Fourteen patients with "dystonic clenched fist" (three with Corticobasal Ganglionic Degeneration, seven with Parkinson's disease, and four with Dystonic-Complex Regional Pain Syndrome) were treated with botulinum toxin A (BTXA, Dysport). The muscles involved were identified by the hand posture and EMG activity recorded at rest and during active and passive flexion/extension movements of the finger and wrist. EMG was useful in distinguishing between muscle contraction and underlying contractures and to determine the dosage of BTX. All patients had some degree of flexion at the proximal metacarpophalangeal joints and required injections into the lumbricals. The response in patients depended on the severity of the deformity and the degree of contracture. All patients had significant benefit to pain, with accompanying muscle relaxation, and palmar infection, when present, was eradicated. Four patients with Parkinson's disease and one patient with Dystonia-Complex Regional Pain Syndrome obtained functional benefit.
The efficacy of botulinum toxin (BTX) without systemic effects has led to the rapid development of applications in neuromuscular disorders, hyperactivity of sudomotor cholinergic-mediated glandular function, and pain syndromes. The successful use of BTX in conditions with muscle overactivity, such as dystonia and spasticity, has been established and new areas in the field of movement disorders such as tics, tremor, myoclonic jerks, and stuttering has been explored with satisfactory results. Strategies to temporarily inactivate muscle function after orthopaedic or neurosurgery have also been developed. BTX treatment of hyperhidrosis was followed by its application in other hypersecretory conditions (hyperlacrimation and nasal hypersecretion) and in excessive drooling. Studies are in progress, aimed at optimising the technique and protocol of administration. Other applications for BTX have been proposed in gastroenterological and urogenital practice; it appears to be effective in replacing standard surgical procedures. Trials of BTX in painful conditions are ongoing mainly on refractory tension headache, migraine, and backache as well as dystonia-complex regional pain syndrome and myofascial pain with promising results. Recently, the fastest growing use for BTX toxin has been in the cosmetic applications. Clearly, the indications for the use of BTX are expanding, but further clinical trials will be needed in many different areas.
High and rising neutralizing antibody titers (NATs) to enterovirus type 70 (EV70) were detected in the serum and cerebrospinal fluid (CSF) of patients with polio-like motor paralysis accompanying acute hemorrhagic conjunctivitis (AHC) in an outbreak of AHC in 1981 in Bombay, India. Fifty-four (88.5%) of 61 patients with AHC with or without neurologic disease had serum NATs of greater than or equal to 1:16, and some paired sera from these patients showed significant increases in NAT. Serum from noninfected control subjects had no significant neutralizing antibody to EV70. Thirty-six (94.7%) of 38 CSF specimens from 30 patients with spinal or a combination of spinal and cranial motor paralysis associated with AHC had NATs ranging from 1:2 to 1:256. No neutralizing antibody was found in CSF specimens from patients with AHC alone or in those from non-infected control subjects, and a reduced ratio of serum NAT to CSF NAT was detected in patients with neurologic disease. Therefore, it is highly likely that intrathecal synthesis of antibody occurred in response to direct invasion of the central nervous system by EV70. The results represent strong laboratory evidence of the neurovirulence of EV70.
SUMMARY Ninety cases of the neurological manifestations associated with acute haemorrhagic conjunctivitis caused by Enterovirus 70 (EV 70) are reported. The patients were seen during the widespread epidemics in 1971 and 1981. Male adults were predominantly affected by a "poliolike" paralysis of the limbs and/or cranial nerves. Root pains were often complained of early in the disease. In the absence of a necropsy, clinical and neurophysiological examinations helped to localise the lesions. Significant antibody titres against EV 70 were demonstrated in the serum and more relevantly in the CSF. Though other viruses can cause sporadic and epidemic conjunctivitis and similar paralysis independently, the combination of a haemorrhagic conjunctivitis and a neurological disease mostly simulating poliomyelitis is caused by EV 70 alone. It is therefore suggested that this combination be called "Enterovirus 70 disease". Because of its neurovirulence, it is important to identify this virus at the very beginning of an epidemic of conjunctivitis, so as to limit its spread by strict public health measures.Amongst the new diseases known to have afflicted man in the last decade, acute haemorrhagic conjunctivitis stands out prominently. Its global incidence to date is hard to assess, but 70 to 80 millions in a decade would perhaps be an und-erestimate, considering reports of recent epidemics in the Indian subcontinent' 2 and the Americas.During the 1971 pandemic, two independent observations were made which clearly indicated the aetiopathology of the disease. Wadia and his colleagues in Bombay6I showed that the disease was not confined to the eyes, but caused a "poliomyelitis-like illness" and Kono' s group8 in Japan isolated a new enterovirus (EV 70) from the conjunctiva of Japanese patients. Neurovirulence of the virus in monkeys was shown,9 and the two groups jointly demonstrated that a single type of virus was responsible for the epidemics in Japan and India. 10 As a large epidemic (May-October, 1981) of acute haemorrhagic conjunctivitis caused a similar illness, a comprehensive report of 90 cases of 1971
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