Cases reported "Neuritis"

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1/16. Management of foot pain associated with accessory bones of the foot: two clinical case reports.

    STUDY DESIGN: Case study. OBJECTIVES: To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot. BACKGROUND: Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined. methods AND MEASURES: Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status. RESULTS: The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 100% return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 100% reduction of swelling with ankle girth to normal; 100% range of motion of ankle and subtalar joints. Strength in plantar flexion and eversion remained 20% impaired (80% return to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 100% of strength in hip and ankle, and 100% return of balance. She could squat and jump without pain and she returned to full premorbid activity level. CONCLUSIONS: Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain.
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2/16. Heterotopic ossification of peripheral nerve ("neuritis ossificans"): report of two cases.

    OBJECTIVE AND IMPORTANCE: Heterotopic ossification ("neuritis ossificans") is among the least frequently encountered reactive lesions in peripheral nerves. Only two cases have been described previously, one in the median nerve of a 34-year-old man, and the other in the ulnar nerve of an adult woman. The architecture of this lesion is distinctly zonal. Consisting of a central fibroblastic core, an intervening zone of osteoid production, and a peripheral layer of ossification, the pattern is remarkably similar to that of myositis ossificans. This similarity and the occurrence of the process in superficial nerves have led to speculation that trauma plays a role in its pathogenesis; this hypothesis remains unproved. We describe two additional cases of neuritis ossificans. CLINICAL PRESENTATION: One patient, a 41-year-old man, experienced pain and numbness in the left leg for several months but had no history of local trauma. A mass was detected in the saphenous nerve. The second patient, a 16-year-old boy, noted subacute onset of pain in the popliteal fossa and decreased sensation in the distribution of the lateral sural cutaneous nerve. A mass was found within the tibial nerve at the knee level. INTERVENTION: In each patient, resection of the mass required sacrifice of a segment of the nerve. CONCLUSION: In each patient, the mass was composed of fibrovascular tissue with osteoid and bone deposition arranged in a zonal pattern. The ossifying process was intraneural but encased rather than directly involving nerve fascicles. These exceptionally intact examples of neuritis ossificans underscore its resemblance to myositis ossificans. Nerve-sparing resection of such masses is not always possible.
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3/16. Early guillain-barre syndrome without inflammation.

    A patient with typical acute guillain-barre syndrome died 72 hours after his first symptoms occurred, and an autopsy was performed 8 hours after his death. Extensive sampling of cranial and peripheral nerves, sensory ganglia, and autonomic nerves showed only minimal inflammatory lymphocytic and macrophage infiltrates. This case, one of the earliest studied extensively, represents an extreme example of a noninflammatory mechanism that has been proposed in some cases of Gullain-Barre syndrome.
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4/16. Inflammatory peripheral neuropathy following high dose chemotherapy and autologous bone marrow transplantation.

    A 40-year-old man with non-Hodgkin's lymphoma developed severe ascending sensorimotor neuropathy 10 days after treatment with high dose chemotherapy and autologous bone marrow rescue. The neuropathy had axonal plus demyelinating features on electrophysiological studies. sural nerve biopsy showed heavy infiltration of the epineurium and endoneurium with mononuclear cells. The patient had no other evidence of graft-versus-host disease. He failed to respond to plasmapheresis but responded to high dose steroids.
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5/16. Inflammatory demyelinating lesions in two patients with IgM monoclonal gammopathy and polyneuropathy.

    We report two patients with polyneuropathy and IgM monoclonal gammopathy in whom peripheral nerve biopsy showed the widening of myelin lamellae which is characteristic of IgM paraproteinaemic neuropathy. Moreover, certain myelinated fibres were invaded by histiocytes overloaded with myelin debris, and in some instances elongated macrophage processes could be seen peeling away the myelin lamellae. The latter ultrastructural features are characteristic of inflammatory demyelinating polyneuropathies in both human and experimental pathology. Such an association has not been reported to date in human pathology, but could explain the prevalence of inflammatory demyelinating lesions in experimental models of IgM paraproteinaemic neuropathy. These two cases seem to bridge the gap between inflammatory demyelinating polyneuropathies and polyneuropathies associated with IgM monoclonal gammopathy.
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6/16. Polyarthritis, mononeuritis multiplex and eczematous ulcerative skin rash in a patient with myelodysplastic syndrome and peripheral large granular lymphocytosis.

    A patient with polyarthritis, peripheral mononeuritis multiplex with spatial and temporal fluctuation, and eczematous, ulcerative skin rash in the lower extremities was found to have myelodysplastic syndrome (MDS) in the bone marrow and concomitant large granular lymphocytosis in the peripheral blood. Histochemical study showed that cells with large granular lymphocyte markers (CD2 , 11b , 16 , 57 , HLA-DR ) had infiltrated into the skin and around the nerve fibers. Both the bone marrow dyscrasia and rheumatic manifestations of this patient improved significantly after prednisolone therapy. The unusual rheumatologic manifestations of this patient appear to derive from a delicate balance between MDS and large granular lymphocytosis.
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7/16. role of macrophages in onion-bulb formation in localized hypertrophic mononeuritis (LHM).

    A unique pathogenetic process for onion-bulb (Ob) formation is disclosed with disclosed with immunohistochemistry and electron microscopy. biopsy of a swollen segment of tibial nerve from a 42 year-old white female histologically demonstrated diffuse and angiocentric lymphocytic infiltrate in both endo- and perineurium with occasional lymphofollicular formation. Extensive Ob formation of nerve fibers was most striking with or without associated lymphocytes. axis-cylinders were intact in the majority of Ob. Immunocytochemically, Ob are composed of alternately laminated leaflets of schwann cells (S100 ) and mononuclear macrophage (HAM56 /LeuMl /muramidase ) processes but no perineurial (EMA ) cells. Immunohistochemical evidence of antigen presentation (HLA-DR/LN3 /Ia ) was confined to macrophages. Electron microscopy insinuates that intricate interactions between macrophages and schwann cells exists. Putative inhibition of remyelination along with proliferation of schwann cells most probably is secondary to the effects of macrophages secretory products. No direct participation of B or T lymphocytes was detected in Ob. Thus, modified macrophages may emit a factor for concomitantly promoting proliferation of schwann cells and an enzyme for myelin breakdown. In addition, only a few macrophages could be detected in some Ob and could be easily overlooked or misinterpreted as "vacuolated fibroblasts", if no immunohistochemical correlation is made, as modified macrophages making the external leaflets of Ob are more vacuolated.
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keywords = macrophage
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8/16. Os peroneum fracture with sural nerve entrapment neuritis.

    The os peroneum is a sesamoid bone contained in the peroneus longus tendon. When present, it usually is located at the plantar lateral aspect of the cuboid. The author presents a case of os peroneum fracture causing sural nerve entrapment. A review of literature is also presented.
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9/16. Peripheral nerve involvement in cutaneous leishmaniasis (Old World).

    A review of 288 skin biopsy specimens from cutaneous leishmaniasis lesions caused by leishmania major showed assorted nerve changes in 14 biopsy specimens (5%). Ten patients had perineural inflammatory cell infiltrate consisting of either lymphocytes or a mixture of lymphocytes, plasma cells, and macrophages. Four patients had inflammatory cell invasion of the nerves (neuritis), and in one of them the inflammation was granulomatous and associated with nerve destruction. Amastigotes were seen inside the nerves in two patients. Sensory testing of 50 consecutive patients with cutaneous leishmaniasis identified two patients with diminished sensations over the lesions.
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10/16. neuritis cordis due to the acute polyneuritis of the guillain-barre syndrome.

    Three patients with the guillain-barre syndrome which followed the course of Landry's acute ascending paralysis died a sudden cardiac death. Autonomic dysfunction had appeared clinically, consisting of sphincter disturbances in one patient and fluctuating blood pressure and bradycardia in the other. In a twenty-three year old female patient cardiac function had been inconspicuous, apart from tachycardia, but the ECG showed S-T segment depression and flat T waves. Postmortem examination revealed acute inflammatory demyelinating polyradiculoneuritis involving the peripheral autonomic nervous system and especially the nerves of the heart. Immunohistochemically, the inflammatory cell infiltrations of this neuritis cordis consisted of macrophages (MAC 387 positive) and T lymphocytes (UCHL1 positive). No indication of a direct viral infection of the inflamed cardiac nerves was detectable by immunohistochemistry (HSV, CMV, influenza virus) nor by electron microscopy. The neuritis cordis was classified as an inflammatory cardio-neuropathy secondary to a patchy acute polyneuritis of the guillain-barre syndrome, involving the autonomic nervous system. myocarditis could be discounted, and the neuritis cordis was thought to be responsible for the sudden cardiac death.
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