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Cureus Mar 2024The deep tendon reflex (DTR) is a more objective indicator than sensory and muscle assessments for lumbar spine disorders. Further, unlike sensory and muscle assessments... (Review)
Review
The deep tendon reflex (DTR) is a more objective indicator than sensory and muscle assessments for lumbar spine disorders. Further, unlike sensory and muscle assessments that require patient cooperation, the DTR can be assessed even in patients with impaired consciousness or cognition. Therefore, DTR assessment with a hammer is an essential neurological test for lumbar spinal diseases. However, despite the usefulness of DTR assessment, few reports have described the significance of increased, diminished, or absent deep lower extremity reflexes in lumbar spine diseases. This review outlines the history of DTR of the lower limbs and describes the techniques, evaluation, and interpretation of DTR for the diagnosis of lumbar spine diseases. The patellar tendon reflex (PTR) was the first parameter of lower extremity DTR identified to have clinical usefulness, followed by the Achilles tendon reflex (ATR), pathological reflexes (Babinski reflex), and reflex enhancement (Jendrassik maneuver). They have now become an integral part of clinical examination. To determine whether an increase or decrease in DTR is pathological, it is necessary to determine left-right differences, differences between the upper and lower extremities, and the overall balance of the limb. There are several critical limitations and pitfalls in interpreting DTRs for lumbar spine diseases. Attention should be paid to examiner and patient factors that make the DTR assessment less objective. When there is a discrepancy between clinical and imaging findings and the level of the lumbosacral nerve root disorder is difficult to diagnose, the presence of a lumbosacral transitional vertebra, nerve root malformation, or furcal nerve should be considered. In addition, assessing the DTR after the gait loading test and standing extension loading test, which induce lumbosacral neuropathy, will help provide a rationale for the diagnosis.
PubMed: 38586775
DOI: 10.7759/cureus.55772 -
Annals of Medicine and Surgery (2012) Feb 2024Acute disseminated encephalomyelitis (ADEM) is a rare neurological disorder characterized by inflammation in the brain and spinal cord. This systematic review aims to... (Review)
Review
INTRODUCTION
Acute disseminated encephalomyelitis (ADEM) is a rare neurological disorder characterized by inflammation in the brain and spinal cord. This systematic review aims to investigate the potential association between ADEM and influenza vaccination by analyzing relevant case reports. ADEM is traditionally thought to be a monophasic condition, predominantly affecting children, often following viral illnesses or immunizations. Recent attention has focused on a possible link between ADEM and influenza vaccination, prompting the need for a thorough investigation.
METHODS
The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the AMSTAR2 (A MeaSurement Tool to Assess systematic Reviews 2) guidelines. Electronic searches were conducted on PubMed, Cochrane Library, and clinicaltrials.gov databases, spanning up to August 2023. Inclusion criteria encompassed full-text articles in English, observational studies, case reports, and case series providing comprehensive details for confirming clinical diagnoses of ADEM following influenza vaccination. Data were extracted, including demographic information, vaccination details, clinical symptoms, diagnostic evaluations, treatment modalities, and outcomes. Quality assessment was performed using the Joanna Briggs Institute (JBI) Critical Appraisal tool.
RESULTS
A total of 23 cases of ADEM following influenza vaccination were identified from 19 included articles. The mean age of affected individuals was 40.2 years (±25.7) with 60.8% being male. Common presenting symptoms included muscle weakness (52.1%), urinary abnormalities (30.4%), altered consciousness (26%), and sensory disturbances (26%). Neurological examination revealed findings such as extensor plantar reflex (positive Babinski sign) in 26%, hyperreflexia in 30.4%, and generalized hyporeflexia in 13% of the cases. Diagnostic evaluations involved MRI, showing multiple hyperintense lesions in cerebral hemispheres (43.4%), subcortex (60.8%), and spinal cord (39.1%). Cerebrospinal fluid analysis indicated elevated white blood cell count in 69.5% of cases, with lymphocytic pleocytosis in 52.1%. Oligoclonal bands were reported positively in 8.6% of cases. Treatment approaches varied, with intravenous methylprednisolone being the most common (39.1%). Out of the 23 cases, two (8.6%) patients had a fatal outcome, while the rest showed clinical improvement with complete or partial resolution of symptoms. Persisting symptoms included numbness in the lower extremities (8.6%) and impaired ability to walk after 10 months (4.3%).
CONCLUSION
While the association between ADEM and influenza vaccination is rare, healthcare professionals should remain vigilant and consider patients' vaccination history, particularly following an influenza immunization. This systematic review highlights the clinical manifestations, diagnostic tools, treatment approaches, and outcomes of ADEM cases post-influenza vaccination. Further research is essential to understand this association and improve clinical decision-making, ensuring the safety and efficacy of immunization programs.
PubMed: 38333316
DOI: 10.1097/MS9.0000000000001656 -
Open Forum Infectious Diseases Nov 2023Neurological opportunistic infections cause significant morbidity and mortality in people with human immunodeficiency virus (HIV) but are difficult to diagnose.
BACKGROUND
Neurological opportunistic infections cause significant morbidity and mortality in people with human immunodeficiency virus (HIV) but are difficult to diagnose.
METHODS
One hundred forty people with HIV with acute neurological symptoms from Iquitos, Peru, were evaluated for cerebral toxoplasmosis with quantitative polymerase chain reaction (qPCR) of cerebrospinal fluid (CSF) and for cryptococcal meningitis with cryptococcal antigen test (CrAg) in serum or CSF. Differences between groups were assessed with standard statistical methods. A subset of samples was evaluated by metagenomic next-generation sequencing (mNGS) of CSF to compare standard diagnostics and identify additional diagnoses.
RESULTS
Twenty-seven participants were diagnosed with cerebral toxoplasmosis by qPCR and 13 with cryptococcal meningitis by CrAg. Compared to participants without cerebral toxoplasmosis, abnormal Glasgow Coma Scale score ( = .05), unilateral focal motor signs ( = .01), positive Babinski reflex ( = .01), and multiple lesions on head computed tomography (CT) ( = .002) were associated with cerebral toxoplasmosis. Photophobia ( = .03) and absence of lesions on head CT ( = .02) were associated with cryptococcal meningitis. mNGS of 42 samples identified 8 cases of cerebral toxoplasmosis, 7 cases of cryptococcal meningitis, 5 possible cases of tuberculous meningitis, and incidental detections of hepatitis B virus (n = 1) and pegivirus (n = 1). mNGS had a positive percentage agreement of 71% and a negative percentage agreement of 91% with qPCR for . mNGS had a sensitivity of 78% and specificity of 100% for diagnosis.
CONCLUSIONS
An infection was diagnosed by any method in only 34% of participants, demonstrating the challenges of diagnosing neurological opportunistic infections in this population and highlighting the need for broader, more sensitive diagnostic tests for central nervous system infections.
PubMed: 37965640
DOI: 10.1093/ofid/ofad515 -
Journal of Orthopaedic Case Reports Mar 2024Numerous reflexive responses have been documented as alterations to the Babinski sign within upper motor neuron lesions. However, scant attention has been given to...
INTRODUCTION
Numerous reflexive responses have been documented as alterations to the Babinski sign within upper motor neuron lesions. However, scant attention has been given to reflexes beyond these, which exhibit independence from the extensor plantar response. These reflexes predominantly form polysynaptic arcs, with nociceptive stimuli acting as afferents.
CASE REPORT
The reflex was serendipitously discovered in an 18-year-old female patient who presented with spastic paraplegia with bowel and bladder involvement, as a consequence of an aneurysmal bone cyst of the D3 (dorsal) vertebrae, and the same was named after the authors as "Yadav-Kunal reflex" which can be defined as: "In individuals with spastic paraparesis, forcibly plantarflexing the toes will result in sudden jerky flexion of the knee and hip on the same side." This novel reflex was further investigated and validated in two additional patients with spastic paraplegia: one, a 45-year-old female with D9-D10 Pott's spine and bowel and bladder involvement, and the other, a 65-year-old male with D10-D11 compressive myelopathy and bowel and bladder involvement. This reflex was meticulously tracked until the abatement of spasticity following surgical intervention. Notably, its manifestation was evident in individuals experiencing spastic paraparesis, dissipating concomitantly with the resolution of spasticity - a direct clinical correlation. Conversely, the reflex was conspicuously absent in cases of flaccid paraplegia.
CONCLUSION
Spasticity, characterized by an increase in muscle tone on swift stretching movements, is a manifestation of a stretch reflex disorder. This condition is primarily induced by lesions affecting upper motor neurons. The activation of muscle spindles in toe dorsiflexors (primarily governed by the L5 nerve) occurs during forceful elongation caused by plantarflexion.
PubMed: 38560301
DOI: 10.13107/jocr.2024.v14.i03.4326 -
Oxford Medical Case Reports May 2023Amyotrophic lateral sclerosis (ALS) is a progressive, degenerative neuromuscular condition. The procedure and difficulties involved in the clinical diagnosis of ALS have...
Amyotrophic lateral sclerosis (ALS) is a progressive, degenerative neuromuscular condition. The procedure and difficulties involved in the clinical diagnosis of ALS have been the subject of numerous investigations. The understanding of the genetics and the epigenetics of the disease is still at infancy with several missing links. We present a case report of a 73-year-old woman suffering from bulbar onset ALS with a 4-month history of progressive dysphagia and dyspnea. She displayed tongue fasciculations and muscle atrophy. The bilateral palmomental reflexes, snout reflex, Hoffman, Babinski, diminished gag reflex, bilateral clonus and wild mood swings confirmed the neurodegenerative condition of the patient. The diagnosis of ALS can be challenging; therefore, the data presented may be useful to investigate its characteristics of the onset and to improve the understanding of the aspects of differentiation from other neurodegenerative disorders.
PubMed: 37260726
DOI: 10.1093/omcr/omad045