21/227. Acute diaphragmatic paralysis caused by chest-tube trauma to phrenic nerve. A 3 1/2-year-old child developed unilateral diaphragmatic paralysis after chest drain insertion. Plain chest X-ray demonstrated paravertebral positioning of the chest-tube tip, and magnetic resonance imaging revealed hematomas in the region of the chest-tube tip and the phrenic nerve fibers. The trauma to the phrenic nerve was apparently secondary to malposition of the chest tube. This is a rare complication and has been reported mainly in neonates. Radiologists should notify the treating physicians that the correct position of a chest drain tip is at least 2 cm distant from the vertebrae. ( info) |
22/227. Transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature. Diaphragmatic paresis following trauma to the phrenic nerves is a rare complication after neck surgery. The resulting elevation of the ipsilateral hemi-diaphragm is diagnosed on post-operative chest radiography and may be confirmed by ultrasound or fluoroscopy. When unilateral, this may lead to respiratory, cardiac or gastrointestinal symptoms and atelectasis and pulmonary infiltrates on radiography. If nerve damage is bilateral a period of ventilation may be required. ( info) |
| Platypnea-orthodeoxia is a rare syndrome that is often associated with interatrial shunting through a patent foramen ovale or atrial septal defect. We describe the case of a 65-year-old woman with progressive dyspnea and hypoxia when standing and walking, which was relieved by assuming the recumbent position. The diagnosis was confirmed by tilt-table transesophageal echocardiography demonstrating a large right-to-left shunt through a patent foramen ovale while the patient was in a semiupright position and no significant shunt while in a recumbent position. This case demonstrates that platypnea-orthodeoxia caused by a patent foramen ovale can be clearly demonstrated by the technique of contrast transesophageal echocardiography performed on a tilt table. ( info) |
24/227. Congenital hypomyelination neuropathy in a newborn infant: unusual cause of diaphragmatic and vocal cord paralyses. We report a case of congenital hypomyelination neuropathy presenting at birth. The infant had generalized hypotonia and weakness. There was decreased respiratory effort along with a right phrenic nerve and left vocal cord paralyses. tongue fasciculations were present. Deep tendon reflexes were absent in the upper extremities and hypoactive (1 ) in the lower extremities. magnetic resonance imaging of the head revealed no intracranial abnormalities, including normal cerebral myelination. Nerve conduction study showed absence of motor and sensory action potentials in the hands when the nerves in the upper limbs were stimulated. A motor response could be elicited only in the proximal leg muscles. Needle electromyography study was normal in the proximal limb muscles, but showed active denervation in the distal muscles of the arm and leg. These findings were thought to be consistent with a length-dependent sensorimotor peripheral polyneuropathy of axonal type with greater denervation of the distal muscles. A biopsy of the quadriceps muscle showed mild variability in fiber diameter, but no group typing or group atrophy. The muscle fibers showed no intrinsic abnormalities. biopsy of the sural nerve showed scattered axons with very thin myelin sheaths. There was also a nearly complete loss of large diameter myelinated fibers. No onion bulb formations were noted. These findings were thought to be consistent with congenital hypomyelination neuropathy with a component of axonopathy. dna analysis for identification of previously characterized mutations in the genes MPZ, PMP22, and EGR2 was negative. Several attempts at extubation failed and the infant became increasingly ventilator-dependent with increasing episodes of desaturation and hypercapnea. He also developed increasing weakness and decreased movement of all extremities. He underwent surgery at 2 months of age for placement of a gastrostomy tube and a tracheostomy. He was discharged from the hospital on a ventilator at 6 months of age. The infant was 13 months old at the time of submission of this report. Although he appears cognitively normal, he remains profoundly hypotonic and is on a home ventilator. There was no evidence of progressive weakness. Congenital hypomyelination neuropathy is a rare form of neonatal neuropathy that should be considered in the differential diagnosis of a newborn with profound hypotonia and weakness. It appears to be a heterogeneous disorder with some of the cases being caused by specific genetic mutations. ( info) |
25/227. Bilateral diaphragmatic paralysis after open heart surgery. The purpose of the present case report is to present a case of bilateral diaphragmatic paralysis as a complication of open-heart surgery. A 47-year-old male was operated for aortic and mitral valve replacement. After discontinuation of sedation, bilateral diaphragmatic paralysis as well as motor and sensitive dysfunction in the four extremities was observed. The patient remained with mechanical ventilation support for twenty months. Two years after the operation a complete normalisation of the diaphragmatic motion was observed. Although uncommon, bilateral diaphragmatic paralysis after open-heart surgery could take place, being necessary long term mechanical ventilation support until recovery. ( info) |
26/227. Unilateral diaphragmatic palsy in association with a subclavian vein thrombus in a very-low- birth-weight infant. phrenic nerve paralysis due to iatrogenic injury is not uncommon in neonates. We report an unusual case of acquired unilateral paralysis of the diaphragm in a very-low-birth-weight infant, associated with a thrombus secondary to percutaneous subclavian vein catheterization. Conservative management resulted in complete resolution of the paralyzed diaphragm. ( info) |
27/227. Right hemidiaphragmatic elevation with a right-to-left interatrial shunt through a patent foramen ovale: a case report and literature review. A right-to-left shunt (RLS) is an uncommon complication of a patent foramen ovale (PFO) that may cause hypoxemia from venous admixture and ischemic complications from paradoxic embolization. This report presents the third described patient whose RLS through a PFO and profound hypoxemia developed in association with right hemidiaphragm dysfunction (but without a pressure gradient driving the right-to-left flow). In addition to extending the available experience with this unusual clinical event, we report on the successful closure of the PFO by a catheter-deployed double-umbrella device, after the positioning of which the patient's oxygenation normalized. ( info) |
28/227. Acute lead poisoning: Five cases resulting from self-injection of lead and opium. Five cases of acute lead poisoning resulted from the self-injection of lead and opium pills which were crushed, heated and suspended in water. Two of the five patients died of illnesses in which hepatic failure and reversible acute tubular necrosis were prominent features. One of these two had a severe neuropathy, with flaccid quadriplegia and respiratory paralysis. The other three patients had relatively minor symptoms but unequivocal biochemical evidence of lead toxicity. autopsy changes included hepatic degeneration with inclusion bodies, regenerating renal tubular epithelium and wasting of skeletal muscle. Hepatic lead content was extremely high in one case. chelation therapy in the other fatal case resulted in a fall in blood lead to within normal limits and a clinical improvement, which was terminated by massive haemorrhage from a ruptured innominate artery. ( info) |
29/227. Hypoxia following interscalene block. BACKGROUND AND OBJECTIVES: Interscalene brachial plexus block is often used for surgeries involving the shoulder and upper arm. Known complications include phrenic nerve paralysis, intravascular injection, and cervical epidural block. We report a patient who developed acute hypoxia immediately following this block, presumably secondary to an acute pulmonary thromboembolus (PTE) coupled with phrenic nerve paralysis. CASE REPORT: A 43-year-old man with end-stage renal disease secondary to hypertension was scheduled for primary placement of a left upper extremity arteriovenous fistula. A technically unremarkable interscalene brachial plexus block was performed using a 22-gauge regional block needle and 35 mL of 1.5% mepivacaine. Immediately following injection, the patient's oxygen saturation decreased from 99% to 85%, and he complained of chest pain and shortness of breath and developed hemoptysis. Workup revealed an elevated hemidiaphragm, but no pneumothorax or evidence of local trauma. A spiral computed tomogram (CT) suggested acute pulmonary thromboemboli as the etiology of the hypoxia and hemoptysis, although the diagnosis was uncertain. CONCLUSIONS: This case report suggests that manipulations and vasodilation related to an interscalene block may have facilitated the dislodgement of a pre-existing upper extremity thrombus. ( info) |
30/227. Idiopathic bilateral diaphragmatic paralysis. A 41-year-old man complained of subacute onset of dyspnea and pain in the neck and chest. He was diagnosed with bilateral diaphragmatic paralysis, based on clinical inspection of the breathing pattern and transdiaphragmatic pressure recording, and was trained to use a portable bi-level positive airway pressure apparatus (BiPAP). Needle electromyography showed profuse fibrillation potentials and positive waves in the diaphragm, more abundant on the right than left side, and no response to phrenic nerve stimulation. Other muscles were not involved. Follow-up examinations, performed at 9 and 12 months after onset of paralysis, demonstrated a slow but progressive improvement of the patient's respiratory function, together with the appearance of reinnervation potentials in the diaphragm, and polyphasic, long-latency responses to phrenic nerve stimulation. The subacute onset of the paralysis associated with local pain, and its subsequent recovery, suggest bilateral proximal lesions in the phrenic nerves. In the absence of traumatic or metabolic causes, these findings suggest that the phrenic nerve can be a target in idiopathic neuritis. ( info) |