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Sleep Recording for the Diagnosis and Treatment of Paraplegia

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME

A woman in her 30s was working as a nurse’s aide in an intensive care unit, regularly practiced sports, and had severe asthma treated with corticosteroid therapy. She was hospitalized for a urinary retention associated with pluriradicular sacral neuropathic pain and discrete bilateral weakness of the lower limbs. Spinal cord magnetic resonance imaging revealed a T2 hyperintensity, and contrast enhancement from T12 to the conus medullaris and cauda equina roots. Brain magnetic resonance imaging showed no abnormality. Findings of infectious, inflammatory, and metabolic biological investigations were normal except for a multiplex polymerase chain reaction in the cerebrospinal fluid detecting the herpes simplex virus type 2 genome. A diagnosis of herpetic myeloradiculitis was made (Elsberg syndrome), and a treatment with aciclovir, 800 mg per 8 hours, was administered intravenously for 14 days. Despite this treatment, urinary retention and neuropathic pain persisted. One month later, her symptoms rapidly worsened without any identified factor, and she became almost completely paraplegic. Findings of cerebral and spinal cord magnetic resonance imaging, cerebrospinal fluid analysis, and electroneuromyographic study as well as sensory and motor evoked potentials were normal. Despite rehabilitation, a nearly complete flaccid paraplegia persisted, including muscular contractions without any observed movement and the need for a wheelchair. However, some discrepancies on motor examination (including fluctuating motor deficit on different maneuvers) suggested a functional neurological disorder (FND).1 Given the extent of the symptoms, positive clinical signs of FND were difficult to demonstrate. Additionally, several physicians involved in her care questioned the diagnosis of FND because of the initial myeloradiculitis, the clinical severity, and the need for self-catheterization 8 times a day.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Béatrice Garcin, MD, PhD, Neurology Department, Avicenne Hospital, APHP, Sorbonne Paris Nord University, 125 Rue de Stalingrad, Bobigny 93000, France (beatrice.garcin@aphp.fr).

Published Online: April 11, 2022. doi:10.1001/jamaneurol.2022.0619

Conflict of Interest Disclosures: Dr Arnulf has received personal fees from UCB Pharma and IDORSIA Pharmaceuticals. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We thank Anne Ladarre, MSc (Sleep Disorders Unit, Pitié-Salpêtrière Hospital, APHP, Sorbonne University, Paris, France), Delphine Conrad, MD (Neurology Department, Avicenne Hospital, APHP, Sorbonne Paris Nord University, Bobigny, France), Marie Mongin, MD (Neurology Department, Avicenne Hospital, APHP, Sorbonne Paris Nord University), Francine Mesrati, MD (Neurophysiology Department, Avicenne Hospital, APHP, Sorbonne Paris Nord University, Bobigny, France), and Bertrand Degos, MD, PhD (Neurology Department, Avicenne Hospital, APHP, Sorbonne Paris Nord University), who participated in the sleep study and in the care of the patient. None of the contributors were compensated for their work.

References
1.
Espay  AJ , Aybek  S , Carson  A ,  et al.  Current concepts in diagnosis and treatment of functional neurological disorders.   JAMA Neurol. 2018;75(9):1132-1141. doi:10.1001/jamaneurol.2018.1264PubMedGoogle ScholarCrossref
2.
Stone  J , Carson  A , Hallett  M .  Explanation as treatment for functional neurologic disorders.   Handb Clin Neurol. 2016;139:543-553. doi:10.1016/B978-0-12-801772-2.00044-8PubMedGoogle ScholarCrossref
3.
Stone  J , Hoeritzauer  I , Brown  K , Carson  A .  Therapeutic sedation for functional (psychogenic) neurological symptoms.   J Psychosom Res. 2014;76(2):165-168. doi:10.1016/j.jpsychores.2013.10.003PubMedGoogle ScholarCrossref
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