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A 48-year-old man presented with rapidly progressive heart failure and monoclonal gammopathy of uncertain significance. No specific cause was detected on endomyocardial biopsy. As the heart failure worsened, he also developed progressive skeletal myopathy. This provided the clue to the diagnosis, and cardiac function recovered rapidly with cause-directed therapy. (Level of Difficulty: Intermediate.), Graphical abstract, A 48-year-old man presented with rapidly progressive heart failure and monoclonal gammopathy of uncertain significance. No specific cause was…

ObjectiveTo test the hypotheses that blood concentrations of neurofilament light chain protein (NfL) and glial fibrillary acidic protein (GFAp) can serve as biomarkers for disease severity in COVID-19 patients.MethodsForty-seven inpatients with confirmed COVID-19 had blood samples drawn on admission for assessing serum biomarkers of CNS injury by Single molecule array (Simoa). Concentrations of NfL and GFAp were analyzed in relation to symptoms, clinical signs, inflammatory biomarkers and clinical outcomes. We used multivariate linear models to test for differences in biomarker concentrations in the subgroups, accounting for confounding effects.ResultsIn total, 21 % (n = 10) of the patients were admitted to an intensive care unit, whereas the overall mortality rate was 13 % (n = 6). Non-survivors had higher serum concentrations of NfL than patients who were discharged alive both in adjusted analyses (p = 2.6 × 10−7) and unadjusted analyses (p = 0.001). Serum concentrations of GFAp were significantly higher in non-survivors than survivors in adjusted analyses (p = 0.02). The NfL concentrations in non-survivors increased over repeated measurements, whereas the concentrations in survivors were stable. Significantly higher concentrations of NfL were found in patients reporting fatigue, while reduced concentrations were found in patients experiencing cough, myalgia and joint pain.ConclusionIncreased concentrations of NfL and GFAp in COVID-19 patients on admission may indicate increased mortality risk. Measurement of blood biomarkers for nervous system injury can be useful to detect and monitor CNS injury in COVID-19.

Background A wide range of patients are referred to multidisciplinary pain clinics. An important part of the work-up is a thorough pain analysis that might reveal a specific cause for chronic pain. Method We describe a patient with chronic pain in one foot after a light trauma and repeated surgery. However, careful examination revealed symptoms and clinical finings in both feet. This led to referral to a University Hospital and the diagnosis of a chronic neurologic condition explaining both symptoms and findings. The diagnosis of this condition has implications both for further follow-up for this patient and possibly also other family members. Implications Professionals working in the pain-field should be aware of diagnosis that might partly explain increased pain or complications after surgery.

Objectives: To compare the prevalence of myasthenia gravis (MG) subgroups based on immunological markers and clinical presentation in two geographically complete MG populations in northern Europe. Methods: This cross-sectional study included all living MG patients in Norway and a regional cohort from the Netherlands. Patients were identified using their hospital registration codes. Medical charts of subjects >16 years were reviewed. Inclusion criteria were clinical MG, a positive antibody test for acetylcholine receptor (AChR MG) or muscle-specific kinase (MuSK MG), or if seronegative MG, confirmed by an electrophysiological test. Results: 1,205 MG patients (534 Norwegians and 671 Dutch) fulfilled the criteria, giving a higher point prevalence in the Netherlands (167/million, 95% CI 155-180) than in Norway (138/million, 95% CI 126-150). In particular, rates of AChR MG (143 vs. 111/million), MuSK MG (6.5 vs. 0.5/million), and ocular phenotype (62 vs. 24/million) were higher in the Netherlands. Conclusion: Novel findings are an AChR MG geographical north-south gradient and a 2.6-fold more ocular MG patients in the Netherlands than in Norway. The MuSK MG latitudinal gradient supports the notion of a north-south gradient in Europe, with a higher prevalence in the south. The variation is probably explained by genetic differences between the populations, in addition to environmental interactions.

Myasthenia gravis (MG) is an autoimmune disease causing muscle weakness due to impaired transmission at the neuromuscular junction. MG or a MG-like condition may be triggered or exacerbated by several drugs used for treatment of other diseases. Drugs may interfere with the neuromuscular transmission through several mechanisms, either by affecting pre- or postsynaptic ion channels or by affecting acetylcholinesterase. Based on a literature search in PubMed and the authors' own clinical experiences, we provide an overview focusing on the most frequently used drugs that may exacerbate weakness in patients with MG. In our experience, symptomatic MG-patients who have a generalised disease are especially vulnerable to drug-induced exacerbations, while stable MG patients with few symptoms more seldom are. Nevertheless, patients with MG must receive treatment for co-existing conditions. It is important to be aware of a possible increase in muscle weakness when introducing a new drug. If the patient deteriorates, the new treatment must be withdrawn or the dose reduced.

Background Cerebellar and cerebral infarctions caused by the syndrome of cervical rib with thrombosis of subclavian artery are very unusual. Case presentation We report the case of a 49-year-old male patient with a right cervical rib compression leading to subclavian arterial thrombosis and both cerebellar and cerebral infarctions secondary to retrograde thromboembolisation. Follow-up imaging revealed partial resolution of the thrombosis after combined anti-coagulant and anti-platelet therapy. The cervical rib and first costa were surgically removed to prevent additional events. Conclusion Cervical rib vascular compression should be promptly diagnosed and treated in order to avoid further complications, including cerebrovascular ischemic events.