Female patient, 61 years-old, heavy smoker, and heavy drinker, sought care because of watery diarrhea, severe weight loss (around 40 pounds), alteration of mental state, and skin rash. She presented with signs of dementia (blurry speech, mental confusion, and amnesia) and severe malnutrition. Initial investigation had shown anemia (hemoglobin = 8.5 g/dL), low albumin (2.05 g/dL), and an increase of liver enzymes (GGT = 450 U/L and alkaline phosphatase = 287 U/L). Serological tests for syphilis, HIV, hepatitis C virus, and hepatitis B virus were negative. Parasitological stool examination and fecal leukocyte tests were normal, anti-transglutaminase IgA and IgG antibodies were negative, and she had a normal oral lactose tolerance test. Colonoscopy was performed, showing normal mucosa with a normal anatomopathological study of colon biopsies. The skin rash, tough, was very relevant for the case: hyperpigmentation, scaling, and skin thickening on the face, upper chest, and upper and lower limbs-areas exposed to sunlight (Figs. 1, 2). A presumptive diagnosis of pellagra was made by the clinical gastroenterology team. Supplementation of nicotinamide in the dose of 50 mg QID was began and maintained for 28 days, with resolution of diarrhea and of the skin rash, a substantial weight gain, and a considerable improvement of mental status. Because in Brazil there is no commercial nicotinamide presentation, it was used 20 daily tablets of complex B vitamins, which contain 10 mg of nicotinamide each. The patient was discharged with maintenance supplementation of complex B vitamins and a plan for treatment of alcoholism. Pellagra is a disease caused by the deficiency of niacin (vitamin B3), first described in 1735 by the Spanish physician Gaspar
Background: spasticity affects up to 90% of multiple sclerosis (MS) patients, being a major cause of disability. Repetitive transcranial magnetic stimulation (rTMS) appears to be a potential treatment, but literature is scarce. Objectives: to evaluate the effects of combined rTMS and physical therapy for spasticity in MS patients. Methods: relapsing-remitting MS patients suffering from lower limb spasticity were included. The rTMS protocol consisted of 20 sessions of 18 trains of 50 stimuli at 5Hz and at 100% of rest potential threshold, with 10 seconds per train and 40 second pauses, amounting for 900 pulses (15 minutes) with a Neurosoft- MS/D double coil. Optimal coil positioning was determined by motor responses in the contralateral soleus muscle. The physical therapy protocol included active exercising – stationary bicycle, step climbing with partial weight suspension – followed by mild gradual resistance exercising for knee extension and hip and foot flexion, proprioceptive exercises and active stretching. The primary outcome was improvement on the Modified Ashworth Scale (MAS) score at baseline and 4 weeks after treatment. Results: five female patients were recruited. At the 4-week follow-up, 4 out the 5 patients had a significant improvement regarding spasticity. There was a reduction in mean MAS score from 2.30 to 1.42. Patient 1 had a MAS score reduction from 2 to 1 (50%). Patient 2 from 3 to 1 (66%), patient 3 from 4 to 3 (25%) and patient 4 from 0.5 to 0.125 (75%). Conclusion: combined rTMS and physical therapy protocols presents as a beneficial treatment modality for MS spasticity.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.