Objective: To analyze the changes in electroencephalography (EEG) during tilt table study in sync... more Objective: To analyze the changes in electroencephalography (EEG) during tilt table study in syncope and other orthostatic syndromes. Background: Tilt table testing is routinely performed for evaluation of unexplained syncope. Occasionally convulsive syncope is misdiagnosed as an epileptic seizure, and EEG with video during tilt table can help differentiate these conditions. However, the diagnostic utility of simultaneous EEG during tilt table testing is unknown. Prior studies have described multiple patterns of EEG changes with syncope, but others have not replicated these findings. In addition, it is unclear whether any significant EEG changes occur during severe symptomatic neurogenic orthostatic hypotension. Design/Methods: We retrospectively reviewed all consecutive tilt table studies with simultaneous EEG from April 2014 to May 2016. All patients had video EEG before (baseline) and during tilt table. All patients had at least 10 minutes of head up tilt unless they had syncope or did not tolerate the study. In addition, all patients performed deep breathing and valsalva testing. All studies were supervised and interpreted by autonomic specialists, and EEG was visually read by trained epileptologists. Results: Eighty-eight patients met the inclusion criteria. Mean age was 45 years, and 56 were women. Seven patients (~8%) had syncope during tilt table, 11 (~12%) had significant neurogenic orthostatic hypotension, another 11 (~12%) had significant orthostatic tachycardia. Nineteen(~21%) had abnormal baseline EEG. Visually discernable EEG changes were seen in only 3 patients (~3%) with syncope and in 1patient (~1%) with orthostatic tachycardia. Conclusions: In our cohort, qualitative EEG analysis based on visual inspection during tilt table study revealed abnormalities in only a few patients with syncope and in one patient with orthostatic tachycardia. No discernable EEG changes were noted in patients with severe orthostatic hypotension. Quantitative or computerized EEG analysis might be more sensitive and objective for detecting cerebral hypoperfusion during tilt table studies. Disclosure: Dr. Muppidi has received personal compensation for activities with Alexion Pharmaceuticals and Alnylam Pharmaceuticals. Dr. Razavi has received personal compensation for activities with Ceribell as a consultant. Dr. Miglis has nothing to disclose. Dr. Jaradeh has nothing to disclose.
Objectives/Hypothesis Although the cricopharyngeus muscle is a ring‐like structure, unilateral cr... more Objectives/Hypothesis Although the cricopharyngeus muscle is a ring‐like structure, unilateral cricopharyngeal dysfunction can produce significant dysphagia. This entity has not been well described in the literature. The aims of the study were to identify the characteristic findings on videofluoroscopic swallow studies in patients with dysphagia secondary to unilateral cricopharyngeal dysfunction, to note the associated vagal nerve injury, and to evaluate patient outcomes following ipsilateral cricopharyngeal myotomy.Study Design Retrospective clinical investigation.Methods The clinic charts, electromyographic tests, videostroboscopic examinations, and videofluoroscopic swallow studies were reviewed from a series of patients who presented to our institution from 1993 to 2001 with dysphagia and findings on videofluoroscopic swallow studies suggestive of unilateral cricopharyngeal dysfunction on posterior–anterior view. In patients treated with ipsilateral cricopharyngeal myotomy, postoperative findings on swallow studies and patient outcomes were also reviewed.Results Eighteen patients demonstrated findings characteristic of unilateral cricopharyngeal muscle dysfunction on videofluoroscopic swallow study. The common feature was a unilateral shelf‐like barrier at the cricopharyngeus on the posterior–anterior view with pooling of liquid bolus in the ipsilateral pyriform sinus and episodic shunting to the contralateral side. Eight patients did not have evidence of cricopharyngeal dysfunction (ie, cricopharyngeal bar) on lateral films. Of the 18 patients, 14 had histories consistent with vagal injury secondary to trauma (n = 2), neoplastic involvement (n = 7), iatrogenic injury (n = 2), or central nervous system disease (n = 3). Results of videostroboscopic examinations demonstrated vocal fold motion impairment in 14 patients, and electromyographic test results confirmed unilateral vagal injuries in those who underwent electromyographic testing (n = 6). In the remaining 4 of 18 patients, videostroboscopic examinations demonstrated normal vocal fold abduction but impaired lengthening with a posterior glottic gap, and electromyographic test results (n = 4) indicated unilateral superior laryngeal nerve involvement. Of the 15 patients treated with ipsilateral cricopharyngeal myotomy, 1 patient required postoperative esophageal dilations for an esophageal stricture distal to the cricopharyngeus, whereas the remaining 14 patients had functional resolution of their dysphagia.Conclusion In patients presenting with dysphagia and evidence of unilateral vagal injury, careful assessment of posterior–anterior view on videofluoroscopic swallow study should be included to evaluate for unilateral cricopharyngeal dysfunction.
Objective: To better characterize the profiles of patients with postural orthostatic tachycardia ... more Objective: To better characterize the profiles of patients with postural orthostatic tachycardia (POTS) seen in the Stanford Autonomic Disorders Program. Background: POTS represents an orthostatic increase in heart rate (HR) > 30 bpm in adults, or HR > 40 bpm in children in the first 10 minutes, without sustained orthostatic hypotension (OH). The standing heart rate for all subjects is often > 120 bpm. We embarked on this project to understand various POTS phenotypes. Design/Methods: We reviewed HR and BP waveforms for 850 head-up tilt tests conducted in the past 2 years in our Lab. We reviewed the tests for 2 criteria: (1) HR increase ≥ 30 bpm above baseline for at least 3 consecutive minutes during the first 10 minutes of tilt for patients ≥ 20, and 40 bpm increase for patients Results: We eliminated 16 HR waveforms because of artifacts, and found 169 with sustained HR increase; 46 were young and 25 of these had HR increase 30 to 40 bpm. We examined the 144 remaining records for OH. We excluded one (artifact), and 9 with SBP drop exceeding 20 mmHg in the first 3 minutes of tilt. This left 134 tilt records that satisfied both criteria. These were 75% female, age 12 years to 74 years. In 60%, the HR increase started in the first 3 minutes of tilt. In 90%, the HR increase extended to 10 minutes. In 37%, the increase led to a HR ≥ 120 bpm. Conclusions: We identified 134 patients that met HR and BP criteria for exaggerated postural tachycardia. We will analyze this group to identify subtypes of POTS, and classify their HR and PB profiles. Disclosure: Dr. Jaradeh has nothing to disclose. Dr. Muppidi has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Alexion, Lundbeck. Dr. Miglis has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Lundbeck, Schlesinger Associates, Defined Health, Elsevier. Dr. Sinn has nothing to disclose. Dr. Krugomova has nothing to disclose. Dr. Prieto has nothing to disclose.
Annals of Otology, Rhinology, and Laryngology, Sep 1, 2007
Cricopharyngeal achalasia (CA) can be defined as inadequate opening of the cricopharyngeus muscle... more Cricopharyngeal achalasia (CA) can be defined as inadequate opening of the cricopharyngeus muscle (CPM) resulting in dysphagia. Myosin heavy chain (MHC) isoform fiber type composition and size are key determinants of muscle function. These parameters have not been described in CA. It is hypothesized that there is a difference between the MHC isoform composition of the CPM in patients with the clinical diagnosis of CA and that in normal subjects. Patients who had received prior botulinum were excluded. The MHC fiber type composition and size in patients and cadaveric controls were determined by adenosine triphosphatase staining and image analysis. The CPMs of 12 CA patients (6 male, 6 female; mean age, 61 years) and 5 control cadaveric subjects (3 male, 2 female; mean age, 67 years) were analyzed. There were relatively fewer type I fibers (67%) in patients with CA than in controls (81%), but the difference was not significant (p = .18). Type I fibers were slightly smaller in CA patients (38.7 microm) than in controls (47.2 microm), but this was not significantly different (p > .05). Of the 12 CA patients, 3 had type II predominance, a feature not seen in normal subjects. Patients with CA had relatively fewer type I fibers, although the difference was not statistically significant. The MHC isoform composition and fiber size were not different between CA patients and normal subjects. This is the first report to characterize the CPM in patients with CA.
The cauda equina region is prone to injury from a variety of causes, all of which have to be cons... more The cauda equina region is prone to injury from a variety of causes, all of which have to be considered during the performance of spinal anesthesia. This article reviews these causes and discusses their approach.
Purpose: Epilepsy and syncope can be difficult to distinguish, with misdiagnosis resulting in unn... more Purpose: Epilepsy and syncope can be difficult to distinguish, with misdiagnosis resulting in unnecessary or incorrect treatment and disability. Combined tilt-table and video EEG (vEEG) testing (tilt-vEEG) is infrequently used to parse these entities even at large centers. Because of the discovery of a rare case of epileptic seizure induced by head-up tilt (HUT) (no prior cases have been published), the authors sought to verify the rarity of this phenomenon. Methods: An observational, retrospective case series study of all combined tilt-vEEG studies performed at Stanford Health Care over a 2-year period was performed. Studies were grouped into categories: (1) abnormal tilt and normal vEEG; (2) abnormal vEEG and normal tilt; (3) abnormal vEEG and abnormal tilt; (4) normal tilt and normal vEEG, with neurologic symptoms; and (5) normal tilt and normal vEEG without neurologic symptoms. Results: Sixty-eight percent of patients had an abnormal study (categories A–C), with only 3% having both an abnormal tilt and an abnormal EEG (category C). Of these, one patient had a focal epileptic seizure induced by HUT. With HUT positioning, the patient stopped answering questions and vEEG showed a left temporal seizure; systolic blood pressure abruptly dropped to 89 mm Hg (64 mm Hg below baseline); heart rate did not change, but pacemaker showed increased firing (threshold: <60 bpm). Conclusions: Combined tilt-table and vEEG evaluation was able to identify a previously unreported scenario—head-up tilt provocation of an epileptic seizure—and improve treatment. Combined tilt and vEEG testing should be considered for episodes that persist despite treatment to confirm proper diagnosis.
As previous chapters have illustrated, the oropharyngeal swallow is the end result of several coo... more As previous chapters have illustrated, the oropharyngeal swallow is the end result of several coordinated neuromuscular elements: velopharyngeal closure, tongue loading, tongue pulsion, closure of the laryngeal vestibule, upper esophageal sphincter opening, and pharyngeal clearance. It is estimated that more than 30 muscles are involved in the various stages of the swallow. Muscular disorders leading to impairment in any of these steps can cause dysphagia. A better understanding of the swallowing problems associated with these conditions may help in guiding treatment, choosing technical aids, modifying the consistency of foods, swallowing rehabilitation, and nutritional support by the non-oral route.
Journal of Clinical Neuromuscular Disease, Dec 1, 2003
ABSTRACT The spectrum of hereditary neuropathies has evolved recently as a result of the exponent... more ABSTRACT The spectrum of hereditary neuropathies has evolved recently as a result of the exponential growth of genetic research. For the purpose of this review, we will use Charcot-Marie-Tooth (CMT), hereditary liability to pressure palsy (HNPP) and hereditary sensory and autonomic neuropathies (HSAN) to illustrate the current clinical and genetic approach to such neuropathies.
Journal of Bone and Joint Surgery, American Volume, 1996
Pseudoparalysis or apparent weakness of a limb associated with septic arthritis or osteomyelitis ... more Pseudoparalysis or apparent weakness of a limb associated with septic arthritis or osteomyelitis is a well documented phenomenon. Muscular spasm associated with pain caused by the infection can lead to the apparent weakness. In contrast, true nerve paralysis associated with osteomyelitis is uncommon, and documentation of the electromyographic changes is rare. We describe a five-week-old male infant who had a brachial plexus neuropathy and paralysis of the right upper extremity secondary to septic arthritis of the glenohumeral joint and osteomyelitis of the proximal part of the humerus. A male infant was delivered by cesarean section after thirty-six weeks of gestation to a primiparous thirty-five-year-old woman. No problems with the use of the upper extremities were noted at birth. At the age of three weeks, the infant had projectile vomiting and was admitted to the hospital for the operative correction of pyloric stenosis. The hospital course was uneventful, and he was discharged. One week later, he was admitted to the pediatric service for evaluation of a loss of movement of the right upper extremity of several days' duration. There was no history of fever or signs of constitutional illness while the infant was at home, but the mother reported that he had had mild upper respiratory symptoms for two days. The rectal temperature on admission was 37.2 degrees Celsius, and the vital signs were stable. The physical examination revealed a palpable mass in the right axilla, and the right upper extremity was flaccid. The patient had poor grasp, active flexion of the elbow was decreased, and active abduction of the shoulder was absent. Laboratory evaluation revealed a white blood-cell count of 20,800 per cubic millimeter (20.8 x 109 per liter) with a differential of 60 per cent segmented neutrophils, 2 per cent bands, 2 per cent lymphocytes, 16 per cent …
Objective: To analyze the changes in electroencephalography (EEG) during tilt table study in sync... more Objective: To analyze the changes in electroencephalography (EEG) during tilt table study in syncope and other orthostatic syndromes. Background: Tilt table testing is routinely performed for evaluation of unexplained syncope. Occasionally convulsive syncope is misdiagnosed as an epileptic seizure, and EEG with video during tilt table can help differentiate these conditions. However, the diagnostic utility of simultaneous EEG during tilt table testing is unknown. Prior studies have described multiple patterns of EEG changes with syncope, but others have not replicated these findings. In addition, it is unclear whether any significant EEG changes occur during severe symptomatic neurogenic orthostatic hypotension. Design/Methods: We retrospectively reviewed all consecutive tilt table studies with simultaneous EEG from April 2014 to May 2016. All patients had video EEG before (baseline) and during tilt table. All patients had at least 10 minutes of head up tilt unless they had syncope or did not tolerate the study. In addition, all patients performed deep breathing and valsalva testing. All studies were supervised and interpreted by autonomic specialists, and EEG was visually read by trained epileptologists. Results: Eighty-eight patients met the inclusion criteria. Mean age was 45 years, and 56 were women. Seven patients (~8%) had syncope during tilt table, 11 (~12%) had significant neurogenic orthostatic hypotension, another 11 (~12%) had significant orthostatic tachycardia. Nineteen(~21%) had abnormal baseline EEG. Visually discernable EEG changes were seen in only 3 patients (~3%) with syncope and in 1patient (~1%) with orthostatic tachycardia. Conclusions: In our cohort, qualitative EEG analysis based on visual inspection during tilt table study revealed abnormalities in only a few patients with syncope and in one patient with orthostatic tachycardia. No discernable EEG changes were noted in patients with severe orthostatic hypotension. Quantitative or computerized EEG analysis might be more sensitive and objective for detecting cerebral hypoperfusion during tilt table studies. Disclosure: Dr. Muppidi has received personal compensation for activities with Alexion Pharmaceuticals and Alnylam Pharmaceuticals. Dr. Razavi has received personal compensation for activities with Ceribell as a consultant. Dr. Miglis has nothing to disclose. Dr. Jaradeh has nothing to disclose.
Objectives/Hypothesis Although the cricopharyngeus muscle is a ring‐like structure, unilateral cr... more Objectives/Hypothesis Although the cricopharyngeus muscle is a ring‐like structure, unilateral cricopharyngeal dysfunction can produce significant dysphagia. This entity has not been well described in the literature. The aims of the study were to identify the characteristic findings on videofluoroscopic swallow studies in patients with dysphagia secondary to unilateral cricopharyngeal dysfunction, to note the associated vagal nerve injury, and to evaluate patient outcomes following ipsilateral cricopharyngeal myotomy.Study Design Retrospective clinical investigation.Methods The clinic charts, electromyographic tests, videostroboscopic examinations, and videofluoroscopic swallow studies were reviewed from a series of patients who presented to our institution from 1993 to 2001 with dysphagia and findings on videofluoroscopic swallow studies suggestive of unilateral cricopharyngeal dysfunction on posterior–anterior view. In patients treated with ipsilateral cricopharyngeal myotomy, postoperative findings on swallow studies and patient outcomes were also reviewed.Results Eighteen patients demonstrated findings characteristic of unilateral cricopharyngeal muscle dysfunction on videofluoroscopic swallow study. The common feature was a unilateral shelf‐like barrier at the cricopharyngeus on the posterior–anterior view with pooling of liquid bolus in the ipsilateral pyriform sinus and episodic shunting to the contralateral side. Eight patients did not have evidence of cricopharyngeal dysfunction (ie, cricopharyngeal bar) on lateral films. Of the 18 patients, 14 had histories consistent with vagal injury secondary to trauma (n = 2), neoplastic involvement (n = 7), iatrogenic injury (n = 2), or central nervous system disease (n = 3). Results of videostroboscopic examinations demonstrated vocal fold motion impairment in 14 patients, and electromyographic test results confirmed unilateral vagal injuries in those who underwent electromyographic testing (n = 6). In the remaining 4 of 18 patients, videostroboscopic examinations demonstrated normal vocal fold abduction but impaired lengthening with a posterior glottic gap, and electromyographic test results (n = 4) indicated unilateral superior laryngeal nerve involvement. Of the 15 patients treated with ipsilateral cricopharyngeal myotomy, 1 patient required postoperative esophageal dilations for an esophageal stricture distal to the cricopharyngeus, whereas the remaining 14 patients had functional resolution of their dysphagia.Conclusion In patients presenting with dysphagia and evidence of unilateral vagal injury, careful assessment of posterior–anterior view on videofluoroscopic swallow study should be included to evaluate for unilateral cricopharyngeal dysfunction.
Objective: To better characterize the profiles of patients with postural orthostatic tachycardia ... more Objective: To better characterize the profiles of patients with postural orthostatic tachycardia (POTS) seen in the Stanford Autonomic Disorders Program. Background: POTS represents an orthostatic increase in heart rate (HR) > 30 bpm in adults, or HR > 40 bpm in children in the first 10 minutes, without sustained orthostatic hypotension (OH). The standing heart rate for all subjects is often > 120 bpm. We embarked on this project to understand various POTS phenotypes. Design/Methods: We reviewed HR and BP waveforms for 850 head-up tilt tests conducted in the past 2 years in our Lab. We reviewed the tests for 2 criteria: (1) HR increase ≥ 30 bpm above baseline for at least 3 consecutive minutes during the first 10 minutes of tilt for patients ≥ 20, and 40 bpm increase for patients Results: We eliminated 16 HR waveforms because of artifacts, and found 169 with sustained HR increase; 46 were young and 25 of these had HR increase 30 to 40 bpm. We examined the 144 remaining records for OH. We excluded one (artifact), and 9 with SBP drop exceeding 20 mmHg in the first 3 minutes of tilt. This left 134 tilt records that satisfied both criteria. These were 75% female, age 12 years to 74 years. In 60%, the HR increase started in the first 3 minutes of tilt. In 90%, the HR increase extended to 10 minutes. In 37%, the increase led to a HR ≥ 120 bpm. Conclusions: We identified 134 patients that met HR and BP criteria for exaggerated postural tachycardia. We will analyze this group to identify subtypes of POTS, and classify their HR and PB profiles. Disclosure: Dr. Jaradeh has nothing to disclose. Dr. Muppidi has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Alexion, Lundbeck. Dr. Miglis has received personal compensation for consulting, serving on a scientific advisory board, speaking, or other activities with Lundbeck, Schlesinger Associates, Defined Health, Elsevier. Dr. Sinn has nothing to disclose. Dr. Krugomova has nothing to disclose. Dr. Prieto has nothing to disclose.
Annals of Otology, Rhinology, and Laryngology, Sep 1, 2007
Cricopharyngeal achalasia (CA) can be defined as inadequate opening of the cricopharyngeus muscle... more Cricopharyngeal achalasia (CA) can be defined as inadequate opening of the cricopharyngeus muscle (CPM) resulting in dysphagia. Myosin heavy chain (MHC) isoform fiber type composition and size are key determinants of muscle function. These parameters have not been described in CA. It is hypothesized that there is a difference between the MHC isoform composition of the CPM in patients with the clinical diagnosis of CA and that in normal subjects. Patients who had received prior botulinum were excluded. The MHC fiber type composition and size in patients and cadaveric controls were determined by adenosine triphosphatase staining and image analysis. The CPMs of 12 CA patients (6 male, 6 female; mean age, 61 years) and 5 control cadaveric subjects (3 male, 2 female; mean age, 67 years) were analyzed. There were relatively fewer type I fibers (67%) in patients with CA than in controls (81%), but the difference was not significant (p = .18). Type I fibers were slightly smaller in CA patients (38.7 microm) than in controls (47.2 microm), but this was not significantly different (p > .05). Of the 12 CA patients, 3 had type II predominance, a feature not seen in normal subjects. Patients with CA had relatively fewer type I fibers, although the difference was not statistically significant. The MHC isoform composition and fiber size were not different between CA patients and normal subjects. This is the first report to characterize the CPM in patients with CA.
The cauda equina region is prone to injury from a variety of causes, all of which have to be cons... more The cauda equina region is prone to injury from a variety of causes, all of which have to be considered during the performance of spinal anesthesia. This article reviews these causes and discusses their approach.
Purpose: Epilepsy and syncope can be difficult to distinguish, with misdiagnosis resulting in unn... more Purpose: Epilepsy and syncope can be difficult to distinguish, with misdiagnosis resulting in unnecessary or incorrect treatment and disability. Combined tilt-table and video EEG (vEEG) testing (tilt-vEEG) is infrequently used to parse these entities even at large centers. Because of the discovery of a rare case of epileptic seizure induced by head-up tilt (HUT) (no prior cases have been published), the authors sought to verify the rarity of this phenomenon. Methods: An observational, retrospective case series study of all combined tilt-vEEG studies performed at Stanford Health Care over a 2-year period was performed. Studies were grouped into categories: (1) abnormal tilt and normal vEEG; (2) abnormal vEEG and normal tilt; (3) abnormal vEEG and abnormal tilt; (4) normal tilt and normal vEEG, with neurologic symptoms; and (5) normal tilt and normal vEEG without neurologic symptoms. Results: Sixty-eight percent of patients had an abnormal study (categories A–C), with only 3% having both an abnormal tilt and an abnormal EEG (category C). Of these, one patient had a focal epileptic seizure induced by HUT. With HUT positioning, the patient stopped answering questions and vEEG showed a left temporal seizure; systolic blood pressure abruptly dropped to 89 mm Hg (64 mm Hg below baseline); heart rate did not change, but pacemaker showed increased firing (threshold: <60 bpm). Conclusions: Combined tilt-table and vEEG evaluation was able to identify a previously unreported scenario—head-up tilt provocation of an epileptic seizure—and improve treatment. Combined tilt and vEEG testing should be considered for episodes that persist despite treatment to confirm proper diagnosis.
As previous chapters have illustrated, the oropharyngeal swallow is the end result of several coo... more As previous chapters have illustrated, the oropharyngeal swallow is the end result of several coordinated neuromuscular elements: velopharyngeal closure, tongue loading, tongue pulsion, closure of the laryngeal vestibule, upper esophageal sphincter opening, and pharyngeal clearance. It is estimated that more than 30 muscles are involved in the various stages of the swallow. Muscular disorders leading to impairment in any of these steps can cause dysphagia. A better understanding of the swallowing problems associated with these conditions may help in guiding treatment, choosing technical aids, modifying the consistency of foods, swallowing rehabilitation, and nutritional support by the non-oral route.
Journal of Clinical Neuromuscular Disease, Dec 1, 2003
ABSTRACT The spectrum of hereditary neuropathies has evolved recently as a result of the exponent... more ABSTRACT The spectrum of hereditary neuropathies has evolved recently as a result of the exponential growth of genetic research. For the purpose of this review, we will use Charcot-Marie-Tooth (CMT), hereditary liability to pressure palsy (HNPP) and hereditary sensory and autonomic neuropathies (HSAN) to illustrate the current clinical and genetic approach to such neuropathies.
Journal of Bone and Joint Surgery, American Volume, 1996
Pseudoparalysis or apparent weakness of a limb associated with septic arthritis or osteomyelitis ... more Pseudoparalysis or apparent weakness of a limb associated with septic arthritis or osteomyelitis is a well documented phenomenon. Muscular spasm associated with pain caused by the infection can lead to the apparent weakness. In contrast, true nerve paralysis associated with osteomyelitis is uncommon, and documentation of the electromyographic changes is rare. We describe a five-week-old male infant who had a brachial plexus neuropathy and paralysis of the right upper extremity secondary to septic arthritis of the glenohumeral joint and osteomyelitis of the proximal part of the humerus. A male infant was delivered by cesarean section after thirty-six weeks of gestation to a primiparous thirty-five-year-old woman. No problems with the use of the upper extremities were noted at birth. At the age of three weeks, the infant had projectile vomiting and was admitted to the hospital for the operative correction of pyloric stenosis. The hospital course was uneventful, and he was discharged. One week later, he was admitted to the pediatric service for evaluation of a loss of movement of the right upper extremity of several days' duration. There was no history of fever or signs of constitutional illness while the infant was at home, but the mother reported that he had had mild upper respiratory symptoms for two days. The rectal temperature on admission was 37.2 degrees Celsius, and the vital signs were stable. The physical examination revealed a palpable mass in the right axilla, and the right upper extremity was flaccid. The patient had poor grasp, active flexion of the elbow was decreased, and active abduction of the shoulder was absent. Laboratory evaluation revealed a white blood-cell count of 20,800 per cubic millimeter (20.8 x 109 per liter) with a differential of 60 per cent segmented neutrophils, 2 per cent bands, 2 per cent lymphocytes, 16 per cent …
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