Neurologische Komplikationen bei Akrodermatitis chronica atrophicans
(Herxheimer) und ihre Beeinflussung durch die
Penicillintherapie.
[NOTE The following is not a full translation of all the German text just part of it]
Out of a total of 242 in whom ACA was diagnosed in 1958-70, in the University
Dermatology Clinic in Göttingen, Germany - 167 patients were invited by letter
and 120 of these patients could be evaluated.
Patients older than 70 were not
included, a few had other complicating diseases, some were lost due to
insufficient address, and a few had died. Material:
During years
1958-68, 78 of 128 women came (60,9%) and 29 of 39 men came (77,4%??, I get this
to 74,4%), totalling 107 patients.
During 169-70, 12 patients, 4 men and 8
women were included and 1 woman couldn't be re-evaluated, but is included in the
report.
All patients had a thorough neurological evaluation, especially regarding
sensibility disturbances (pain, touch, temperature, 2-point discrimination,
vibration, digit-discrimination test). Author discuss the difficulty of
repeating these subjective findings.
11 patients, 2 men and 9 women were
excluded due to atypical presentation at time of reevaluation or course of skin
disease, leaving 109 patients, of whom 76 were women and 33 men..
sexratio
female:male=2,3:1 (69,7%:30,7%) - compared to all patients diagnosed with ACA
1958-70: 188 women and 66 men, i.e. a sex-ratio of 3,5:1.
Mean age of the 109
patients for first treatment was 47 years (14-67). At time of neurological
evaluation mean age: 53 years (16-70).
The anamnestic duration of skin problems was mean 3,6 years (2 mo - 25
years). Total duration of disease at time of study was mean 10
years.
Regarding the relation between penicillin treatment and re-evaluation,
the patients were divided in 3 groups:
Skin:
34% only one extremity involved
38% either both arms or both
legs
28% legs as well as arms
Upper extremities: 24%, lower extremities:
48%, all four 28%.
Extreme atrophy: 8,5%
Medium atrophy: 11,5%
Slight
atrophy: 27%
Other skin manifestations than atrophy: 53%
The patients often (51) had other subjective complaints and a
great number had neurological deficits (44). The authors problem was to
determine if and how these symptoms and findings were related to the skin
disease.
28 patients with neurological findings formed a separate
group, among these 18 had another possible cause of the neurological problems -
but many of these symptoms is now known to be part of the picture we today know
as Lyme disease.
The remaining 81 patients:
- 44 had subjective symptoms
and objective neurological deficits which could be attributed to ACA with a high
degree of probablilty - most symptoms were of polyneuropathic nature, sensory
disturbances
- objective findings:
reduced vibration sense
(36)
reduced 2-punct discrimination (19)
hypestesia (10)
hypalgesia
(8)
""hyperpathie"" (6)
motoric (3) muscle atrophy, palsy,
reduced or
total lack of achilles tendon reflex (7)
- 51 patients
had only subjective symptoms - 80% improved after penicillin
13 had itch,
hyperpathie, tenseness -> 11 asymptomatic, 1 relapse, 1 rest symptom
10
cold or warm sense -> 8 asymptomatic, 1 relapse, 1 rest symptom
5 numbness
-> all asymptomatic
17 pain -> 11 improved, 2 unchanged
20 fatigue
or weakness or fascicular movements -> 13 asymptomatic, 5 unchanged, 2 only
seen before treatment
5 cramps -> 3 asymptomatic, 1 relapse
(fasciculations), 1 unchanged - 8 patient without relapse were examined
both before and after penicillin treatment (not specified); 4/5 of the
subjective symptoms and 4/5 of the objective findings improved or completely
resolved (3/5). Sensory disturbances:
1 warm, 4 parestsias, 2 pain, 3 fatigue
or weakness, 2 muscle cramps.
Objective findings: weak mm. Interossei 1,
weak achilles tendon reflex, 1 digit discrimination, 2 vibration sense, 4
hypaestesia (2 glove or sock formed distal area), 1 hypalgesia (glove), 3
hyperpathia (local in the affected area), 2 hyperaesresia (red skin area).
- patients with extreme atrophy more often had neurological defecits than
those with milder atrophy.
- there was a clear, but due to small number not
significant, relation between duration and/or age of the patient and
neurological symptoms.
- overweigth of women
- relapses were seen
My comments:
The patients were ALL treated with penicillin one or more
times, but dose, administration and duration was not specified at all - so it is
impossible to evaluate the cause of relapses in more detail.
Despite
describing clear effect of penicillin treatment on neurological symptoms as well
as on ACA - the author doesn't discuss the possible etiology of the disease as
being an infection especially he does not mention a spirochete as the possible
culprit - this is remarkable as it was proposed much earlier by Lennhoff,
Hollström and several others.
Looking at the reference list: of the
Scandinavian's only Thyresson and Pirilä's work are mentioned, and lot of
German works, but it is quite surprising that Afzelius, Hollström, Hellerström
and Lennhoff's work is not mentioned at all - Why not??