Cervical osteophytes causing vocal fold paralysis: case report and literature review

Objectives: To increase awareness of cervical osteophytes as an extremely rare cause of recurrent laryngeal nerve palsy; to outline the clinical approach to patients with unilateral vocal fold paralysis and to provide an update on the current management of osteoarthritis and osteophytes. Case report: An elderly man presented with right unilateral vocal fold immobility and a small phonatory gap. By a diagnosis of exclusion, a cervical osteophyte at the level of the sixth and seventh cervical vertebrae was shown to be the cause. The patient responded to speech therapy and no further intervention was required. Method: A literature review, using Medline, identified only one previously published case of vocal fold paralysis due to osteophytes secondary to osteoarthritis. Conclusion: The aetiology of unilateral paralysis of the hemilarynx must be fully investigated, as the innervating system has a protracted course, particularly on the left side. Degenerative cervical spine disease, although rare, should be considered as part of the differential diagnosis.     

Differences in characteristics and outcome of delirium as based on referral patterns

The authors studied factors associated with referral of delirium patients to psychiatry consultation and its outcome implications. Characteristics and treatment outcomes of delirium patients referred to psychiatry were compared with those not referred. Referred patients were younger, had a more hyperactive subtype, greater substance abuse, less comorbid dementia, were more likely to be recognized as having delirium, and be prescribed medications. Improvement in referred patients was indicated by lower readmission rate postdischarge. No differences were noted in length of stay, discharge status, or mortality within 1 year of the index episode. Psychiatric interventions were moderately helpful. Patients' characteristics and delirium subtypes may influence referral and should inform future liaison efforts.     

Neuromyelitis Optica (Devic’s Syndrome): an Appraisal

Neuromyelitis optica (NMO) and neuromyelitis optica spectrum disorders (NMOSD), previously known as Devic’s syndrome, are a group of inflammatory disorders of the central nervous system (CNS) characterized by severe, immune-mediated demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord typically associated with a disease-specific serum NMO-IgG antibody that selectively binds aquaporin-4 (AQP4). The classic and best-defined features of NMOSD include acute attacks of bilateral or rapidly sequential optic neuritis (leading to visual loss) or transverse myelitis (often causing limb weakness and bladder dysfunction) or both with a typically relapsing course. The diagnosis of NMO/NMOSD requires a consistent history and examination with typical clinical presentations, findings on spinal cord neuroimaging with MRI, cerebrospinal fluid analysis along with determination of AQP4-IgG serum autoantibody status, and exclusion of other disorders. Two major advances in this field has been the development of diagnostic criteria and treatment recommendations. Consensus diagnostic criteria have been established and were recently revised and published in 2015, enhancing the ability to make a diagnosis and appropriately evaluate these disorders. Expert recommendations and uncontrolled trials form the basis of treatment guidelines. All patients with suspected NMOSD should be treated for acute attacks as soon as possible with high-dose intravenous methylprednisolone ?1 gram daily for three to five consecutive days and in some cases, plasma exchange should be used. It is recommended that every patient with NMOSD be started on an immunosuppressive agent, such as, azathioprine, methotrexate, or mycophenolate and in some cases, rituximab, soon after the acute attack and usually be treated for about 5 years after the attack. These advances have helped improve the prognosis and outcome in these disorders.     

Membranous (Class V) Renal Disease in Systemic Lupus Erythematosus May Be More Common Than Previously Reported: Results of a 6-Year Retrospective Analysis

BackgroundThe actual incidence and prevalence of the various histological classes (based on World Health Organization classification) of lupus nephritis (LN) are not known but seem to vary with sex, age, and ethnicity. We have analyzed renal biopsies in patients with systemic lupus erythematosus (SLE) at our center, and hereby report our experience.MethodsAll renal biopsies performed at the University of Mississippi between January 1999 and December 2004 in patients with SLE were retrospectively analyzed. Results were validated by a detailed review of renal biopsy reports and additional records were reviewed for data specific to LN disease activity.ResultsThere were 92 renal biopsies performed in patients with SLE during a 6-year period. These included 84 African Americans (72 women and 12 men), 5 whites (4 women and 1 man), and 3 unknown race (1 F, 2 M) subjects. The prevalence of LN classes in our cohort was as follows: class I (0%), class II (9.8%), class III (8.7%), class IV (36.9%), class V (40.2%), and class VI (4.3%). Prevalence of class V LN among males was high at 40%.ConclusionsIn contrast to previous literature, isolated membranous lupus nephritis (MLN) was much more prevalent in this series—40% versus 14%. Also, no sex difference in the prevalence of MLN was seen. This biopsy cohort suggests that MLN/ class V disease may be more common than previously reported especially in African American population.     

Transverse myelitis,a rare neurological manifestation of mixed connective tissue disease—a case report and a review of literature

Although neurological involvement occurs in about 10% of patients with mixed connective tissue disease (MCTD), acute transverse myelitis (TM) has only been described in seven cases of MCTD. We hereby report a case of 70-year-old white female with transverse myelitis complicating her underlying MCTD. Our patient presented with lower extremity weakness, loss of sensation and incontinence one year after her diagnosis of MCTD. Her work-up revealed an abnormal MRI, with findings consistent with TM. She had an excellent response to initial therapy with six cycles of monthly intravenous immunoglobulins and steroids, with subsequent maintenance on azathioprine. She had a good neurological recovery with mild residual sequelae only. On basis of this case report and review of literature, we recommend ongoing surveillance and reporting of this rare neurological presentation in MCTD.