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"Dr.
Diaosi Wang Xiaopeng" series of novels have a lot of professional knowledge, each chapter is a case, there are difficult cases, and there are ordinary cases
.
The purpose of this book is to hope that you can read leisurely and relax after busy work.
If you can inspire your profession, it will be great
.
Author: Wang Mingyue This article is published by Yimaitong authorized by the author, please do not reprint without authorization
.
Chapter 20: Skin itching and cramps in NMOSD Xiong Qing is a 40-year-old woman with itching in her waist and abdomen for 3 months and weakness in her lower limbs for 2 months
.
Three months ago, the patient had no obvious cause of pruritus on the left side ribs, no obvious rash, no redness, swelling, heat and pain.
The patient went to the hospital to consider neuropathy, the treatment effect was not good, and the symptoms progressed to the skin of the waist, abdomen and back.
The itching sensation turns into a tingling sensation, and there is pain when touching clothes
.
Urinary effort, constipation, numbness and weakness of both lower limbs occurred 2 months ago, lumbar puncture cerebrospinal fluid pressure 250mmH2O, white blood cells 50/L, neutrophils 90%, protein 0.
9g/L, spinal cord enhancement prompts: T1-L1 intramedullary abnormalities Signal, serum and cerebrospinal fluid AQP4 antibody is positive, consider "NMOSD", give methylprednisolone 500mg + gamma globulin 25g continuous application for 5 days, symptoms improve after treatment, after discharge, oral hormone 60mg QD, azathioprine 50mg BID
.
When Zhou Feng was seeing Xiong Qing, she was once confused by her skin itching, because of the core symptoms of NMOSD, including: optic neuritis, long-segment myelitis, and posterior zone syndrome (refractory hiccups and vomiting) ), diencephalic syndrome (drowsiness), etc.
, itching is indeed rarely heard
.
After consulting the data, I learned that the probability of skin itching symptoms in NMOSD patients is 12.
4-27.
3%, which is much higher than 4.
3% of MS, and it is a symptom in the onset period.
The positive AQP4 antibody of subsequent patients also proves the reliability of the literature data and reference.
Value
.
One week ago, Xiong Qing found Zhou Feng again.
The reason was that he had paroxysmal spastic cramps in both lower limbs in the past week, which was easily induced by movements or changes in posture, and he couldn't control it
.
Zhou Feng suspects that Xiong Qing may have a recurrence of NMOSD, because the recurrence rate of NMOSD is as high as 80%, and he intends to use hormone shock therapy again
.
However, Zhou Feng was cautious.
Before the hormone shock, he performed a cerebrospinal fluid test and a head + spinal MRI examination on the patient
.
Because NMOSD belongs to humoral immunity, there will be a slight increase in white blood cells and protein during recurrence, and there may be increased lesions in imaging
.
However, Zhou Feng was surprised that the patient's lumbar puncture cerebrospinal fluid examination was normal, and there were no new lesions on imaging
.
Zhou Feng consulted Wang Xiaopeng, and Wang Xiaopeng smiled and said: "Fortunately, you did not have a hormone shock, because cramps do not mean recurrence, but recovery symptoms.
You can try carbamazepine or phenytoin to relieve symptoms
.
" Zhou Feng gave the patient orally.
After 0.
1 tid of carbamazepine, the patient's cramps were significantly relieved
.
Knowledge NMOSD core symptoms, including: optic neuritis, myelitis long segment, after the polar region syndrome (intractable hiccups, vomiting), between brain syndrome (sleepiness) and so on
.
AQP-4 positive requires one core symptom, while AQP-4 negative requires two core symptoms (one of which must be optic neuritis, long segment myelitis, or posterior zone syndrome), in other words, optic neuritis, long segment Duan myelitis and posterior zone syndrome are the core of the core, belonging to the first echelon, and their key position cannot be shaken
.
The ultra-posterior zone syndrome, which manifests as intractable hiccups and vomiting, has only become hot in recent years.
When I read the relevant literature 2-3 years ago, I still found it new and interesting, and now it is dull to read related similar articles
.
Because the speed of knowledge network spread is too fast, the speed of popularization is far from what it used to be.
It only takes a few months for a new knowledge point to appear from the beginning to widely known
.
This time we are discussing an unpopular symptom that is easily overlooked-cramps
.
The unpopularity is because this symptom of NMOSD is not recognized and familiar to clinicians.
Even if you see it, it is easy to miss it.
People who are confused and forget how they intervened and dealt with it at that time
.
We discuss cramps.
The main reference is the clinical trial of KimSM.
This article was published in Archives of Neurology in 2012.
In this study, 10 out of 40 patients in the NMOSD group developed cramps, and the incidence was It was 25%, 1 out of 35 patients in the MS group, the incidence was 2.
9%, and 1 out of 41 patients in the idiopathic acute myelitis group, the incidence was 2.
4%
.
Therefore, the incidence of cramps in NMOSD is very high, much higher than that of MS and idiopathic acute myelitis
.
Most patients in the NMO group (8 out of 10 patients [80.
0%]) developed symptoms after the first episode of myelitis at an average interval of 48.
13 days, and there were no demyelinating episodes during the first episode
.
Therefore, cramps are generally not the first symptom of NMOSD myelitis, but the symptoms of recovery
.
Painful ankylosing spasm with myelitis is another special symptom of NMO patients, and it is an important predictor of NMOSD patients (odds ratio = 6.
545)
.
In the study, the incidence of PTS in the NMO group was significantly higher than that in the MS and IATM groups
.
Generally speaking, compared with MS or ATM, the typical characteristics of NMO include severe acute onset, a higher average annual recurrence rate, and longitudinally widespread myelitis
.
We speculate that the unique pathophysiology of NMO spinal cord lesions (ie, severe demyelination, early loss of AQP4 expression, and astrocytic damage) is the cause of cramps
.
Although the early MS research reports on the Western population showed a low incidence of cramps (2.
1%), the Japanese population reported that the incidence rate was as high as 17.
2%
.
However, most Japanese patients with MS and cramps have severe optic nerve and spinal cord damage, which may reflect the performance of NMOSD
.
These results also support that cramps are common in NMOSD, but not common in MS
.
The specificity of painful tonic spasm in the NMO group is as high as 98.
7%.
Therefore, patients with these symptoms can benefit from anti-AQP-4 antibody testing for further diagnosis
.
In the NMO group, most cramps occurred during the recovery period from the first occurrence of myelitis.
This finding suggests that the partial remyelination of the spinal cord may play a more important role in the cramps of NMOSD patients than demyelination itself.
More important role
.
Myelitis at the onset was significantly correlated with cramps in NMOSD patients (odds ratio = 6.
545)
.
In addition, most cramps in NMOSD patients are not related to new demyelinating NMO episodes, but appear during the recovery from the initial episode of myelitis
.
Compared with other NMO patients with optic neuritis or brain damage, NMOSD patients with myelitis at the onset seem to have a higher risk of developing cramps
.
By reading this document, we can preliminarily draw the following conclusions: 1.
The incidence of cramps in NMOSD is very high, much higher than that of MS and idiopathic acute myelitis
.
2.
Pain is generally not the first symptom of NMOSD myelitis, but a symptom of recovery period
.
3.
Partial remyelination of the spinal cord may play a more important role in the cramps of NMOSD patients than demyelination itself
.
4.
Compared with other NMOSD patients with optic neuritis or brain damage, NMOSD patients with myelitis at the onset have a higher risk of developing cramps
.
As for the treatment of cramps, we emphasize an old anti-epileptic drug that has almost been eliminated: phenytoin
.
In the clinical trial of KimSM, 1 patient was treated with carbamazepine and phenytoin, and 1 patient was treated with gabapentin.
The other patient experienced relapse after changing the drug from phenytoin to gabapentin
.
These results suggest that phenytoin or carbamazepine may be more effective than gabapentin in the treatment of cramps
.
Of course, these results need more clinical trials to verify
.
Diaosi Wang Xiaopeng" series of novels have a lot of professional knowledge, each chapter is a case, there are difficult cases, and there are ordinary cases
.
The purpose of this book is to hope that you can read leisurely and relax after busy work.
If you can inspire your profession, it will be great
.
Author: Wang Mingyue This article is published by Yimaitong authorized by the author, please do not reprint without authorization
.
Chapter 20: Skin itching and cramps in NMOSD Xiong Qing is a 40-year-old woman with itching in her waist and abdomen for 3 months and weakness in her lower limbs for 2 months
.
Three months ago, the patient had no obvious cause of pruritus on the left side ribs, no obvious rash, no redness, swelling, heat and pain.
The patient went to the hospital to consider neuropathy, the treatment effect was not good, and the symptoms progressed to the skin of the waist, abdomen and back.
The itching sensation turns into a tingling sensation, and there is pain when touching clothes
.
Urinary effort, constipation, numbness and weakness of both lower limbs occurred 2 months ago, lumbar puncture cerebrospinal fluid pressure 250mmH2O, white blood cells 50/L, neutrophils 90%, protein 0.
9g/L, spinal cord enhancement prompts: T1-L1 intramedullary abnormalities Signal, serum and cerebrospinal fluid AQP4 antibody is positive, consider "NMOSD", give methylprednisolone 500mg + gamma globulin 25g continuous application for 5 days, symptoms improve after treatment, after discharge, oral hormone 60mg QD, azathioprine 50mg BID
.
When Zhou Feng was seeing Xiong Qing, she was once confused by her skin itching, because of the core symptoms of NMOSD, including: optic neuritis, long-segment myelitis, and posterior zone syndrome (refractory hiccups and vomiting) ), diencephalic syndrome (drowsiness), etc.
, itching is indeed rarely heard
.
After consulting the data, I learned that the probability of skin itching symptoms in NMOSD patients is 12.
4-27.
3%, which is much higher than 4.
3% of MS, and it is a symptom in the onset period.
The positive AQP4 antibody of subsequent patients also proves the reliability of the literature data and reference.
Value
.
One week ago, Xiong Qing found Zhou Feng again.
The reason was that he had paroxysmal spastic cramps in both lower limbs in the past week, which was easily induced by movements or changes in posture, and he couldn't control it
.
Zhou Feng suspects that Xiong Qing may have a recurrence of NMOSD, because the recurrence rate of NMOSD is as high as 80%, and he intends to use hormone shock therapy again
.
However, Zhou Feng was cautious.
Before the hormone shock, he performed a cerebrospinal fluid test and a head + spinal MRI examination on the patient
.
Because NMOSD belongs to humoral immunity, there will be a slight increase in white blood cells and protein during recurrence, and there may be increased lesions in imaging
.
However, Zhou Feng was surprised that the patient's lumbar puncture cerebrospinal fluid examination was normal, and there were no new lesions on imaging
.
Zhou Feng consulted Wang Xiaopeng, and Wang Xiaopeng smiled and said: "Fortunately, you did not have a hormone shock, because cramps do not mean recurrence, but recovery symptoms.
You can try carbamazepine or phenytoin to relieve symptoms
.
" Zhou Feng gave the patient orally.
After 0.
1 tid of carbamazepine, the patient's cramps were significantly relieved
.
Knowledge NMOSD core symptoms, including: optic neuritis, myelitis long segment, after the polar region syndrome (intractable hiccups, vomiting), between brain syndrome (sleepiness) and so on
.
AQP-4 positive requires one core symptom, while AQP-4 negative requires two core symptoms (one of which must be optic neuritis, long segment myelitis, or posterior zone syndrome), in other words, optic neuritis, long segment Duan myelitis and posterior zone syndrome are the core of the core, belonging to the first echelon, and their key position cannot be shaken
.
The ultra-posterior zone syndrome, which manifests as intractable hiccups and vomiting, has only become hot in recent years.
When I read the relevant literature 2-3 years ago, I still found it new and interesting, and now it is dull to read related similar articles
.
Because the speed of knowledge network spread is too fast, the speed of popularization is far from what it used to be.
It only takes a few months for a new knowledge point to appear from the beginning to widely known
.
This time we are discussing an unpopular symptom that is easily overlooked-cramps
.
The unpopularity is because this symptom of NMOSD is not recognized and familiar to clinicians.
Even if you see it, it is easy to miss it.
People who are confused and forget how they intervened and dealt with it at that time
.
We discuss cramps.
The main reference is the clinical trial of KimSM.
This article was published in Archives of Neurology in 2012.
In this study, 10 out of 40 patients in the NMOSD group developed cramps, and the incidence was It was 25%, 1 out of 35 patients in the MS group, the incidence was 2.
9%, and 1 out of 41 patients in the idiopathic acute myelitis group, the incidence was 2.
4%
.
Therefore, the incidence of cramps in NMOSD is very high, much higher than that of MS and idiopathic acute myelitis
.
Most patients in the NMO group (8 out of 10 patients [80.
0%]) developed symptoms after the first episode of myelitis at an average interval of 48.
13 days, and there were no demyelinating episodes during the first episode
.
Therefore, cramps are generally not the first symptom of NMOSD myelitis, but the symptoms of recovery
.
Painful ankylosing spasm with myelitis is another special symptom of NMO patients, and it is an important predictor of NMOSD patients (odds ratio = 6.
545)
.
In the study, the incidence of PTS in the NMO group was significantly higher than that in the MS and IATM groups
.
Generally speaking, compared with MS or ATM, the typical characteristics of NMO include severe acute onset, a higher average annual recurrence rate, and longitudinally widespread myelitis
.
We speculate that the unique pathophysiology of NMO spinal cord lesions (ie, severe demyelination, early loss of AQP4 expression, and astrocytic damage) is the cause of cramps
.
Although the early MS research reports on the Western population showed a low incidence of cramps (2.
1%), the Japanese population reported that the incidence rate was as high as 17.
2%
.
However, most Japanese patients with MS and cramps have severe optic nerve and spinal cord damage, which may reflect the performance of NMOSD
.
These results also support that cramps are common in NMOSD, but not common in MS
.
The specificity of painful tonic spasm in the NMO group is as high as 98.
7%.
Therefore, patients with these symptoms can benefit from anti-AQP-4 antibody testing for further diagnosis
.
In the NMO group, most cramps occurred during the recovery period from the first occurrence of myelitis.
This finding suggests that the partial remyelination of the spinal cord may play a more important role in the cramps of NMOSD patients than demyelination itself.
More important role
.
Myelitis at the onset was significantly correlated with cramps in NMOSD patients (odds ratio = 6.
545)
.
In addition, most cramps in NMOSD patients are not related to new demyelinating NMO episodes, but appear during the recovery from the initial episode of myelitis
.
Compared with other NMO patients with optic neuritis or brain damage, NMOSD patients with myelitis at the onset seem to have a higher risk of developing cramps
.
By reading this document, we can preliminarily draw the following conclusions: 1.
The incidence of cramps in NMOSD is very high, much higher than that of MS and idiopathic acute myelitis
.
2.
Pain is generally not the first symptom of NMOSD myelitis, but a symptom of recovery period
.
3.
Partial remyelination of the spinal cord may play a more important role in the cramps of NMOSD patients than demyelination itself
.
4.
Compared with other NMOSD patients with optic neuritis or brain damage, NMOSD patients with myelitis at the onset have a higher risk of developing cramps
.
As for the treatment of cramps, we emphasize an old anti-epileptic drug that has almost been eliminated: phenytoin
.
In the clinical trial of KimSM, 1 patient was treated with carbamazepine and phenytoin, and 1 patient was treated with gabapentin.
The other patient experienced relapse after changing the drug from phenytoin to gabapentin
.
These results suggest that phenytoin or carbamazepine may be more effective than gabapentin in the treatment of cramps
.
Of course, these results need more clinical trials to verify
.
