gastrointes- findings for the upper limbs on admission to the reha- tinal symptoms, a diverse range of symptoms have been bilitation unit are shown in table 1. In the lower limbs, reported. Descriptions of neurological manifestations there was 5/5 power throughout. Sensation to light include reports of encephalopathies, central nervous touch was reduced in areas consistent with C8 and T1 system vasculitides, cerebrovascular events and periph- http://casereports.bmj.com/ dermatomes on the right, and T1 dermatome on the eral nervous system disease in particular Guillain-Barré left. He was found to have reduced proprioception syndrome (GBS) and its variants.2 in fourth and fifth digits on the right hand. Sensation, The pathogenesis of these manifestations is including proprioception, was grossly normal in his yet to be fully elucidated. Evidence from other lower limbs. Tone was normal in the lower limbs. similar viruses suggests mechanisms may include Repeat NCS (table 2) were carried out 83 days direct effects of the virus on the nervous system, following initial admission. The study showed parainfections or postinfection immune- mediated evidence for a peripheral neuropathy which may in disease as well as neurological complications of part have been due to a length-dependent sensory the systemic effects of COVID-19 and critical care motor axonal neuropathy; however, the striking on September 29, 2021 by guest. Protected copyright. admission.2 Here, we describe the case of a patient aspect was the distribution, with profound dener- who developed asymmetrical predominantly upper- vation of both upper limbs and relative preserva- limb sensorimotor polyneuropathy following tion of lower limb strength including distally with COVID-19 infection.3 minimal axonal loss. This pattern was not typical for a critical illness CASE PRESENTATION myopathy but rather raised the possibility of pref- The patient is a man in his 60s who first presented erential sensory motor peripheral nerve fibre loss with severe shortness of breath. His symptoms either affecting the lower aspect of the brachial started 12 days prior with dry cough, mild short- plexus bilaterally or possibly a combination of ness of breath, fever and chest tightness. Following a sensory neuropathy, in addition to perhaps a advice from his general practitioner, he had been localised cervical spinal cause at the C7–T1 levels. self- isolating and had been commenced on Amox- Further investigation with MRI brachial plexus and C- spine, however, showed no focal injury or © BMJ Publishing Group icillin for suspected community- acquired pneu- Limited 2021. No commercial monia 1 day prior. On admission, he was in severe inflammation to the brachial plexus either side with re- use. See rights and respiratory distress with saturations of 91% on minor degenerative change in the lower cervical permissions. Published by BMJ. 12 L of oxygen, respiratory rate 34 breaths/min, spine only. To cite: Saif A, Pick A. BMJ temperature 37.6°C, heart rate 101 beats/min and Case Rep 2021;14:e242330. blood pressure 163/89 mm Hg. He had a prolonged doi:10.1136/bcr-2021- admission on intensive care requiring intubation 242330 and ventilation and later tracheostomy formation. Saif A, Pick A. BMJ Case Rep 2021;14:e242330. doi:10.1136/bcr-2021-242330 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-242330 on 24 May 2021. Downloaded from Brachial plexus injury due to compression or stretch from Table 1 Upper limb examination findings proning has been reported, with the majority of cases recov- Power (MRC grade) 4 5 Movement ering well. This likely played a contributing role to the clin- Left Right ical picture in the current case, the patient having been proned Shoulder abduction (C5) 2 2 in intensive care. However, MRI showed no features to suggest Elbow flexion (C5, C6) 0 4 focal injury or inflammation of either brachial plexus; that is, no Elbow extension (C7) 3 1 pseudomeningocele to suggest traumatic nerve root avulsion, no Wrist extension (C6) 3 3 focal collection or haematoma and no inflammatory change or Wrist flexion (C8) 2 1 thickening of the brachial plexus elements on either side. Local- Finger extension (C7) 2 0 ised cervical spine injury at the C7–T1 levels was also considered Finger flexion (C8) 0 0 but imaging showed only minor degenerative change with no Finger abduction (T1) 0 0 nerve root impingement. MRC, Medical Research Council. There has been an association of asymmetric neuropathies with other viruses in particular cytomegalovirus, HIV and hepa- titis C.6–8 However, viral screen in this case was negative and DIFFERENTIAL DIAGNOSIS there were no other abnormal blood tests or signs suggestive of Critical illness neuropathy was the proposed diagnosis to explain these. the initial findings in intensive care. However, repeat NCS were Cases of GBS associated with COVID-19 have also been 2 carried out following the acute COVID-19 infection given the reported. Differentiating the axonal variants of GBS from crit- asymmetry of presentation. The clinical and neurophysiological ical illness polyneuropathy can be difficult. The major clinical picture was atypical for this diagnosis alone with the dispropor- distinction is that the critical illness polyneuropathy occurs tionate upper-limb involvement suggesting an additional patho- during the period of severe illness and stay in intensive care logical process. while GBS often occurs after the acute illness and leads to an Table 2 Nerve conduction study results taken 83 days following initial admission Sensory NCS Nerve /sites Rec. site Onset latency (ms) PP amplitude (µV) Velocity (m/s) R Median, ulnar—median ulnar orthodromic Median Dig II Wrist NR NR NR Ulnar Dig V Wrist NR NR NR L Median, ulnar—median ulnar orthodromic http://casereports.bmj.com/ Median Dig III Wrist NR NR NR Ulnar Dig V Wrist NR NR NR R Radial—anatomical snuff box (forearm) Forearm Wrist NR NR NR L Radial—anatomical snuff box (forearm) Forearm Wrist NR NR NR L Sural, superficial peroneal Sural calf Ankle NR NR NR Superficial peroneal calf Ankle NR NR NR on September 29, 2021 by guest. Protected copyright. Motor NCS Nerve /sites Muscle Latency (ms) Amplitude (mV) PP amplitude (mV) Relative amplitude (%) Duration (ms) Velocity (m/s) L Median—APB Wrist APB NR NR NR NR NR Elbow APB NR NR NR NR NR R Median—APB Wrist APB NR NR NR NR NR L Ulnar—ADM Wrist ADM NR NR NR NR NR R Ulnar—ADM Wrist ADM NR NR NR NR NR R Peroneal—EDB Ankle EDB 5.68 1.2 1.6 100 24.9 Fib head EDB 12.81 0.9 1.2 78.8 24.53 42 Pop fossa EDB 14.53 0.6 0.9 53.1 24.64 40.7 R Tibial—AH Ankle AH 4.17 5.2 7.7 100 22.24 ADM, abductor digiti minimi; AH, abductor hallucis; APB, abductor pollicis brevis; EDB, extensor digitorum brevis; NCS, nerve conduction studies. 2 Saif A, Pick A. BMJ Case Rep 2021;14:e242330. doi:10.1136/bcr-2021-242330 Case report BMJ Case Rep: first published as 10.1136/bcr-2021-242330 on 24 May 2021. Downloaded from intensive care admission.9–11 Furthermore, GBS more often role of rehabilitation medicine in managing patients following involves the cranial nerves. Without cerebrospinal fluid (CSF) COVID-19 infection. Table 3 shows the multiple functional results or serum immunological markers in this case, GBS cannot impairments in this patient and the holistic programme to be ruled out. However, a recent epidemiological study found an manage each aspect. overall reduction in incidence of GBS during the pandemic and He showed improvement in impairment, activity and partic- while a link could not be ruled out, no epidemiological clues ipation, following a period of intensive cardiopulmonary and of SARS- CoV-2 causing GBS have been identified.12 Given the neurorehabilitation.
Load more

Recommended publications
  • An Improved Technique for Radial Nerve Conduction Studies
    J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.30.4.332 on 1 August 1967. Downloaded from J. Neurol. Neurosurg. Psychiat., 1967, 30, 332 An improved technique for radial nerve conduction studies ALLAN W. DOWNIE1 AND THOMAS R. SCOTT From the Division of Neurology, Department of Medicine, School of Medicine, University ofNorth Carolina, Chapel Hill, North Carolina, U.S.A. A technique for recording evoked sensory potentials MATERIALS AND METHOD from the radial nerve has already been reported by us (Downie and Scott, 1964). This technique, The apparatus used was a TECA two-channel electro- myograph. The recording electrodes consisted of a pair although reliable, is time consuming and occasion- of chlorided silver discs 1 cm. in diameter, mounted ally difficult and the amplitude of potentials may be 2 5 cm. apart on a plastic base. The active recording as low as 1 to 2 microvolts. The purpose of this electrode was placed over the largest palpable branch communication is to describe a simpler technique by of the radial nerve as it crossed the tendon of the extensor which potentials of greater amplitude can be pollicis longus. The distal recording electrode was placed obtained. In addition, the segment of nerve tested is over the first dorsal interosseous muscle but not neces- Protected by copyright. one which can be readily identified and biopsied if sarily over the nerve, of which the position in this area so desired without causing unpleasant or disturbing cannot be precisely determined (Fig. 1). An experiment sensory loss to the subject. made to assess the importance of the position of this electrode showed no significant difference in latency to The location of a nerve which is to be tested is peak when it was placed in turn on three points along usually determined by stimulating its motor fibres a line between the tendons of the extensor pollicis and finding the stimulus site from which maximal longus and extensor indicis provided the interelectrode muscle contraction is obtained.
    [Show full text]
  • A Guide to Transthyretin Amyloidosis
    A Guide to Transthyretin Amyloidosis Authored by Teresa Coelho, Bo-Goran Ericzon, Rodney Falk, Donna Grogan, Shu-ichi Ikeda, Mathew Maurer, Violaine Plante-Bordeneuve, Ole Suhr, Pedro Trigo 2016 Edition Edited by Merrill Benson, Mathew Maurer What is amyloidosis? Amyloidosis is a systemic disorder characterized by extra cellular deposition of a protein-derived material, known as amyloid, in multiple organs. Amyloidosis occurs when native or mutant poly- peptides misfold and aggregate as fibrils. The amyloid deposits cause local damage to the cells around which they are deposited leading to a variety of clinical symptoms. There are at least 23 different proteins associated with the amyloidoses. The most well-known type of amyloidosis is associated with a hematological disorder, in which amyloid fibrils are derived from monoclonal immunoglobulin light-chains (AL amyloidosis). This is associated with a clonal plasma cell disorder, closely related to and not uncommonly co-existing with multiple myeloma. Chronic inflammatory conditions such as rheumatoid arthritis or chronic infections such as bronchiectasis are associated with chronically elevated levels of the inflammatory protein, serum amyloid A, which may misfold and cause AA amyloidosis. The hereditary forms of amyloidosis are autosomal dominant diseases characterized by deposition of variant proteins, in dis- tinctive tissues. The most common hereditary form is transthyretin amyloidosis (ATTR) caused by the misfolding of protein monomers derived from the tetrameric protein transthyretin (TTR). Mutations in the gene for TTR frequently re- sult in instability of TTR and subsequent fibril formation. Closely related is wild-type TTR in which the native TTR protein, particu- larly in the elderly, can destabilize and re-aggregate causing non- familial cases of TTR amyloidosis.
    [Show full text]
  • Expert Consensus Recommendations to Improve Diagnosis of ATTR Amyloidosis with Polyneuropathy
    Journal of Neurology https://doi.org/10.1007/s00415-019-09688-0 REVIEW Expert consensus recommendations to improve diagnosis of ATTR amyloidosis with polyneuropathy David Adams1 · Yukio Ando2 · João Melo Beirão3 · Teresa Coelho4 · Morie A. Gertz5 · Julian D. Gillmore6 · Philip N. Hawkins6 · Isabelle Lousada7 · Ole B. Suhr8 · Giampaolo Merlini9,10 Received: 10 December 2019 / Revised: 20 December 2019 / Accepted: 23 December 2019 © The Author(s) 2020 Abstract Amyloid transthyretin (ATTR) amyloidosis with polyneuropathy (PN) is a progressive, debilitating, systemic disease wherein transthyretin protein misfolds to form amyloid, which is deposited in the endoneurium. ATTR amyloidosis with PN is the most serious hereditary polyneuropathy of adult onset. It arises from a hereditary mutation in the TTR gene and may involve the heart as well as other organs. It is critical to identify and diagnose the disease earlier because treatments are available to help slow the progression of neuropathy. Early diagnosis is complicated, however, because presentation may vary and family history is not always known. Symptoms may be mistakenly attributed to other diseases such as chronic infammatory demyelinating polyradiculoneuropathy (CIDP), idiopathic axonal polyneuropathy, lumbar spinal stenosis, and, more rarely, diabetic neuropathy and AL amyloidosis. In endemic countries (e.g., Portugal, Japan, Sweden, Brazil), ATTR amyloidosis with PN should be suspected in any patient who has length-dependent small-fber PN with autonomic dysfunction and a family history of ATTR amyloidosis, unexplained weight loss, heart rhythm disorders, vitreous opacities, or renal abnormali- ties. In nonendemic countries, the disease may present as idiopathic rapidly progressive sensory motor axonal neuropathy or atypical CIDP with any of the above symptoms or with bilateral carpal tunnel syndrome, gait disorders, or cardiac hypertro- phy.
    [Show full text]
  • Practical Neurology: Peripheral Neuropathy for the Internist
    Practical Neurology: Polyneuropathy for the Non-Neurologist Steven A. Day, MD Providence Neurological Specialties Definitions Foundational Principle: With neurological problems think of LOCALIZATION before SYNDROME Definitions • Neuronopathy – Motor neuronopathy – Sensory neuronopathy • Radiculopathy • Plexopathy • Neuropathy – Mononeuropathy – Polyneuropathy The Netter Collection of Medical Illustrations, Volume 1, Nervous System, 2002 “ROOTS” C4 TRUNKS C5 Dorsal scapular n. C6 TRUNKS C7 Suprascapular n. T1 DIVISIONS Musculocut- aneous n. CCF CORDS 2002 Long thoracic n. TERMINAL NERVES CCF ©2002 Axillary n. Radial n. Median n. Ulnar n. Definitions ‘Neuropathy’ is a diagnosis which specifies the location of pathology, not a symptom Definitions • Axonal = axon loss pathology • Demyelinating = myelin loss pathology Topical Diagnosis in Neurology, 3rd ed. 1998 Topical Diagnosis in Neurology, 3rd ed. 1998 Duss’ Topical Diagnosis in Neurology, 4th ed. 2005 Polyneuropathy Polyneuropathy: Typical Presentation • Insidious onset • Distal (toes, pads of feet) • Gradual progression • Complaints are primarily sensory Polyneuropathy: Key Exam Features • Sensory – Distal gradient of sensory loss • Pin prick or cold • Monofilament • Cotton wisp • Vibration at toes and ankles • Proprioception: toe movements Polyneuropathy: Key Exam Features • Motor – Is there intrinsic foot or hand muscle atrophy? – Weakness pattern • Distal • Proximal and distal • Asymmetric – Able to stand/elevate on toes and heels? Polyneuropathy: Key Exam Features • Reflexes – Distal
    [Show full text]
  • The Usefulness of Proximal Radial Motor Conduction in Acute Compressive Radial Neuropathy
    JCN Open Access ORIGINAL ARTICLE pISSN 1738-6586 / eISSN 2005-5013 / J Clin Neurol 2015;11(2):178-182 / http://dx.doi.org/10.3988/jcn.2015.11.2.178 The Usefulness of Proximal Radial Motor Conduction in Acute Compressive Radial Neuropathy Kun Hyun Kima b Background and PurposezzThe objective of this study was to determine diagnostic and Kee-Duk Park a prognostic values of proximal radial motor conduction in acute compressive radial neuropathy. Pil-Wook Chung a MethodszzThirty-nine consecutive cases of acute compressive radial neuropathy with radial Heui-Soo Moon conduction studies–including stimulation at Erb’s point–performed within 14 days from a Yong Bum Kim clinical onset were reviewed. The radial conduction data of 39 control subjects were used as a Won Tae Yoon reference data. b Hyung Jun Park ResultszzThirty-one men and eight women (age, 45.2±12.7 years, mean±SD) were enrolled. Bum Chun Suha All 33 patients in whom clinical follow-up data were available experienced complete recov- ery, with a recovery time of 46.8±34.3 days. Partial conduction block was found frequently a Department of Neurology, Kangbuk Samsung Hospital, (17 patients) on radial conduction studies. The decrease in the compound muscle action po- Sungkyunkwan University tential area between the arm and Erb’s point was an independent predictor for recovery time. School of Medicine, Seoul, Korea zzProximal radial motor conduction appears to be a useful method for the early b Conclusions Department of Neurology, detection and prediction of prognosis of acute compressive radial neuropathy. Mokdong Hospital, Ewha Womans University Key Wordszz radial neuropathy, nerve conduction study, conduction block, diagnosis, School of Medicine, Seoul, Korea prognosis.
    [Show full text]
  • A Case of Bickerstaff S Brainstem Encephalitis in Childhood '
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Directory of Open Access Journals Korean Journal of Pediatrics Vol. 53, No. 4, 2010 DOI : 10.3345/kjp.2010.53.4.607 Case report 1)jtj A case of Bickerstaff’s brainstem encephalitis in childhood Ji Youn Kim, M.D., Young Ok Kim, M.D., Young Jun Son, M.D. and Young Jong Woo, M.D. Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea = Abstract = Bickerstaff's brainstem encephalitis (BBE) is a rare disease diagnosed by specific clinical features such as 'progressive, relatively symmetric external ophthalmoplegia and ataxia by 4 weeks' and 'disturbance of consciousness or hyperreflexia' after the exclusion of other diseases involving the brain stem. Anti-ganglioside antibodies (GM, GD and GQ) in the serum or cerebrospinal fluid (CSF) are sometimes informative for the diagnosis of BBE because of the rarity of positive findings in other diagnositic methods: brain magnetic resonance imaging (MRI), routine CSF examination, motor nerve conduction study, and needle electromyography. We report a rare case of childhood BBE with elevated anti-GM1 antibodies in the serum, who had specific clinical symptoms such as a cranial polyneuropathy presenting as ophthalmoplegia, dysarthria, dysphagia, and facial weakness; progressive motor weakness; altered mental status; and ataxia. However, the brain MRI, routine CSF examination, nerve conduction studies, electromyography, somatosensory evoked potentials, and brainstem auditory evoked potentials were normal. BBE was suspected and the patient was successfully treated with intravenous immunoglobulins. (Korean J Pediatr 2010;53:607-611) Key Words : Encephalitis, Brain stem, Child bulins (IVIG) for the treatment of BBE suggests an auto- Introduction immune etiology5, 6).
    [Show full text]
  • Peripheral Polyneuropathy in Patients Receiving Long-Term Statin Therapy
    552 Turk Kardiyol Dern Ars 2019;47(7):552-553 doi: 10.5543/tkda.2019.52735 Invited Editorial / Davetli Editöryal Yorum Peripheral polyneuropathy in patients receiving long-term statin therapy Uzun dönem statin kullanan hastalarda periferik polinöropati gelişimi Öner Özdoğan, M.D. Department of Cardiology, Tepecik Training and Research Hospital, İzmir, Turkey Although drug-induced neuropathies (DIN) are not an enzyme which could Abbreviation: very common, they are one of the main reasons of pe- alter the neurons’ energy DIN Drug-induced neuropathies ripheral neuropathies.[1] DIN cause to sensory, motor, utilization.[6] On the con- ENMG Electroneuromyography and autonomic dysfunctions depending on the type of SAMs Statin-associated muscle trary; some animal stu- symptoms the peripheral nerve involvement. As significant re- dies have reported that covery could be observed after discontinuation of the statins provided a neuroprotective effect against pe- causal agent drug, early diagnosis is important. How- ripheral nerve injury.[7] In a recent Danish case-control ever, symptoms of DIN are usually seen after months study, use of statins in 370 cases, was not associated [2] or years of exposure. Therefore, defining the causal with an elevated risk of polyneuropathy. Similarly, no relationship between the drugs and long term side ef- association was observed between polyneuropathy fects like drug-induced peripheral neuropathies is not risk and long-term high-intensity statin.[8] easy always, and commonly missed. Electrodiagnos- tic tests are the most important methods to confirm In this issue of the Archives of Turkish Society tthe peripheral neuropathy.[3] We classify the type of of Cardiology, Ozdemir et al.
    [Show full text]
  • Posterior Interosseous Neuropathy Supinator Syndrome Vs Fascicular Radial Neuropathy
    Posterior interosseous neuropathy Supinator syndrome vs fascicular radial neuropathy Philipp Bäumer, MD ABSTRACT Henrich Kele, MD Objective: To investigate the spatial pattern of lesion dispersion in posterior interosseous neurop- Annie Xia, BSc athy syndrome (PINS) by high-resolution magnetic resonance neurography. Markus Weiler, MD Methods: This prospective study was approved by the local ethics committee and written Daniel Schwarz, MD informed consent was obtained from all patients. In 19 patients with PINS and 20 healthy con- Martin Bendszus, MD trols, a standardized magnetic resonance neurography protocol at 3-tesla was performed with Mirko Pham, MD coverage of the upper arm and elbow (T2-weighted fat-saturated: echo time/repetition time 52/7,020 milliseconds, in-plane resolution 0.27 3 0.27 mm2). Lesion classification of the radial nerve trunk and its deep branch (which becomes the posterior interosseous nerve) was performed Correspondence to Dr. Bäumer: by visual rating and additional quantitative analysis of normalized T2 signal of radial nerve voxels. [email protected] Results: Of 19 patients with PINS, only 3 (16%) had a focal neuropathy at the entry of the radial nerve deep branch into the supinator muscle at elbow/forearm level. The other 16 (84%) had proximal radial nerve lesions at the upper arm level with a predominant lesion focus 8.3 6 4.6 cm proximal to the humeroradial joint. Most of these lesions (75%) followed a specific somato- topic pattern, involving only those fascicles that would form the posterior interosseous nerve more distally. Conclusions: PINS is not necessarily caused by focal compression at the supinator muscle but is instead frequently a consequence of partial fascicular lesions of the radial nerve trunk at the upper arm level.
    [Show full text]
  • Peripheral Nerve Disorders
    CLINICAL GUIDELINES PND Imaging Policy Version 1.0 Effective February 14, 2020 eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight. CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. © 2019 eviCore healthcare. All rights reserved. PND Imaging Guidelines V1.0 Peripheral Nerve Disorders (PND) Imaging Guidelines Abbreviations for Peripheral Nerve Disorders Imaging Guidelines 3 PN-1: General Guidelines 4 PN-2: Focal Neuropathy 5 PN-3: Polyneuropathy 7 PN-4: Brachial Plexus 8 PN-5: Lumbar and Lumbosacral Plexus 9 PN-6: Muscle Disorders 10 PN-7: Magnetic Resonance Neurography (MRN) 13 PN-8: Amyotrophic Lateral Sclerosis (ALS) 14 PN-9: Peripheral Nerve Sheath Tumors (PNST) 15 PN-10: Nuclear Imaging 16 ______________________________________________________________________________________________________
    [Show full text]
  • Acrodermatitis Chronica Atrophicans: Various Faces of the Late Form of Lyme Borreliosis
    Original paper Acrodermatitis chronica atrophicans: various faces of the late form of Lyme borreliosis Anna Moniuszko-Malinowska, Piotr Czupryna, Justyna Dunaj, Sławomir Pancewicz, Adam Garkowski, Maciej Kondrusik, Sambor Grygorczuk, Joanna Zajkowska Department of Infectious Diseases and Neuroinfections, Medical University of Białystok, Białystok, Poland Adv Dermatol Allergol 2018; XXXV (5): 490–494 DOI: https://doi.org/10.5114/ada.2018.77240 Abstract Introduction: Acrodermatitis chronica atrophicans (ACA) is probably the most common late and chronic manifesta- tion of the Lyme borreliosis seen in European patients. Aim: To analyze epidemiological data, and to investigate the effects of treatment of patients with ACA. Material and methods: Nine patients were included in the study. All patients had serological examinations (ELISA and Western blot) and histopathological examination of the skin lesions performed. Eight patients had PCR in the skin biopsy performed. Results: The duration of symptoms ranged from 2 months to 2 years. In 7 patients, skin lesions were located on lower limbs, in 2 patients – in a non-typical body area – abdomen. In 1 patient, scleroderma and in 3 patients, diabetes mellitus was diagnosed. Borrelia burgdorferi DNA was detected in 25% of the skin biopsy specimens. IgG anti-B. burgdorferi specific antibodies were present in serum of all patients (confirmed by Western blot). In all cases, the diagnosis was confirmed by histopathological examination. The response to ceftriaxone therapy varied. In 5 cases, the lesions resolved completely, in others they faded. Conclusions: Despite raising awareness of Lyme borreliosis, late forms of the disease such as ACA are still observed. Acrodermatitis chronica atrophicans skin lesions may be located in non-characteristic areas, e.g.
    [Show full text]
  • Neuromuscular Medicine Core Competencies Outline
    The American Board of Psychiatry and Neurology Neuromuscular Medicine Core Competencies Outline I. Neuromuscular Patient Care Core Competencies A. GENERAL: Neuromuscular Medicine Specialists shall demonstrate the following abilities: 1. To perform and document relevant history and examination of culturally diverse patient to include as appropriate: a. Chief complaint b. History of present illness c. Past medical history d. Developmental history (especially for children) e. Comprehensive review of both neurologic and general systems f. Biological family history g. Sociocultural history h. Neurological examination and a germane general examination as appropriate to the present illness 2. Delineate appropriate differential diagnoses 3. Formulate, assess and recommend effective management B. FOR NEUROMUSCULAR MEDICINE: Based on comprehensive neurological assessments, Neuromuscular Specialists shall demonstrate the following abilities: 1. To determine: a. If a patient’s symptoms are the result of a disease affecting the central and/or peripheral nervous system or are of another origin (e.g., of a systemic, psychiatric, or psychogenic illness) by performing appropriate neuromuscular evaluation b. An initial diagnostic formulation with differential diagnosis c. Appropriate diagnostic modalities to include laboratory blood, urine, and cerebrospinal fluid analyses, electrodiagnostic, imaging, genetic, and pathologic investigations to evaluate and manage such patients d. Management plan 2. To develop and maintain the technical skills to: a. Perform
    [Show full text]
  • A Rare Case of Bickerstaff's Brainstem Encephalitis
    Available online at www.worldscientificnews.com WSN 135 (2019) 144-155 EISSN 2392-2192 A rare case of Bickerstaff’s brainstem encephalitis Krystian Ślusarz*, Krzysztof Wierzbicki, Monika Adamczyk-Sowa Department of Neurology, Medical University of Silesia, Zabrze, Poland *E-mail address: [email protected] ABSTRACT Bickerstaff’s brainstem encephalitis (BBE) is a rare, immune-dependent disease of brainstem characterized by progressive ophthalmoplegia, ataxia and central nervous system involvement, which may take the form of impaired consciousness and/or pyramidal signs. BBE requires differentiation with many neurological conditions and it is extremely difficult to make the proper diagnosis. We describe the case of a 63-year-old female patient admitted to the Department of Neurology due to speech changes, balance disorder, diplopia and weakness of the right limbs. On admission, neurological examination revealed depressed gag and palatal reflexes, central facial nerve palsy on the right side of the face and paresis of the right limbs. On the second day, progression of neurological deficit was observed – quantitative disturbances of consciousness, absence of gag and palatal reflexes and bilaterally positive Babinski sign. Head MRI did not confirm the presence of recent ischemic changes in the brain. From the fourth day, the patient's general and neurological condition was very severe. She was unconscious with ophthalmoplegia and narrow, non-reactive pupils. Multimodal therapy was administered during hospitalization, observing a gradual improvement in the patient's condition from the thirteenth day of hospitalization. Due to the ambiguous clinical picture, the following diseases were considered in the differential diagnosis: ischemic stroke of the brainstem region, venous sinus thrombosis, posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, paraneoplastic brainstem encephalitis and Bickerstaff’s brainstem encephalitis.
    [Show full text]