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Botulism is a very rare disease in Switzerland, with less than one case per year, an incidence of 0.01 cases for 100,000 inhabitants. Indeed, over the past ten years, 9 cases have been reported to Public Health registry. Foodborne botulism (FB) is caused by ingestion of preformed botulinum neurotoxin. Characteristic features should be rapidly recognized, and prompt treatment should be administered to avoid further progression towards respiratory failure and death. We report the case of a patient who developed gastrointestinal symptoms just after a sandwich consumption followed by rapidly progressive cranial nerve impairment, truncal muscle weakness in a descending pattern and respiratory failure requiring mechanical ventilation. The diagnosis of foodborne botulism was delayed due to differential diagnosis considerations. Specific antitoxin therapy was administered immediately after firm clinical conviction of botulism, without waiting for serologic results that later confirmed the diagnosis. As expected, muscle weakness recovery was slow, with persistent chronic deficits nine years later. This case highlights differential diagnosis issues of botulism. These include acute neuromuscular disorders such as myasthenia gravis, Guillain-Barré syndrome, or tick-borne encephalitis. The importance of careful medical history and repeated clinical evaluation to avoid misdiagnosis can be lifesaving. Our case highlights the typical warning signs.

A toxina botulínica A foi aprovada para o tratamento da espasticidade em doentes pós-AVC. Os efeitos adversos são geralmente de dois tipos: efeitos adversos relacionados com a administração local de toxina botulínica A; e efeitos adversos sistémicos relacionados com a difusão à distância da toxina. A paresia muscular dos membros contralaterais após tratamento com toxina botulínica A é um efeito adverso raro. Descrevemos o caso de uma mulher de 33 anos de idade que recebia infiltrações regulares de toxina incobotulínica A por espasticidade dos membros direitos pós-AVC hemorrágico. Foi feita uma troca para toxina abobotulínica A com um factor de conversão global de 1:3,83. A doente apresentou parésia do membro superior contralateral, especialmente do músculo deltóide. A electroneuromiografia foi compatível com bloqueio neuromuscular devido a toxina botulínica A. Recuperou totalmente após oito meses. A troca entre diferentes formulações de toxina botulínica A deve exigir precaução na conversão das unidades. Efeitos adversos à distância podem surgir, incluindo parésia dos membros contralaterais.

Dear Editor, Infection with the SARS-CoV-2 virus may lead to hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS). ARDS is frequently complicated by intensive care unit acquired weakness (ICUAW) [1], which is associated with poor outcomes [2]. Critically ill patients affected with coronavirus disease 2019 (COVID-19) may differ from typical ARDS-patients in baseline factors [3] and ICU exposures associated with ICUAW [4]. Of particular concern may be the need for deep sedation to avoid patient-ventilator dyssynchrony and ventilator-induced/self-inflicted lung-injury because of high respiratory drive [5]. We aimed to assess the incidence of ICUAW in critically ill COVID-19 patients, to identify factors associated with its occurrence, and to describe its short-term outcomes. This single-center, retrospective, observational study involved adult critically ill COVID-19 patients admitted to the University Hospitals Leuven, from March 13th until June 8th 2020. After April 1st, physiotherapists were re-engaged in patient care and performed daily strength-assessment when appropriate. Records of eligible patients were searched for baseline characteristics, ICU exposures and outcomes. The primary outcome was the incidence of ICUAW, assessed with the MRC-sum score [2], at awakening, at ICU and hospital discharge in patients requiring invasive mechanical ventilation (IMV). In addition, we evaluated factors and short-term outcomes associated with weakness at ICU discharge. To assess bias, we compared characteristics and outcomes for patients with and without MRC-sum score, and studied patients without IMV. Of 486 hospitalized COVID-19 patients, 114 required intensive care of whom 74 (64.9%) needed IMV (Supplemental Fig. 1). Admission and ICU characteristics are provided in the Online Supplement. Total hospital mortality was 60/486 (12.3%), ICU mortality was 11/114 (9.6%). All deaths occurred in IMV patients [11/74 (14.9%)]. In 50/74 (67.6%) assessed IMV patients, the incidences of ICUAW at awakening, ICU, and hospital discharge were 72%, 52% and 27% (Fig. 1). Those without MRC-sum-score were older as compared to those with MRC-sum-score [67 (60–76) versus 60 (53–67), p = 0.044] and comprised nine patients who died before awakening, possibly introducing selection bias. Admission characteristics were similar between patients with and without ICUAW, but weak patients had prolonged ventilation (days) [24 (15–29) versus 12 (8–17), p

Patients with chronic obstructive pulmonary disease usually manifest decreases in functional capacity, endurance time at submaximal exercise, and maximal exercise performance compared to age- and sex-matched healthy individuals. The main pathophysiologic changes in this disease are obstruction of expiratory airways and/or pathologic alterations in the lung parenchyma. Many factors are associated with decreased exercise tolerance, including increased airway resistance, inadequate ventilation, increased elastic loading of ventilation, hyperinflation, gas exchange abnormalities, mechanical weakness of respiratory muscles, and varying degrees of disturbances in the central and peripheral nervous systems due to hypoxic response. Skeletal muscles also undergo pathological changes similar to those in ventilation muscles. All these result in decreases in functional capacity and exercise tolerance, giving rise to dyspnea during minimal activity and even at rest. In order to break this vicious circle, supporting rehabilitation programs have to be combined with medical treatment. Turkish Başlık: Kronik Obstrüktif Akciğer Hastalığı Olan Olgularda Efor Kısıtlılığı Anahtar Kelimeler: Solunum egzersizi; egzersiz testi; egzersiz terapisi; egzersiz toleransı/fizyoloji; akciğer hastalığı, obstrüktif/ fizyopatoloji; kas zayıflığı/etyoloji; solunum mekaniği; solunum kasları/patoloji Kronik obstrüktif akciğer hastalığı olan olguların fonksiyonel kapasiteleri, submaksimal egzersizlerdeki dayanıklılık süreleri ve maksimal egzersiz performansları, aynı yaş ve cinsteki kişilerle karşılaştırıldığında genellikle azalmıştır. Bu hastalıkla ilgili temel fizyopatolojik değişiklikler, ekspiratuvar hava akımında obstrüksiyon ve/veya akciğer parenkimindeki patolojik değişikliklerdir. Hava yolu direncinin artması, verimsiz ventilasyon, solunumun elastik yükünün artması, hiperenflasyon, gaz değişim anomalileri ve mekanik olarak solunum kaslarının güçsüzlüğü, merkezi ve periferik sinir sisteminde hipoksik yanıtla ilgili değişik derecelerdeki bozukluklar, egzersize toleransın azalmasına yol açmaktadır. İskelet kaslarında da solunum kaslarına benzer şekilde patolojik değişiklikler gözlenmiştir. Zamanla fonksiyonel kapasite ve egzersiz toleransı azalır, bunlara bağlı olarak hafif düzeyde bir aktivite sırasında, hatta istirahat sırasında dahi dispne gelişir. Bu kısır döngünün kırılması için tıbbi tedavinin yanında mutlaka destekleyici rehabilitasyon programları uygulanmalıdır.

A twenty-two-year-old male patient presented with complaints of muscle atrophy and shoulder pain. Clinical and radiological studies showed a ganglion cyst near the spinoglenoid notch and a diagnosis of compression of the inferior branch of the suprascapular nerve was made. Following open excision of the cyst by a posterior approach, the patient’s complaints subsided. A year after the operation recurrence of the lesion was detected. Arthroscopic control showed no intrarticular lesion. The patient still experiences minimal pain from time to time., Omuzda ağrı ve güçsüzlük yakınması ile kliniğimize başvuran 22 yaşında bir erkek hastada, klinik ve radyolojik incelemeler sonucunda spinoglenoid çentik yakınında sinire bası yapan bir gangliyon kisti saptandı ve supraskapular sinirin tuzak nöropatisi tanısı kondu. Hastanın yakınmaları kistik lezyonun açık cerrahi eksizyonunun ardından geriledi. Ameliyattan bir yıl sonra nüks görüldü. Kontrol artroskopisinde eklem içi bir patoloji saptanmadı. Hastada önemsiz derecede ağrı yakınması zaman zaman görülmektedir.

The signs and symptoms of acute disseminated encephalomyelitis are heterogeneous and dependent on the location and severity of the inflammatory process. The meningoencephalitic presentation may include meningism, impaired consciousness (occasionally leading to coma), seizures and confusion, or behavioral disturbances. Multifocal neurological features include a combination of optic neuritis, visual field defects, cranial neuropathy, sensorimotor impairment, ataxia, aphasia, and involuntary movements. One definition of acute disseminated encephalomyelitis is "an initial clinical event with a presumed inflammatory and demyelinating cause, with acute or sub-acute onset affecting multifocal areas of the central nervous system". Patients with acute disseminated encephalomyelitis frequently suffer from seizures, disturbances of consciousness, fever, and headaches, and occasionally there are focal signs and symptoms. Here, we report on two cases who presented with different symptoms, but the clinical findings that the patients showed were benign.