| 제목 |
A Case of Unilateral Diaphragm Paralysis Associated with Neurosyphilis |
| 소속 |
Pusan National University Yangsan Hospital, Department of Rehabilitation Medicine1, Pusan National University School of Medicine, Department of Rehabilitation Medicine2 |
| 저자 |
Ju Hyun Son1*, Zee Won Seo1, Sungchul Huh1, Hyun-Yoon Ko1,2† |
Case Report
A 34-year-old man experienced a sore throat and penile ulcers for 3 months after sexual intercourse and complained of recent blurred vision. He was diagnosed with syphilis based on laboratory test results and was also diagnosed with neurosyphilis based on the ophthalmologic manifestations, positive serologic tests, and CSF analysis. A month after antibiotic and steroid therapy the patient's blurred vision returned to normal. The patient also complained of mild shortness of breath while running or climbing stairs.
The chest postero-anterior X-ray showed marked elevation of the right diaphragm to the 7th intercostal space. Chest and abdominal computed tomography did not reveal any space-occupying lesions along the course of the phrenic nerve. Diaphragm ultrasonography showed the right diaphragm paralysis with no actual excursion in the M-mode and no thickness change in the B-mode. The ultrasonography revealed that the left diaphragmatic excursion was > 7 cm during forceful breathing. The thickness of the left diaphragm was 0.38 cm at end-expiration and 0.58 cm at end-inspiration, while that of the right diaphragm was 0.22 cm and did not change during breathing. Electrophysiological studies revealed that the amplitude of the compound muscle action potential of the right phrenic nerve had significantly decreased (0.1 mV). Needle electromyography of the right diaphragm showed abnormal spontaneous activity of positive sharp waves and fibrillation potentials and no recruitment of motor units during inspiration, suggesting a lesion associated with the right phrenic nerve. The spirometry revealed a forced vital capacity (FVC) of 2.10 L or 50% of the predicted value, forced expiratory volume in 1 second (FEV1) of 1.62 L or 46% of the predicted value, and FEV1/FVC ratio of 77.1%. He denied any history of trauma or respiratory distress, and his previous chest radiographs had been unremarkable.
We excluded multiple sclerosis, spinal cord lesions, and motor neuron disease as possible diagnoses because there was no other related neurology. We concluded that the right phrenic nerve neuropathy was likely due to neurosyphilis. We started pulmonary rehabilitation 2 hours daily, including air-stacking exercise and inspiratory muscle strengthening to prevent atelectasis and pneumonia of the right lung. After 2 months, follow-up ultrasonography showed paradoxical movement of the right diaphragm, which indicated complete paralysis.
Conclusion
There are several infectious causes of diaphragm paralysis. Phrenic nerve palsy with viral involvement is very rare, particularly in neurosyphilis. The information regarding diaphragmatic involvement in neurosyphilis should be made available to clinicians, and diaphragm paralysis, which can lead to shortness of breath and orthopnea in patients with neurosyphilis, should be excluded.
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Initial ultrasonography of the right diaphragm. Ultrasonography was performed in two different views. The hyperechoic right diaphragm in the seventh intercostal space was identified at the distal end of the liver, which served as an acoustic window. The excursion of the diaphragm was viewed through M-mode and there was no movement of the right diaphragm (Panel A). The thickness of the right diaphragm is viewed through B-mode and the value was 0.22 cm (Panel B).
Nerve conduction studies of both phrenic nerves. The compound muscle action potential of the right phrenic nerve showed a decreased amplitude (0.1 mV), while the left showed a normal amplitude (0.7 mV).
Follow-up ultrasonography of the right diaphragm. The follow up ultrasonography after 2 months showed a paradoxical movement of the right diaphragm, which indicated complete paralysis (Panel A). The thickness of the right diaphragm was 0.15 cm (Panel B).
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