Lok-Ming Tang

Guillain-Barré syndrome in Taiwan: a clinical study of 167 patients

OBJECTIVE To identify clinical characteristics of various forms of Guillain-Barré syndrome in Taiwan. METHODS The clinical and electrophysiological data of 167 consecutive patients with Guillain-Barré syndrome admitted to Chang Gung Memorial Hospital, a general paediatric and adult hospital in Taiwan, were reviewed. RESULTS Analysis of age distribution disclosed a high incidence (21%) among patients under the age of 10 years. Seasonal preponderance in Spring (March to May) was found. Utilising clinical and electrophysiological data, these 167 patients with Guillain-Barré syndrome were subclassified; 82 (49%) had acute inflammatory demyelinating polyradiculoneuropathy (AIDP), 32 (19%) had Fisher syndrome (FS), and six (4%) had axonal forms of Guillain-Barré syndrome. The remaining 47 (28%) patients were unclassified. Patients with AIDP and FS had many common clinical features, including seasonal distribution, history of preceding illness, sensory abnormalities, cranial nerve involvement except for extraocular motor nerves, and albuminocytological dissociation on examination of CSF. Follow up study on 145 patients disclosed that 127 (87%) recovered satisfactorily, 14 (10%) were persistently disabled, and four (3%) died during admission to hospital. Clinical features associated with poor outcome (persistent disability or death) were requirement for mechanical ventilation, a low mean compound muscle action potential amplitude (⩽ 10% of the lower limit of normal), and age greater than 40 years. CONCLUSION Guillain-Barré syndrome in Taiwan showed a peculiar age and seasonal distribution and a high frequency of FS not seen in other series. Given that patients with AIDP and FS had many common clinical features, AIDP and FS may have similar underlying pathological mechanisms.

Spinal Epidural Abscess Successfully Treated with Percutaneous, Computed Tomography-guided, Needle Aspiration and Parenteral Antibiotic Therapy: Case Report and Review of the Literature

OBJECTIVE AND IMPORTANCE We describe a case of a posterior spinal epidural abscess that was successfully treated with percutaneous, computed tomography-guided, needle aspiration and parenteral antibiotic therapy. CLINICAL PRESENTATION A 48-year-old man experienced acute pain in the paralumbar region for 1 week, followed by gait disturbance and micturition difficulty. Laboratory studies demonstrated leukocytosis and hyperglycemia. Blood cultures yielded Staphylococcus aureus. Magnetic resonance imaging scans of the thoracolumbar spine revealed a posterior spinal epidural abscess located between L2 and the lower cervical spine. INTERVENTION The patient’s low back pain persisted despite 10 days of antibiotic therapy. Therefore, percutaneous, computed tomography-guided, needle aspiration was performed. The low back pain was relieved dramatically and immediately after the procedure. The spinal epidural abscess completely resolved after 6 weeks of antibiotic treatment. CONCLUSION Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscesses. Selected patients may be treated nonsurgically. Rarely, percutaneous drainage of the abscess has been reported to be helpful. Our case suggests that percutaneous, computed tomography-guided, needle aspiration might be a rational alternative to surgical decompression for treatment of spinal epidural abscesses.

Klebsiella meningitis in Taiwan: an overview

Klebsiella infection has been considered to be an uncommon cause of meningitis. To determine its incidence and clinical features, we reviewed the microbiologic records of cerebrospinal fluid (CSF) and blood cultures and the medical records of patients with bacterial meningitis admitted between 1981 and 1995. Klebsiella meningitis was diagnosed in 79 patients with 83 episodes. All patients had klebsiella isolated from CSF and/or blood and typical symptoms and signs of acute bacterial meningitis. Of these, 74 were over 16 years of age and 2 of the 5 children were infants. There was an increased prevalence rate of klebsiella meningitis after 1986. Of the 83 episodes, only 9 occurred between 1981 and 1986, accounting for 7.8% of 115 cases with CSF and/or blood culture-proven acute bacterial meningitis, whereas in 1987-95, there were 74 episodes accounting for 17.7% of 419 bacteriologically proven cases. K. pneumoniae accounted for 69 episodes, K. oxytoca, 11 episodes and K. ozaenae, 3 episodes. Male gender, diabetes mellitus and liver cirrhosis were commonly associated with K. pneumoniae meningitis. Neurosurgical procedures were frequently associated with K. oxytoca meningitis. All three patients with K. ozaenae meningitis had a primary disease of the nasopharyngeal pathway. The mortality rate due to K. pneumoniae was 48.5%, K. oxytoca, 10% and K. ozaenae, 0%. In patients with K. pneumoniae meningitis, poor prognostic factors included age over 60 years, diabetes mellitus, bacteremia and severe neurological deficits on the first day of treatment.

Brain Abscess as a Complication of Stroke

BACKGROUND Systemic infection is a common complication of stroke. However, brain abscess as a complication of stroke has never been reported. CASE DESCRIPTIONS We report two patients, one with a hypertensive intracerebral hemorrhage and the other with nonseptic cerebral infarction. In both patients, brain abscess developed at the stroke lesion site after an infectious complication. After surgical aspiration and antibiotic treatment, one patient recovered and the other died. CONCLUSIONS These two cases demonstrate that brain abscess may occur in a previous hemorrhage or infarction area as a complication of systemic infection. Recognition of the risk is important for early diagnosis and proper treatment of this potentially fatal complication of stroke.

Ventriculoperitoneal shunt in cryptococcal meningitis with hydrocephalus.

Fourteen patients with cryptococcal meningitis were reviewed. All patients had a ventriculoperitoneal shunt for hydrocephalus. Early recognitions and prompt relief of hydrocephalus were useful for eight patients who showed rapid deterioration of consciousness or signs of cerebral herniation. There was no surgical response in four patients who had had weeks of confusion or mental change. It seems, therefore, that the duration of disturbance of consciousness or change of mentality before shunting is critical in determination of the outcome of the treatment. Ventricular shunting was effective in relieving papilledema in five patients. However, the surgery did not prevent the development of papilledema to optic atrophy and subsequent blindness in two patients. Hence, in addition to hydrocephalus with increased intracranial pressure, conditions such as direct invasion of the optic pathways by Cryptococcus neoformans or optochiasmatic arachnoiditis may be responsible for the visual failure. Ventricular shunting was also helpful in restoring paraparesis in one patient. Of the cerebrospinal fluid determinations, low protein concentration was a favorable indicator for surgery. Of the seven patients who received the surgical procedure before the start of antifungal therapy, four showed a significant improvement despite active infection of the central nervous system. None of the seven patients deteriorated because of the surgical operation. Thus, active stage of cryptococcal meningitis does not contraindicate the necessity of shunting, and premedication with antifungal drugs is unnecessary. Also, no shunt-related morbidity and mortality was seen in this study.

Local application of anti-NGF blocks the collateral sprouting in rats following chronic constriction injury of the sciatic nerve.

Systemic administration of anti-nerve growth factor (NGF) antibodies can block nociceptive fiber sprouting into denervated adult rat skin. However, the effect of local application of anti-NGF on collateral sprouting in rats caused by chronic constriction injury (CCI) has not been well studied. We investigated the influence of local anti-NGF on collateral sprouting caused by CCI of the rats sciatic nerve. Using a dye-labeled plasma extravasation technique, we can easily evaluate the extent of collateral sprouting by the clearly defined blue coloration area. Our results showed that local application of anti-NGF either in a high or low dose significantly prevented the spread of collateral sprouting from the saphenous nerve into the sciatic innervation territory. In contrast, distilled water did not show a significant block of the saphenous nerve collateral sprouting. Our study suggests that collateral sprouting is dependent on the local availability of NGF by the nearby intact cutaneous nerve fibers.

Klebsiella pneumoniae meningitis: prognostic factors.

All 42 cases of Klebsiella pneumoniae meningitis diagnosed between 1981 and 1991 were evaluated. These accounted for 13% of patients with blood and/or cerebrospinal fluid culture-proven bacterial meningitis. There was an increased incidence of K. pneumoniae meningitis from the first 6 years of study (7%) to the last 5 years (16%). K. pneumoniae became increasingly important not only in community-acquired meningitis but also in nosocomial meningitis. 12/13 nosocomial cases were patients who had undergone neurosurgical procedures. The overall mortality rate was 43%. The mortality rate in patients with spontaneous meningitis was higher than that in patients with post-traumatic or postoperative meningitis. Factors that adversely affected mortality were age over 60, diabetes mellitus, and severe neurological deficits on admission. The use of third-generation cephalosporins did not reduce the mortality rate.

Acute transverse myelopathy and cutaneous vasculopathy in primary Sjögren's syndrome.

Neurologic complications of primary Sjögrens syndrome (SS) may be under-estimated. Here, we report a patient with primary SS, who developed acute transverse myelopathy (ATM) and skin purpuric lesions simultaneously. In the first episode of myelopathy, the patients neurologic deficits improved after steroid therapy. However, she died of recurrent myelopathy with systemic complications 4 months later. Review of the English-language literature revealed only 3 cases of primary SS associated with ATM, none of the 3 patients had skin lesions. Anti-Ro(SS-A) antibodies, and ATM in our patient suggests that immune-mediated vasculopathy may play a role in the pathogenesis of acute myelopathy in primary SS.

Cardiovascular autonomic function and sympathetic skin response in chronic inflammatory demyelinating polyradiculoneuropathy

Quantitative cardiovascular autonomic function tests (AFTs) and sympathetic skin response (SSR) were performed in 12 patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Parasympathetic autonomic function was examined by Valsalva ratio and R‐R interval variation during rest and deep breathing. Sympathetic autonomic function was evaluated by blood pressure responses to sustained handgrip and active standing. Using quantitative AFTs, subclinical autonomic dysfunction was demonstrated in three (25%) patients. Abnormal SSR was seen in six (50%) patients. Thus, mild autonomic dysfunction is present in many CIDP patients. The autonomic abnormalities involve parasympathetic or sympathetic components; in the sympathetic nervous system, both vasomotor and sudomotor fibers may be involved.

A Longitudinal Cardiovascular Autonomic Function Study in Mild Guillain-Barré Syndrome

To identify subclinical autonomic dysfunction in mild Guillain-Barré syndrome (GBS), a set of autonomic function tests was serially performed for up to 6 months in 5 GBS patients with mild disability at the nadir. Parasympathetic autonomic function tests consisted of Valsalva ratio and R-R interval variation during rest and deep breathing. Sympathetic autonomic function was evaluated by blood pressure responses to sustained handgrip, hand immersion in ice water, and active standing. The results showed that abnormal parasympathetic and sympathetic function was frequently encountered in all 5 patients during the acute stage of the illness. Autonomic dysfunction occurred both in axonal and demyelinating types of GBS. There was a trend of improvement in most autonomic function tests after 3 months, comparable to the recovery of motor function. In conclusion, subclinical autonomic dysfunction was present in mild GBS. It was temporary and would resolve spontaneously.