[Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
2. 3. 4. 5.
and long-term surgical results in 30 patients. Neurosurgery 2002;50:276-85. Liu YG. Epidermoid cysts. In: Liu YG, editor. Congenital Cranial – Cerebral Diseases. 1st ed. Jinan: Jinan Press; 1993. p. 92-6. Giannotta SL, Pauli F, Farhat SM. Epidermoid cyst of the third ventricle. Surg Neurol 1976;5:164-6. Iaconetta G, Samii M. Third ventricle epidermoid cyst. Br J Neurosurg 2001;15:529-30. Tancredi A, Fiume D, Gazzeri G. Epidermoid cysts of the fourth ventricle: Very long follow up in 9 cases and review of the literature. Acta Neurochir (Wien) 2003;145:905-10. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128345
Received: 25-12-2013 Review completed: 11-01-2014 Accepted: 26-01-2014
Acute transverse myelitis: A rare neurological complication following wasp sting Sir, Neurological complications following wasp stings are rare. Here, we report a rare case of long segment acute transverse myelitis following a single wasp sting. A 15-year-old boy was admitted for weakness of all four limbs, diminished sensations below the mid-thoracic level, difficulty in passing urine and constipation of 2 days duration. Seven days prior to onset of weakness, he had been stung by a single wasp over the abdomen, when he had tried to disturb a wasp nest. He had pain, local swelling and redness at the sting site, lasting several hours. On examination, he was conscious, had flaccid quadriparesis (power in upper limbs grade 2-3/5 and lower limbs 2/5) with truncal weakness, diminished deep tendon reflexes in upper limbs and preserved reflexes in the lower limbs, extensor plantar responses and normal optic fundi. Sensations were reduced below T-4 dermatomal level. Magnetic resonance imaging of the spine revealed hyperintensity within the spinal cord adjoining C-5 to D-4 vertebrae in T2-weighted images [Figure 1], confirming long segment acute transverse myelitis. Cerebrospinal fluid showed 0.02 × 109 cells/l (all lymphocytes), protein: 0.60 g/l, glucose: 0.78 g/l and no oligoclonal band. MRI of brain, nerve conduction studies, visually evoked 88
a
b
Figure 1: Magnetic resonance imaging of spinal cord (sagittal view) showing normal spinal cord in T1-weighted image (a) and hyperintensity within the cord adjoining C-5 to D-4 vertebrae in T2-weighted image (b), suggesting long segment acute transverse myelitis
potentials, neuromyelitis optica-IgG antibodies, workup for other autoimmune disorders and viral infections associated with myelitis were unremarkable. He received intravenous methylprednisolone 750 mg/day for 3 days, followed by oral prednisolone 45 mg/day (1 mg/kg) for 1 month. He showed complete neurological recovery at 1 month and prednisolone was tapered over next 6 weeks. He is doing well at 12 months follow-up. Wasp stings have been rarely reported to cause neurological complications such as acute encephalitis, acute myelitis, encephalomyelitis, cerebral infarction, exacerbation of multiple sclerosis, seizures, acute inflammatory polyradiculoneuropathy (Guillain-Barre syndrome [GBS]), myeloradiculopathy, optic neuritis, myasthenia gravis, autoimmune neuromyotonia, cavernous sinus thrombosis and parkinsonism. [1-6] Quadriparesis following wasp sting can result from acute myelitis, GBS, brainstem encephalitis/infarction and hypokalemia. Hypokalemia resulting from renal tubular acidosis has been reported to cause quadriparesis, following wasp sting.[5] Although acute myelitis has been reported in association with polyradiculoneuropathy and encephalitis,[2] isolated myelitis following hymenoptera sting is very rare and to the best of our knowledge has been reported in only one earlier report.[6] Pathogenesis of neurological complications is unclear but may involve direct neurotoxic effect of venom, IgE mediated immediate hypersensitivity, delayed immunological responses to wasp venom antigens leading to autoimmune reaction by antigenic cross reactivity to human myelin basic protein.[1,2,4] Latency period of hours to weeks has been reported between the wasp sting and onset of neurological event.[1] In the present patient, delayed hypersensitivity to venom antigens[4] might have contributed to acute demyelinating myelitis. Systemic steroids are useful for treating complications such as optic neuritis, acute myelitis and encephalitis, where demyelination plays a vital role in the Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
[Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
pathogenesis.[1-3] Plasma exchange may be useful when there is incomplete response to steroids.[2]
Kolar Vishwanath Vinod, Madasamy Ponraj, Khened Swetharani, Tarun Kumar Dutta Department of General Medicine, JIPMER, Dhanvantari Nagar, Puducherry, India E-mail: [email protected]
References 1. 2. 3. 4.
5. 6.
Bánovcin P, Havlíceková Z, Jesenák M, Nosál S, Durdík P, Ciljaková M, et al. Severe quadriparesis caused by wasp sting. Turk J Pediatr 2009;51:485-8. L i k i t t a n a s o m b u t P, Wi t o o n p a n i c h R , Vi r a n u v a t t i K . Encephalomyeloradiculopathy associated with wasp sting. J Neurol Neurosurg Psychiatry 2003;74:134-5. Maltzman JS, Lee AG, Miller NR. Optic neuropathy occurring after bee and wasp sting. Ophthalmology 2000;107:193-5. Ridolo E, Albertini R, Borghi L, Meschi T, Montanari E, Dall’Aglio PP. Acute polyradiculoneuropathy occurring after hymenoptera stings: A clinical case study. Int J Immunopathol Pharmacol 2005;18:385-90. D’Cruz S, Chauhan S, Singh R, Sachdev A, Lehl S. Wasp sting associated with type 1 renal tubular acidosis. Nephrol Dial Transplant 2008;23:1754-5. Defer G, Cesaro P, Roualdes B, Degos JD. Acute myelitis following Hymenoptera sting. Presse Med 1984;13:227. Access this article online Quick Response Code:
limb hyporeflexia. Cerebrospinal fluid (CSF) examination revealed 303 × 106 cells/L (84% were lymphocytes), 917 mg/L protein, normal glucose and chloride and positive rapid plasma regain test (RPR). The Treponema pallidum hemagglutination test was positive and the serum RPR was positive with 1:16. Serological test for other viral infections including HIV were negative. Spinal magnetic resonance imaging (MRI) revealed swelling and high signal intensity of the spinal cord parenchyma at level of T6 through to T11 on T2-weighted images and focal gadolinium enhancement [Figure 1]. Brain MRI was normal. Treatment with ceftriaxone (2 g twice a day for 30 days) and methylprednisolone (100 mg/day, 50 mg/day and 12.5 mg/day for 3 days each) was initiated. He had symptomatic improvement by day-5. CSF examination at 1 month showed 34 × 106 cells/L, 454 mg/L protein, negative RPR. Serum RPR was positive with 1:4. Spinal MRI showed decreased abnormal signal [Figure 2]. After 3 months, neurologic examination, CSF findings and spinal MRI were normal [Figure 3]. Serum RPR titer was 1:2, indicating cure. Syphilis is a sexually transmitted infectious disease caused by spirochete T. pallidum. The incidence of neurosyphilis is estimated to be 4-10% in untreated cases and 1.5% of neurosyphilis will progress to syphilitic myelitis.[4,5]
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128346
Received: 04-01-2014 Review completed: 29-01-2014 Accepted: 29-01-2014 a
Syphilitic myelitis: Magnetic resonance imaging features
b
c
d
Figure 1: (a) Sagittal T2-weighted image of the thoracic spinal cord shows long-segment diffuse high signal intensity from T6 to T11 with cord swelling. (b) Coronal T1-weighted image with contrast shows focal enhancement at T8/T9 level. (c) Sagittal T1-weighted image with contrast. (d) Axial T1-weighted image with contrast at T8/T9 level
Sir, The incidence of syphilis has markedly declined in the post-penicillin era. However, cases of syphilis have been increasing with the emergence of human immunodeficiency virus (HIV) infection since mid-1980s world-wide.[1,2] Although approximately one-third of patients with early syphilis have central nervous system involvement, symptomatic neurosyphilis, especially syphilitic myelitis is rare,[3] hence this report. A 63-year-old male patient presented with a 12-day history of progressive lumbago and weakness of both lower extremities. Examination documented bilateral lower-limb weakness with motor power of 4-5, lower Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
a
b
Figure 2: Follow-up magnetic resonance imaging performed 1 month after onset of treatment. (a) Sagittal and (b) axial gadolinium-enhanced T1-weighted images show residual focal enhancement in the thoracic cord at T8/T9 level
89
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
2. 3. 4. 5.
and long-term surgical results in 30 patients. Neurosurgery 2002;50:276-85. Liu YG. Epidermoid cysts. In: Liu YG, editor. Congenital Cranial – Cerebral Diseases. 1st ed. Jinan: Jinan Press; 1993. p. 92-6. Giannotta SL, Pauli F, Farhat SM. Epidermoid cyst of the third ventricle. Surg Neurol 1976;5:164-6. Iaconetta G, Samii M. Third ventricle epidermoid cyst. Br J Neurosurg 2001;15:529-30. Tancredi A, Fiume D, Gazzeri G. Epidermoid cysts of the fourth ventricle: Very long follow up in 9 cases and review of the literature. Acta Neurochir (Wien) 2003;145:905-10. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128345
Received: 25-12-2013 Review completed: 11-01-2014 Accepted: 26-01-2014
Acute transverse myelitis: A rare neurological complication following wasp sting Sir, Neurological complications following wasp stings are rare. Here, we report a rare case of long segment acute transverse myelitis following a single wasp sting. A 15-year-old boy was admitted for weakness of all four limbs, diminished sensations below the mid-thoracic level, difficulty in passing urine and constipation of 2 days duration. Seven days prior to onset of weakness, he had been stung by a single wasp over the abdomen, when he had tried to disturb a wasp nest. He had pain, local swelling and redness at the sting site, lasting several hours. On examination, he was conscious, had flaccid quadriparesis (power in upper limbs grade 2-3/5 and lower limbs 2/5) with truncal weakness, diminished deep tendon reflexes in upper limbs and preserved reflexes in the lower limbs, extensor plantar responses and normal optic fundi. Sensations were reduced below T-4 dermatomal level. Magnetic resonance imaging of the spine revealed hyperintensity within the spinal cord adjoining C-5 to D-4 vertebrae in T2-weighted images [Figure 1], confirming long segment acute transverse myelitis. Cerebrospinal fluid showed 0.02 × 109 cells/l (all lymphocytes), protein: 0.60 g/l, glucose: 0.78 g/l and no oligoclonal band. MRI of brain, nerve conduction studies, visually evoked 88
a
b
Figure 1: Magnetic resonance imaging of spinal cord (sagittal view) showing normal spinal cord in T1-weighted image (a) and hyperintensity within the cord adjoining C-5 to D-4 vertebrae in T2-weighted image (b), suggesting long segment acute transverse myelitis
potentials, neuromyelitis optica-IgG antibodies, workup for other autoimmune disorders and viral infections associated with myelitis were unremarkable. He received intravenous methylprednisolone 750 mg/day for 3 days, followed by oral prednisolone 45 mg/day (1 mg/kg) for 1 month. He showed complete neurological recovery at 1 month and prednisolone was tapered over next 6 weeks. He is doing well at 12 months follow-up. Wasp stings have been rarely reported to cause neurological complications such as acute encephalitis, acute myelitis, encephalomyelitis, cerebral infarction, exacerbation of multiple sclerosis, seizures, acute inflammatory polyradiculoneuropathy (Guillain-Barre syndrome [GBS]), myeloradiculopathy, optic neuritis, myasthenia gravis, autoimmune neuromyotonia, cavernous sinus thrombosis and parkinsonism. [1-6] Quadriparesis following wasp sting can result from acute myelitis, GBS, brainstem encephalitis/infarction and hypokalemia. Hypokalemia resulting from renal tubular acidosis has been reported to cause quadriparesis, following wasp sting.[5] Although acute myelitis has been reported in association with polyradiculoneuropathy and encephalitis,[2] isolated myelitis following hymenoptera sting is very rare and to the best of our knowledge has been reported in only one earlier report.[6] Pathogenesis of neurological complications is unclear but may involve direct neurotoxic effect of venom, IgE mediated immediate hypersensitivity, delayed immunological responses to wasp venom antigens leading to autoimmune reaction by antigenic cross reactivity to human myelin basic protein.[1,2,4] Latency period of hours to weeks has been reported between the wasp sting and onset of neurological event.[1] In the present patient, delayed hypersensitivity to venom antigens[4] might have contributed to acute demyelinating myelitis. Systemic steroids are useful for treating complications such as optic neuritis, acute myelitis and encephalitis, where demyelination plays a vital role in the Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
[Downloaded free from http://www.neurologyindia.com on Thursday, March 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for this journal Letters to Editor
pathogenesis.[1-3] Plasma exchange may be useful when there is incomplete response to steroids.[2]
Kolar Vishwanath Vinod, Madasamy Ponraj, Khened Swetharani, Tarun Kumar Dutta Department of General Medicine, JIPMER, Dhanvantari Nagar, Puducherry, India E-mail: [email protected]
References 1. 2. 3. 4.
5. 6.
Bánovcin P, Havlíceková Z, Jesenák M, Nosál S, Durdík P, Ciljaková M, et al. Severe quadriparesis caused by wasp sting. Turk J Pediatr 2009;51:485-8. L i k i t t a n a s o m b u t P, Wi t o o n p a n i c h R , Vi r a n u v a t t i K . Encephalomyeloradiculopathy associated with wasp sting. J Neurol Neurosurg Psychiatry 2003;74:134-5. Maltzman JS, Lee AG, Miller NR. Optic neuropathy occurring after bee and wasp sting. Ophthalmology 2000;107:193-5. Ridolo E, Albertini R, Borghi L, Meschi T, Montanari E, Dall’Aglio PP. Acute polyradiculoneuropathy occurring after hymenoptera stings: A clinical case study. Int J Immunopathol Pharmacol 2005;18:385-90. D’Cruz S, Chauhan S, Singh R, Sachdev A, Lehl S. Wasp sting associated with type 1 renal tubular acidosis. Nephrol Dial Transplant 2008;23:1754-5. Defer G, Cesaro P, Roualdes B, Degos JD. Acute myelitis following Hymenoptera sting. Presse Med 1984;13:227. Access this article online Quick Response Code:
limb hyporeflexia. Cerebrospinal fluid (CSF) examination revealed 303 × 106 cells/L (84% were lymphocytes), 917 mg/L protein, normal glucose and chloride and positive rapid plasma regain test (RPR). The Treponema pallidum hemagglutination test was positive and the serum RPR was positive with 1:16. Serological test for other viral infections including HIV were negative. Spinal magnetic resonance imaging (MRI) revealed swelling and high signal intensity of the spinal cord parenchyma at level of T6 through to T11 on T2-weighted images and focal gadolinium enhancement [Figure 1]. Brain MRI was normal. Treatment with ceftriaxone (2 g twice a day for 30 days) and methylprednisolone (100 mg/day, 50 mg/day and 12.5 mg/day for 3 days each) was initiated. He had symptomatic improvement by day-5. CSF examination at 1 month showed 34 × 106 cells/L, 454 mg/L protein, negative RPR. Serum RPR was positive with 1:4. Spinal MRI showed decreased abnormal signal [Figure 2]. After 3 months, neurologic examination, CSF findings and spinal MRI were normal [Figure 3]. Serum RPR titer was 1:2, indicating cure. Syphilis is a sexually transmitted infectious disease caused by spirochete T. pallidum. The incidence of neurosyphilis is estimated to be 4-10% in untreated cases and 1.5% of neurosyphilis will progress to syphilitic myelitis.[4,5]
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128346
Received: 04-01-2014 Review completed: 29-01-2014 Accepted: 29-01-2014 a
Syphilitic myelitis: Magnetic resonance imaging features
b
c
d
Figure 1: (a) Sagittal T2-weighted image of the thoracic spinal cord shows long-segment diffuse high signal intensity from T6 to T11 with cord swelling. (b) Coronal T1-weighted image with contrast shows focal enhancement at T8/T9 level. (c) Sagittal T1-weighted image with contrast. (d) Axial T1-weighted image with contrast at T8/T9 level
Sir, The incidence of syphilis has markedly declined in the post-penicillin era. However, cases of syphilis have been increasing with the emergence of human immunodeficiency virus (HIV) infection since mid-1980s world-wide.[1,2] Although approximately one-third of patients with early syphilis have central nervous system involvement, symptomatic neurosyphilis, especially syphilitic myelitis is rare,[3] hence this report. A 63-year-old male patient presented with a 12-day history of progressive lumbago and weakness of both lower extremities. Examination documented bilateral lower-limb weakness with motor power of 4-5, lower Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1
a
b
Figure 2: Follow-up magnetic resonance imaging performed 1 month after onset of treatment. (a) Sagittal and (b) axial gadolinium-enhanced T1-weighted images show residual focal enhancement in the thoracic cord at T8/T9 level
89
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
