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Boston: Butterworth-Heinemann; 2007. p. 159-78. McGlone J, Losier BJ, Black SE. Are there sex differences in hemispatial visual neglect after unilateral stroke? Neuropsychiatry Neuropsychol Behav Neurol 1997;10:125-34. Samuelsson H, Jenson C, Ekholm S, Naver H, Blomstrand C. Anatomical and neurological correlates of acute and chronic visuospatial neglect following right hemisphere stroke. Cortex 1997;33:271-85. Karnath Ho, Ferber S, Himmelbach M. Spatial awareness is a function of the temporal not the posterior parietal lobe. Nature 2001;411:950-3. Chatterjee A. The neuropsychology of visual artistic production. Neuropsychologia 2004;42:1568-83. Bazner H, Hennerici MG. Painting after right hemispheric stroke-case studies of professional artists. In: Bogousdavsky J, Hennerici MG, editors. Neurological disorders in famous artists-Part 2. Basel: Karger; 2007. p. 1-13. Dieguez S, Assal G, Bogousslavsky J. Visconti and Fellini: From left social neorealism to right hemispheric stroke. In: Bogousslavsky J, Hennerici MG, editors. Neurological disorders in famous artists - Part 2. Basel: Karger; 2007. p. 44-74. Bazner H, Hennerici MG. Lovis Cornith: Integrating hemineglect and spatial distortions. In: Bogousslavasky J, Hennerici MG, editors. Neurological disorders in famous artists - Part 2. Basel: Karger; 2007. p. 30-43.
Accepted on 06-08-2009
Acute polyradiculoneuropathy following wasp sting Sir, A variety of unusual systemic manifestations have been described following the exposure to Hymenoptera venom. The venom contains phospholipase-A 2 , hyaluronidase, mast cell degranulation protein, apamin and adolapine.[1] Neurological complications are rare and include encephalitis, encephaloradiculoneuropathy, optic neuropathy[1] and neuromuscular paralysis. [2] We report a young man who developed acute radiculoneuropathy following a wasp sting. A 20-year-old, non-hypertensive healthy man who had previous history of wasp sting without systemic complications on three earlier episodes presented with acute and rapidly progressive quadriparesis with truncal weakness after fourth episode of wasp sting. There was mild local swelling over right cheek and right arm. There was no history of tingling, paresthesia, visual blurring, diplopia, dysphasia, vomiting, convulsion, altered sensorium, syncope, bowel or bladder incontinence, oliguria, dyspnoea, palpitation, fever, drug intake or systemic diseases. Neurological examination revealed a conscious and well oriented male with normal cranial nerves’ examination. Motor examination showed normal bulk, decreased tone in all four limbs and power of Grade 3/5 proximally and 4/5 distally in the limbs. Truncal weakness was present. 676
Sensory and autonomic nervous system examination was normal. Deep tendon reflexes were absent. Plantars were bilaterally down going. Investigations showed normal hemogram and metabolic parameters. Creatine phosphokinase (CPK) level was normal. Human immunodeficiency virus (HIV) and hepatic viral markers were negative. Urine was negative for porphobilinogen. Cerebrospinal fluid (CSF) examination showed 4 cells/ mL (all lymphocytes), protein 76 mg/dl and sugar 40 mg/dl (corresponding blood sugar 90 mg/dl). Electrophysiological examination of median nerves from position 1-wrist and position 2-elbow revealed decreased compound muscle action potential (CMAP) amplitude (2.1 mA and 1.2 mA), with reduced conduction velocity 18.6 m/s and conduction block (more than 40% decrement in CMAP amplitude). ‘F’ waves were not generated in any of the limbs. Sensory nerve conduction studies showed normal latency amplitude and conduction velocity. Repetitive nerve stimulation study did not show decremental pattern. Electromyography study done in the second week showed spontaneous activity in the form of fasciculations with long-duration polyphasic motor unit potentials, late recruitment pattern and incomplete interference pattern. Electrophysiological study conclusion was pure motor demyelinating radiculoneuropathy with secondary axonal changes. Sural nerve biopsy showed segmental demyelination. Patient was managed with high-dose intravenous methylprednisolone pulse therapy for five days followed by tapering dose of oral steroid, and anti-allergic treatment. The patient showed partial improvement in symptoms. He was discharged on tapering dose of oral prednisolone and supportive physiotherapy. Hymenoptera sting’s complications range from local to severe systemic reactions and even death. Reactions usually begin within a minute to an hour in 76-96% of patients. Nevertheless, there are reports of delayed responses that can occur days to weeks after the event. Out of 2606 reactions noted in a survey, complication did not occur until several days after the sting in 2.8% cases.[3] Various reported neurological complications include: Myelitis, encephalitis, optic neuropathy, encephaloradiculoneuritis,[1] cerebral infarction,[4] and acute inflammatory polyradiculopathy. [5] Maltzman et al., reported two patients with optic neuropathy following wasp stings. Most of the patients recovered with corticosterioid.[1] These reactions to wasp venom are either Type I or delayed type of hypersensitivity reactions. Bachman et al., reported five patients with acute inflammatory polyradiculopathy following hymenoptera sting, in all the patients good clinical recovery was achieved with steroid. [5] Although exact Neurology India | Sep-Oct 2009 | Vol 57 | Issue 5
Letters to Editor
pathogenesis is not known it is postulated that the venom contains allergic proteins like phospholipase and various non-myelin proteins which elicit an IgE antibody response resulting in mast cell activation and release of preformed substances such as histamine as well as de novo synthesis of other mediators (i.e. thromboxane and leukotrines) leading to anaphylactic response. Sometimes IgE antibody formed by previous sensitization directly cross-reacts with myelin basic proteins resulting in different neurological complications.[6] Our patient was pre-sensitized with hymenoptera venom and the fourth occasion of sting probably caused immediate type hypersensitivity reaction mediated by humoral antibodies of IgE type or reagin antibodies which cross-reacted with myelin basic protein, leading to acute demyelinating polyradiculoneuropathy with secondary axonal changes.
cerebellum, spinal cord, and brainstem.[2] The unusual locations include leptomeninges and sellar-sphenoid sinus.[4-6] Supratentorial location accounts for 4 to13% of the cases.[2] However, hemangioblastomas of the lateral ventricle are extremely rare and only 5 cases have been reported in the English literature till 2001.[2] We report a unique case of a lateral ventricular hemangioblastoma. A 30-year-old male presented with a progressive holocranial headache of six months duration. The neurological examination was normal. Magnetic resonance imaging (MRI) of the brain showed a 3 x 2 cm mass in the left lateral ventricle, which was hypointense on T1-weighted images, hyperintense on T2-weighted as well as fl uid attenuated inversion recovery (FLAIR) images. The tumor showed brilliant contrast enhancement [Figures 1-3]. The patient had a left-sided parietal craniotomy and through a trans-sulcal approach through the superior parietal
Dhiraj Kishore, Vishal Khurana, Indarjeet Singh Gambhir, Surender Misra1 Department of Internal Medicine and 1Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, India. E-mail:
[email protected] PMID: 19934578 DOI: 10.4103/0028-3886.57796
References 1. 2. 3. 4. 5. 6.
Maltzman JS, Lee AG, Miller NR. Optic neuropathy occurring after bee and wasp sting. Ophthalmology 2000; 107:193-5. Hira HS, Mittal A, Kumar SA, Singh A, Ahalawat RS. Myasthenia gravis and acute respiratory muscle paralysis following wasp sting. Indian J Chest Dis Allied Sci 2005;47:197. Barr SE. Allergy to Hymenoptera stings—review of the world literature: 1953-1970. Ann Allergy 1971; 29:49-66. Crawley F, Schon F, Brown MM. Cerebral infarction: A rare complication of wasp sting. J Neurol Neurosurg Psychiatry 1999; 66:550‑1. Bachman DS, Paulson GW, Mandell JR. Acute inflammatory polyradiculoneuropathy following Hymnoptera sting. JAMA 1982; 247:1443-5. Mean ED, Barron KD, Van Dyne BJ. Nervous system lesions after sting by yellow jacket. A case report. Neurology 1973; 23:881-9.
Figure 1: T1-weighted axial magnetic resonance imaging scan of the patient showing a mass in the body and atrium of the left lateral ventricle which is hypointense compared to the normal white matter
Accepted on 06-08-2009
Hemangioblastoma of the lateral ventricle Sir, Hemangioblastomas are the most frequent vascular tumor of the central nervous system (CNS)[1] and can be associated with von Hippel-Lindau (VHL) disease in 3 to 38% of the cases as a major manifestation.[2] These tumors are predominantly found in the Neurology India | Sep-Oct 2009 | Vol 57 | Issue 5
Figure 2: T2-weighted fluid attenuated inversion recovery axial scan of the patient showing a mass in the body and atrium of the left lateral ventricle which is hyperintense compared to the normal white matter
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