Bilateral Parsonage-Turner Syndrome Due to Cytomegalovirus in Two Immunocompetent Men
Dr Sarah Mangan1, Dr Shameer Rafee1, Dr Grainne Mulkerrin2, Prof Christopher Mc Guigan1, Dr Justin Kinsella1
1Neurology, St Vincents University Hospital, Dublin, 2St Vincent’s University Hospital, Dublin 4
Background:
Parsonage-Turner Syndrome (PTS), also known as neuralgic amyotrophy or brachial neuritis is thought to be an inflammatory process affecting the peripheral nerves. It presents with acute, asymmetric upper limb pain, with multifocal sensorimotor neuropathies. The incidence is ~3 per 100,000. Aetiologies include toxic, autoimmune, post viral and post radiation effects.
Cytomegalovirus (CMV) can cause severe systemic conditions in immunocompromised people. It is typically asymptomatic in healthy individuals but has been rarely associated with PTS
Results:
Two immunocompetent men aged 23 and 18 years with no medical history presented with a sudden onset of severe shoulder pain, which progressed bilaterally, resulting in patchy sensorimotor deficits. Both men experienced transient abnormalities in Liver Enzymes, reflecting a systemic response to CMV. Each received opiate analgesia and IVIG, with little clinical improvement. Once serum CMV IgM was confirmed, each received a course of Valgangciclovir. MR Imaging with contrast reported abnormal STIR high signal in the left brachial plexus, suggesting an inflammatory process in the first patient. MR Imaging (non-contrast) performed at day 12 of symptoms was normal in the second man. The first patient partially recovered over a five month period with residual deficits in his left finger flexion (4-/5) and extension (3/5). The second case is embarking on rehabilitation presently
Conclusions:
We present two cases of young, healthy men who presented similarly and were found to be CMV positive. Conventional treatment approaches includes immunoglobulins or steroids but these are usually ineffective. Early identification of CMV prompted Valgangcyclovir use. The recognition of PTS relies on high suspicion from the clinical history- imaging and NCS are frequently used but have low sensitivity. These cases highlight the need for a comprehensive work-up to identify possible triggers and augment treatment accordingly. Prognosis is favourable with up to 90% of patients having a good outcome at 2 years.
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