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PubMed1999

Tick paralysis: development of a vaccine.

The paralysis tick of Australia, Ixodes holocyclus, causes a severe toxicosis in domestic animals such as dogs and cats, livestock, and in some cases, humans. It is characterised by a rapidly ascending flaccid paralysis. The causative agent of the toxicosis is a neurotoxin(s) produced in the tick salivary glands. The current treatment for tick paralysis is in the form of a polyclonal dog antiserum. This antiserum treatment is expensive and effective only in the early stages of paralysis. The aim of current research is to develop a recombinant veterinary vaccine based on the tick neurotoxin peptide sequence. A successful vaccine would provide cost-effective, long-term protective immunity against tick-induced paralysis.

Adolescent↗
PubMed2004

Recurrent laryngeal nerve paralysis: anatomy and etiology.

Etiologies of adult vocal paralysis are varied by the site of the lesion as well as the extent and cause of the damage. Most large series point to surgery and neoplastic causes for recurrent nerve paralysis. A detailed history is important when working up a patient with this voice disorder. Knowledge of the anatomy of the head, neck, and chest as well as the mechanisms behind vocal fold paralysis is essential in the evaluation and treatment of recurrent nerve paralysis. Many of the surgical and traumatic causes of hoarseness are from compression type injuries. Recovery is dependent on the type, extent, and site of nerve lesion. Familiarity with this data allows the otolaryngologist to tailor management to suit each patient with vocal fold paralysis.

Cervical Vertebrae↗
PubMed2000

Bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion in a case of whiplash cervical spine injury: a case report.

BACKGROUND: Bilateral vocal cord paralysis is a risk of anterior cervical discoidectomy and fusion. We discuss the mechanism of vocal cord paralysis and the precautions necessary to avoid this catastrophic complication. A rare case of bilateral vocal cord paralysis after anterior cervical discoidectomy and fusion (ACD/F) is reported. CASE DESCRIPTION: The patient, a 37-year-old male, was paraplegic, had bilateral intrinsic hand muscle weakness and sphincter involvement following a whiplash cervical spinal injury. A C5-C6 ACD/F for traumatic C5-C6 disc prolapse was performed. On the third postoperative day, he developed difficulty in coughing and a husky voice. Otolaryngological evaluation revealed bilateral vocal cord paralysis. He later required a tracheostomy that partially alleviated his major symptoms. CONCLUSION: In patients undergoing ACD/F, a mandatory preoperative evaluation of the vocal cords should be performed. An appropriate modification in surgical planning should be made if vocal cord palsy is diagnosed preoperatively to prevent bilateral vocal cord paralysis. Proper and judicious use of Cloward retractors is advocated.

Adult↗
PubMed1999

Impact of laryngeal paralysis and its treatment on the glottic aperture and upper airway flow characteristics during exercise.

Patients with unilateral vocal fold paralysis occasionally report shortness of breath during exercise. This symptom may persist in some patients after medialization thyroplasty. A review of the literature revealed no study that objectively evaluated laryngeal dynamics or airway flow characteristics during exercise after medialization thyroplasty for unilateral laryngeal paralysis. This study evaluates glottic aperture size and configuration as well as upper airway flow characteristics during exercise in 16 subjects. Six patients who underwent medialization thyroplasty for unilateral vocal fold paralysis were compared with 10 healthy control subjects. During a standardized exercise protocol on an incremental ergometer (bicycle type), real-time videolaryngoscopy was obtained and correlated in a synchronized fashion with maximum-effort respiratory efforts at the beginning, midpoint, and end of the exercise period. Direct calculations of glottic size during various phases of the exercise period were performed from digitized images. These data were correlated with inspiratory flow data for each patient. Patients with laryngeal paralysis demonstrated smaller mean glottic areas and lower peak inspiratory flow rates than controls both at rest and during all phases of the exercise period. This study suggests that after treatment of unilateral laryngeal paralysis with medialization thyroplasty, inspiratory flow rate and glottic area are significantly less than in normal controls.

Adolescent↗
PubMed2006

Paralysis periodica paramyotonica caused by SCN4A Arg1448Cys mutation.

Paralysis periodica paramyotonica is an overlapping disease that shares the features of paramyotonia characteristic of paramyotonia congenita (PC) and periodic paralysis characteristic of hyperkalemic periodic paralysis. We report the case of a 23-year-old man with paralysis periodica paramyotonica. His father and a younger brother also exhibited a similar phenotype. A SCN4A Arg1448Cys mutation was detected in this family. The affected family members exhibited marked shifts in compound muscle action potential amplitudes on exercise test, and muscle weakness could be induced by potassium loading and cold exposure. This case demonstrates that SCN4A Arg1448Cys can produce paralysis periodica paramyotonica. Other genetic or environmental factors may modulate the manifestation of SCN4A Arg1448Cys mutation.

Adult↗
PubMed1994

Recurrent lower motor neurone facial paralysis in four successive pregnancies.

Recurrent lower motor neurone facial paralysis in successive pregnancies is a rare phenomenon of which there are few case reports in the literature. There have been two previous reports of recurrent Bell's palsy in two and three successive pregnancies respectively, but it is felt that these should have more appropriately been reported as recurrent lower motor neurone facial paralysis in pregnancy as, by definition, any facial paralysis that recurs should not be classified as Bell's palsy even though Bell himself commented on the association between facial paralysis and pregnancy. We report the first case of recurrent lower motor neurone facial paralysis in four successive pregnancies and review the literature.

Adult↗
PubMedDate not supplied

T-cell clones specific for myelin basic protein induce chronic relapsing paralysis and demyelination.

Experimental allergic encephalomyelitis (EAE) serves as a model for autoimmune diseases mediated by T lymphocytes. Following sensitization to rat, mouse or guinea pig myelin basic protein (MBP) in complete Freund's adjuvant, inbred mouse strains PL/J (H-2u), SJL/J (H-2s) and (PL/J X SJL/J)F1((PLSJ)F1) develop EAE. Whereas sensitization to the N-terminal 37 amino-acid peptide of rat or guinea pig MBP [MBP(1-37)] induces EAE in PL/J mice, immunization to the C-terminal peptide (89-169) leads to EAE in SJL/J mice. The immune response to MBP in (PLSJ)F1 mice is not co-dominant; sensitization to the N-terminal peptide induces EAE, while sensitization to the C-terminal peptide does not. We have generated MBP-specific T-cell clones restricted to class II (Ia) antigens of the major histocompatibility complex (MHC) from PL/J and (PLSJ)F1 mice following sensitization to rat MBP. Two such I-Au-restricted T-cell clones that proliferate in response to the encephalitogenic N-terminal MBP peptide and recognize a shared determinant with mouse (self) MBP cause paralysis in 100% of (PLSJ)F1 mice tested. Paralysis is induced even when recipients are injected with as few as 1 X 10(5) cloned T cells. Relapsing paralysis followed in two-thirds of the recipients after recovery from acute paralysis, whereas one-third developed chronic persistent paralysis, a form of EAE not usually seen. Histopathology revealed intense perivascular inflammation, demyelination and remyelination within the central nervous system of paralysed mice. The experimental disease induced with these clones shares important features with human demyelinating diseases such as multiple sclerosis. This is the first demonstration that T-cell clones that respond to a defined self-antigen can induce clinical and histological autoimmune disease.

Animals↗
PubMed1982

Improved toxin/antitoxin assays for studies on the Australian paralysis tick Ixodes holocyclus.

Sensitive biological assays of toxin/antitoxin potency have been developed to assist in research on characterization of salivary toxins of the Australian paralysis tick Ixodes holocyclus and on immunity to tick paralysis. The toxin assay utilizes suckling mice (4-5 g); a quantitative paralysis index is applied over a range of doses. The antitoxin assay is based on an in vitro/in vivo neutralization test which required a sensitive toxin assay and methods of standardization of toxin preparations. This assay permits the monitoring of blood antibody levels in animals during the course of development and loss of immunity and is assisting a study into the feasibility of producing an anti-paralysis vaccine. The method also allows standardization of commercial tick paralysis antiserum. The methods and applications are described and comparisons made with previous assays. Sample data are examined statistically by regression and variance analyses; parallelism of dosage-response lines is tested and relative toxicities (toxin) or potencies (antiserum) calculated.

Analysis of Variance↗
PubMed2005

Diaphragmatic paralysis: the use of M mode ultrasound for diagnosis in adults.

STUDY DESIGN: Retrospective, case series. OBJECTIVES: To evaluate the use of M mode ultrasonography in the evaluation of diaphragmatic paralysis in adults. SETTING: Radiology department, Princess Alexandra Hospital, Brisbane, Australia. METHODS: Ten patients who were referred for evaluation of suspected diaphragmatic paralysis were evaluated using M mode ultrasound. RESULTS: Three of the patients who were scanned demonstrated normal diaphragmatic movement. The M mode trace demonstrated normal movement of the diaphragm bilaterally with quiet respiration and a sharp upstroke on the sniff test (indicating normal caudal movement of the diaphragm). Six patients were found to have a unilateral diaphragmatic paralysis. Four of these patients were noted to have a raised hemi-diaphragm on chest radiography. Of the two who did not have a raised hemi-diaphragm on chest radiography, one was permanently ventilated. The M mode trace of the paralyzed side showed no active caudal movement of the diaphragm with inspiration and abnormal paradoxical movement (ie cranial movement on inspiration) particularly with the sniff test. CONCLUSION: M mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphragm, in the adult population. It can be performed, if necessary, at the bedside and can be easily repeated if paralysis is not thought to be permanent. EQUIPMENT: Philips ATL Sono CT 5000 using a 2-5 MHz curved linear transducer.

Adolescent↗
PubMed2002

Effect of unilateral diaphragm paralysis on branch pulmonary artery flow.

BACKGROUND: Respiration is known to be a significant contributor to pulmonary flow in patients who have had Glenn or Fontan procedures. OBJECTIVE: The purpose of this study was to evaluate the effect of respiration on branch pulmonary artery flow in normal participants, in those with uncomplicated Glenn or Fontan procedures, and in those with uncomplicated biventricular (2V) repairs, and to compare them with similar groups of postoperative patients who had unilateral diaphragm paralysis. METHODS: Twenty-one normal infants and children were studied, along with 10 who had undergone uncomplicated bidirectional Glenn or Fontan palliation. Also studied were 10 patients with uncomplicated 2V repairs and 17 patients having ultrasound demonstration of diaphragm paralysis. Nine had undergone Glenn or Fontan procedures and 8 had undergone 2V repair. With the use of conventional pulsed Doppler, branch right and left pulmonary artery waveforms were recorded during spontaneous respiration. The velocity time integral (VTI); heart rate (HR); and systolic, diastolic, and mean velocities were measured at end-expiration and during inspiration. The pulsatility index (PI) (PI = systolic velocity - diastolic velocity/mean velocity) was calculated for each condition. RESULTS: In normal participants PI was 1.69 with a 4.7% increase with inspiration; VTI x HR was 1859. In patients who had undergone uncomplicated Glenn/Fontan procedures PI was 1.06 with a 27.5% increase with inspiration; VTI x HR was 1303, all P =.001 versus normal participants. In patients with 2V repairs PI was 1.7 with a 5.6% increase with inspiration; VTI x HR was 1850, all P = ns versus normal participants. Patients with Glenn/Fontan connections and diaphragm paralysis had lower PI (0.81), inspiratory increase (7.9%), and VTI x HR (610) on the affected side, all P =.001 versus the normal side, and versus patients who had undergone uncomplicated Glenn/Fontan procedures. Patients with 2V repair with a pulsatile source of pulmonary flow had a smaller significant difference in the measured indices. Three patients underwent diaphragm plication with improvement in PI, inspiratory increase in PI, and VTI x HR postplication. CONCLUSION: In normal participants and patients with uncomplicated 2V repair, inspiration has little effect on PI in branch pulmonary arteries. In patients who have undergone uncomplicated Glenn/Fontan procedures, PI is less than that of normal participants and the effect of inspiration is approximately 5-fold greater. This significant effect of inspiration on pulmonary flow is lost on the affected side in patients with Glenn/Fontan connections and diaphragm paralysis, and is blunted on the affected side in patients with 2V repair and diaphragm paralysis. Loss of diaphragm function is associated with redistribution of pulmonary flow away from the affected side.

Blood Flow Velocity↗
PubMed2002

Evaluation of greater petrosal nerve function in patients with acute peripheral facial paralysis: comparison of soft palate electrogustometry and Schirmer's tear test.

We tested sensory and secretomotor function of the greater petrosal nerve (GPN) by means of electrogustometry (EGM) of the soft palate and Schirmer's tear test in 115 patients (59 males, 56 females) with acute peripheral facial paralysis. Facial paralysis was caused by Bell's palsy in 78 cases, Ramsay Hunt syndrome in 27 cases and zoster sine herpetic lesions in 10. All patients had dysfunction of the stapedial nerve. An electrogustometer was used to test taste (GPN sensory function), and elevation of the threshold by > 6 dB on the affected side was considered abnormal. Schirmer's test was used to evaluate lacrimal (GPN secretomotor) function, which was considered abnormal when tear secretion on the affected side was < 50% of secretion on the non-affected side. Of the 78 patients with Bell's palsy, 28.2% had altered taste on the soft palate (sensory dysfunction) and 10.3% had lacrimal dysfunction, indicating that EGM of the soft palate is more sensitive than Schirmer's test for identifying dysfunction of the GPN in patients with facial paralysis due to Bell's palsy. Of the total of 115 patients, 32 (28%) had taste dysfunction and 9 (28.1%) of these 32 patients also had lacrimal dysfunction. This finding indicates that facial paralysis has different effects on the sensory and secretory nerve fibers of the GPN. The results of Schirmer's test were more closely related to the severity of, and prognosis for, facial paralysis than the results of EGM.

Acute Disease↗
PubMed1999

Tick paralysis: 33 human cases in Washington State, 1946-1996.

Tick paralysis is a preventable cause of illness and death that, when diagnosed promptly, requires simple, low-cost intervention (tick removal). We reviewed information on cases of tick paralysis that were reported to the Washington State Department of Health (Seattle) during 1946-1996. Thirty-three cases of tick paralysis were identified, including 2 in children who died. Most of the patients were female (76%), and most cases (82%) occurred in children aged <8 years. Nearly all cases with information on site of probable exposure indicated exposure east of the Cascade Mountains. Onset of illness occurred from March 14 to June 22. Of the 28 patients for whom information regarding hospitalization was available, 54% were hospitalized. Dermacentor andersoni was consistently identified when information on the tick species was reported. This large series of cases of tick paralysis demonstrates the predictable epidemiology of this disease. Improving health care provider awareness of tick paralysis could help limit morbidity and mortality due to this disease.

Aged↗
PubMed1997

Clinical and neurophysiological features of tick paralysis.

The clinical and neurophysiological findings in six Australian children with generalized tick paralysis are described. Paralysis is usually caused by the mature female of the species Ixodes holocyclus. It most frequently occurs in the spring and summer months but can be seen at any time of year. Children aged 1-5 years are most commonly affected. The tick is usually found in the scalp, often behind the ear. The typical presentation is a prodrome followed by the development of an unsteady gait, and then ascending, symmetrical, flaccid paralysis. Early cranial nerve involvement is a feature, particularly the presence of both internal and external ophthalmoplegia. In contrast to the experience with North American ticks, worsening of paralysis in the 24-48 h following tick removal is common and the child must be carefully observed over this period. Death from respiratory failure was relatively common in the first half of the century and tick paralysis remains a potentially fatal condition. Respiratory support may be required for > 1 week but full recovery occurs. This is slow with several weeks passing before the child can walk unaided. Anti-toxin has a role in the treatment of seriously ill children but there is a high incidence of acute allergy and serum sickness. Neurophysiological studies reveal low-amplitude compound muscle action potentials with normal motor conduction velocities, normal sensory studies and normal response to repetitive stimulation. The biochemical structure of the toxin of I. holocyclus has not been fully characterized but there are many clinical, neurophysiological and experimental similarities to botulinum toxin.

Acetylcholine↗
PubMed2005

Prefeeding Dermacentor andersoni (Acari: Ixodidae) on cattle with prior tick exposure may inhibit detection of tick paralysis by using hamster bioassay.

The effect of prefeeding Dermacentor andersoni Stiles on naive and previously challenged cattle before conducting virulence assays by using hamsters was examined. In an initial observational trial, ticks prefed on a previously challenged heifer did not cause paralysis after transfer to hamsters, whereas ticks from the same lot that were prefed on a naive heifer did cause paralysis. Subsequent paired trails were conducted to simultaneously compare paralysis after feeding on naive and previously challenged heifers. In the first trial, prefeeding ticks on a previously challenged heifer did not result in loss of virulence. In a second trial, ticks fed on a previously challenged heifer had greatly diminished virulence after transfer to hamsters. This also occurred in a third trial after the previously challenged animal had two prior exposures to virulent D. andersoni. Weight gains of ticks that did not cause paralysis after transfer to hamsters were higher after feeding on previously challenged cattle, indicating that loss of virulence was not due to failure of ticks to reattach and feed. Ticks gained little weight on paralyzed hamsters due to the reduced time spent feeding on hamsters when paralysis occurred. Results indicate that assaying ticks for virulence requires prefeeding on naive hosts. If these are not available, rabbits, a resistant host, can be used for prefeeding ticks.

Animals↗
PubMed1990

The position and the state of the larynx during general anesthesia and muscle paralysis.

Based on a chance observation in two patients in whom the larynges could be visualized during direct laryngoscopy using topical anesthesia but not after general anesthesia and muscle paralysis, the authors postulated that there will be a shift in the position of the larynx with the onset of general anesthesia and muscle paralysis. To verify this the authors measured the position of larynx in lateral radiographs of necks taken in human volunteers when they were awake, and after induction of general anesthesia and muscle paralysis. The authors found that the hyoid bone and epiglottis were shifted anteriorly and the supraglottic region or the vestibule of the larynx was enlarged with the onset of general anesthesia and muscle paralysis. In addition, the larynx was also stretched longitudinally with wide separation of the vestibular and vocal folds. The authors conclude that consciousness is associated with tonic muscular activity that folds the larynx and partially closes it and that onset of general anesthesia and muscle paralysis opens the larynx wider and shifts it anteriorly, which might make visualization of the larynx during direct laryngoscopy difficult in some patients.

Anesthesia, General↗
PubMed2004

Can acceleromyography detect low levels of residual paralysis? A probability approach to detect a mechanomyographic train-of-four ratio of 0.9.

BACKGROUND: The incidence of residual paralysis, i.e., a mechanomyographic train-of-four (TOF) ratio (T4/T1) less than 0.9, remains frequent. Routine acceleromyography has been proposed to detect residual paralysis in clinical practice. Although acceleromyographic data are easy to obtain, they differ from mechanomyographic data, with which they are not interchangeable. The current study aimed to determine (1) the acceleromyographic TOF ratio that detects residual paralysis with a 95% probability, and (2) the impact of calibration and normalization on this predictive acceleromyographic value. METHODS: In 60 patients, recovery from neuromuscular block was assessed simultaneously with mechanomyography and acceleromyography. To obtain calibrated acceleromyographic TOF ratios in group A, the implemented calibration modus 2 was activated in the TOF-Watch S; to obtain uncalibrated acceleromyographic TOF ratios in group B, the current was manually set at 50 mA (n = 30 for each). In addition, data in group B were normalized (i.e., dividing the final TOF ratio by the baseline value). The agreement between mechanomyography and acceleromyography was assessed by calculating the intraclass correlation coefficient. Negative predictive values were calculated for detecting residual paralysis from acceleromyographic TOFs of 0.9, 0.95, and 1.0. RESULTS GROUP A: : For a mechanomyographic TOF of 0.9 or greater, the corresponding acceleromyographic TOF was 0.95 (range, 0.86-1.0), and the negative predictive values for acceleromyographic TOFs of 0.9, 0.95, and 1.0 were 37% (95% CI, 20-56%), 70% (95% CI, 51-85%), and 97% (95% CI, 83-100%), respectively. Group B: Without normalization, an acceleromyographic TOF of 0.97 (range, 0.68-1.18) corresponded to a mechanomyographic TOF of 0.9 or greater, with negative predictive values for acceleromyographic TOFs of 0.9, 0.95, and 1.0 being 40% (95% CI, 23-59%), 60% (95% CI, 41-77%), and 77% (95% CI, 58-90%), respectively. After normalization, an acceleromyographic TOF of 0.89 (range, 0.63-1.06) corresponded to a mechanomyographic TOF of 0.9 or greater, and the negative predictive values of acceleromyographic TOFs of 0.9, 0.95, and 1.0 were 89% (95% CI, 70-98%), 92% (95% CI, 75-99%), and 96% (95% CI, 80-100%), respectively. CONCLUSION: To exclude residual paralysis reliably when using acceleromyography, TOF recovery to 1.0 is mandatory.

Adult↗
PubMed1999

Paralysis in the critically ill: intermittent bolus pancuronium compared with continuous infusion.

OBJECTIVES: To compare recovery times from neuromuscular blockade between two groups of critically ill patients in whom pancuronium was administered by continuous infusion or intermittent bolus injection. To compare the mean pancuronium requirements (milligrams per kilogram per hour) and to assess the incidence of prolonged recovery times (>12 hrs) and residual muscle weakness. DESIGN: Prospective, observational cohort. SETTING: Intensive care unit in a university-affiliated hospital. PATIENTS: A total of 30 mechanically ventilated patients who required pharmacologic paralysis. Patients were excluded if they had renal failure (creatinine clearance <30 mL/min), heart rate >130 beats/min, hepatic failure, peripheral nerve disease or myopathy, stroke, spinal cord damage, or myasthenia gravis. INTERVENTIONS: Patients were assigned to receive pancuronium either by continuous infusion (n = 14) or intermittent bolus (n = 16). Depth of paralysis was titrated to maintain one or two responses to Train-of-Four stimulation with an accelerograph and desired clinical goals. Recovery time was defined as time from discontinuation of muscle relaxant until the amplitude of the fourth twitch, measured every 15-30 min using an accelerograph, was 70% the amplitude of the first twitch (Train-of-Four > or = 0.7). MEASUREMENTS AND MAIN RESULTS: These patients included the only three patients with status asthmaticus in our study. The groups were similar with respect to age, sex, weight, Acute Physiology and Chronic Health Evaluation II score, mode of ventilation, creatinine clearance, indications for paralysis, and duration of pancuronium administration. The median time for patients to recover from paralysis was 3.5 hrs (95% confidence interval, 1.82-5.18) in the infusion group vs. 6.3 hrs (95% confidence interval, 3.40-9.19) in the intermittent bolus group (p = .10). Less drug was administered in the intermittent group (mean, 0.02+/-0.01 mg/kg/hr) than by infusion (mean, 0.04+/-0.01 mg/kg/hr; p < .001). Six patients (five in the infusion group and one in the intermittent group) developed persistent severe muscle weakness. In addition, six different patients (three from each group) had prolonged recovery >12 hrs. CONCLUSIONS: Our study suggests that recovery time after paralysis with continuous infusion is faster than that after intermittent bolus injection. Although more pancuronium was administered in the continuous-infusion group, recovery time was not prolonged as a consequence. It is uncertain whether pancuronium given by infusion increases the risk of persistent muscle weakness.

APACHE↗
PubMed1998

Pediatric bilateral facial paralysis.

Bilateral facial paralysis is an unusual clinical entity that occurs in less than 1% of patients with facial paralysis. In children bilateral facial paralysis is even more rare, and establishing its etiology can be challenging. Four pediatric patients ranging in age from 3 to 17 years are presented who developed bilateral facial paralysis as a result of acute otitis media, Lyme disease, recurrent central nervous system leukemia, and acute disseminated encephalomyelitis. The diagnosis and treatment of pediatric bilateral facial paralysis are reviewed, as well as the pertinent literature.

Acute Disease↗