RevBrasAnestesiol.2017;67(6):651---654
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL
INFORMATION
Tropical
spastic
paraparesis
---
anesthetic
approach
Margarida
Rodrigues
∗,
Francisco
Cabral,
Fátima
Pina
CentroHospitalarSãoJoão,DepartamentodeAnestesia,Porto,Portugal
Received5November2014;accepted2December2014 Availableonline16September2016
KEYWORDS
Human
T-lymphotropicvirus; HepatitisCvirus; Infectiousdiseases; Cystectomy; Tropicalspastic paraparesis
Abstract
Introduction:HTLV-1 infection is endemic inJapan, Caribbean, Africa, and SouthAmerica. Itistransmittedfrommothertochild,sexualcontact,bloodtransfusions,orsharingneedles. Tropicalspasticparaparesis(TSP)isachronicdegenerativeneurologicaldiseaseassociatedwith thisinfection.Itresultsfromaspinalcordsymmetricaldegenerationatthethoracicleveland ischaracterizedbyprogressivemotorweaknessinthelowerlimbs,hyperreflexia,sensitivity changes,urinaryincontinence,andbladderdysfunction.
Clinicalcase: Female,53yearsold,HTLV-1infectionandTSP.Shehaddecreasedstrengthin thelowerlimbsandhyperreflexia,pareticgait,spasticity,andneurogenicbladdersymptoms, withrecurrenturinaryinfections.Shewasscheduledforcystectomy.Thepatientwasmonitored accordingtostandardASA.Duetoseverecoagulopathyandthepossibilityofneurological wors-ening,epiduralcatheterwasnotplaced.Theinductionofgeneralanesthesiawasperformed withmidazolamandfentanyl,followedbyetomidateandcisatracurium.Shewasintubatedwith atubesizesevenandmaintainedwithdesfluraneandoxygen.Anesthesiawasuneventful;the surgerylasted1hourand50min.Therewerenocomplicationsintheimmediatepostoperative period,duringhospitalization,nordeteriorationoftheneurologicalexamination.Thepatient wasdischarged20dayslater.
Discussion/Conclusion: Therearereportsofdecreasedelectromyographicresponseand neu-rological deteriorationassociated withpropofolinthesepatients,etomidatewasused.The hepaticmetabolismofrocuroniumposedarisk,wechosetousecistracurium.Itwasconcluded thattheanesthesiachosendidnotaffectthecourseofthedisease.
©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:anam1206@hotmail.com(M.Rodrigues). http://dx.doi.org/10.1016/j.bjane.2014.12.004
652 M.Rodriguesetal.
PALAVRAS-CHAVE
Human
T-lymphotropicvirus;
VirusdahepatiteC; Infeciologia; Cistectomia;
Paraparesiaespástica tropical
Paraparesiaespásticatropical---abordagemanestésica
Resumo
Introduc¸ão:Ainfecc¸ãoporHTLV-1éendêmicanoJapão,nasCaraíbas,naÁfricaenaAmérica doSul.Atransmissãoocorredemãeparafilho,porcontatossexuais,transfusõesdesangueou partilhadeagulhas.Aessainfec¸ãoestáassociadaumadoenc¸aneurológicadegenerativacrônica, aparaparesiaespásticatropical(TSP).Essaresultadeumadegenerac¸ãosimétricadaespinal medulaem nível torácico.Caracteriza-se pordiminuic¸ão progressivadaforc¸a nosmembros inferiores,hiperreflexia,alterac¸õesdesensibilidade,incontinênciaurináriaedisfunc¸ãovesical. Casoclínico:Mulherde53anos,infecc¸ãoporHTLV-1eTSP.Apresentavadiminuic¸ãodaforc¸a nosmembrosinferioresehiperreflexia,tinhaumamarchaparética,espasticidadeesintomas debexiganeurogênicacominfecc¸ões urináriasderepetic¸ão.Foipropostaparacistectomia. FoimonitoradadeacordocomopadrãodaASA.Devidoàcoagulopatiagraveeàpossibilidade deagravamentoneurológico,nãosecolocoucateterepidural.Ainduc¸ãodaanestesiageralfoi feitacommidazolamefentanilseguidosdeetomidatoecisatracúrio.Foientubadacomumtubo seteemantidacomdesfluranoeoxigênio.Aanestesiadecorreusemintercorrências,acirurgia terminouem uma horae 50 minutos.Nãohouvequaisquer complicac¸õesno pós-operatório imediato,duranteainternac¸ão,nemdeteriorac¸ãodoexameneurológico.Adoentetevealta 20diasdepois.
Discussão/Conclusão:Há relatos de diminuic¸ãoda respostaeletromiográfica edeteriorac¸ão neurológica associadas ao propofol nesses doentes, razão para uso de etomidato. A metabolizac¸ão hepática do rocurônio representava um risco e se optou pelo cisatracúrio. Conclui-sequeoplanoanestésicoescolhidonãotevequalquerinterferêncianocursodadoenc¸a. ©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
The human T-lymphotropic virus 1 (HTLV-1) infection is endemic in some countries, notably in Japan, Caribbean Countries, and parts of Africa and South America. The prevalence increases with age and is higher in females.1 Itis transmittedfrommothertochild,by sexualcontact, blood transfusions, or sharing contaminated needles. Two diseases are associated with this infection: adult T-cell leukemia/lymphoma (ATL) and tropical spastic parapare-sis (TSP) --- a chronic degenerative neurological disorder. TSP results from symmetrical degeneration of the spinal cord lateral columns at the thoracic level.2 It is charac-terizedby progressivemotor weaknessin thelowerlimbs andhyperreflexia, associated withautonomic dysfunction withurinaryincontinenceandbladderdysfunction.Changes in gait due to decreased strength in the lower limbs are themainsymptomofdisease.Autonomicdysfunction symp-toms may precede, be concomitant, or be manifested laterindiseaseprogression.Noteworthy,thesymptomsof neurogenic bladder, which resultsin high mortality rates, especiallyfeelingofincompleteemptying,pollakiuria, uri-naryurgency,recurrenturinarytractinfections,gallstones,
andevensevere casesof chronicpyelonephritis orkidney failure.3
Unlike the multiple sclerosis (MS), the symptoms develop gradually,withoutperiodsofcrisis andremission. Furthermore,thereisnoinvolvementofthecranialnerves andcognitivefunction.Thissyndromedevelopsinlessthan 1%ofthoseinfectedbyHTLV-1.1
Current knowledge of the anesthetic management of thesepatientsresultsfromclinicalisolatedrarecases.The aimofthispaperistopresentacaseofTSPandexposeits anestheticapproach.
Case
report
Tropicalspasticparaparesis---anestheticapproach 653
Atthetimeofsurgery,thepatientwasneurologically sta-ble.Shehadbilateraldecreasedstrengthinthelowerlimbs, hyperreflexia,andnosensitivitychanges;walkedwith third-party support; had a paretic march, with spasticity; had nochangesofcranial nervesor upperlimbs.She alsohad symptomsofneurogenicbladderwithrecurrenturinary,an indicationtoundergothesurgeryinquestion.Herpersonal history included infectionwith hepatitis C with thrombo-cytopenia (37×109.L−1 platelets) and severe coagulation disorders(aPTT38.6,TP13.8),type2diabetes,and depres-sivesyndrome.Theremainingpreoperativetests(analytical study,ECG,chestX-ray,andkidneyfunctiontest)were nor-mal.
Anesthesia
Monitoring:ASAstandards,BIS,andTOF. Premedication:midazolam.
Itwasdecidednottoinsertanepiduralcatheterdueto patients’severecoagulopathyandthepossibilityof neuro-logicalworsening.
Induction: Fentanyl followed by etomidate and cisatracurium.Intubationwithatubesizeseven.
Maintenance: General anesthesia (GA) was maintained with desflurane and oxygen. Two additional bolus of cisatracuriumweregivenaccordingtoTOF.
Inductionandmaintenanceofanesthesiawere unevent-ful: Due totechnicaldifficulties, the surgical team chose nottoperformthe initiallyscheduled radical cystectomy. Acystostomywasperformed,andtheprocedurelastedone hourand50min.
Recovery: The neuromuscular blockade was reversed withneostigmineandatropineand,fiveminuteslater,the patienthad400mLtidalvolume,respiratoryrate12bpm, andwaswideawake,soshewasextubatedintheoperating room.Therewerenocomplicationsintheimmediate post-operativeperiod,duringhospitalization,ordeteriorationof theneurological examination.The patientwasdischarged 20dayslater.
Discussion
and
anesthetic
considerations
Patients with tropical spastic paraparesis have numer-ous complications resulting from the disease progression; notably, infected scabs of prolonged recumbency, uri-naryretentionduetosphincterdysfunction,andfractures resultingfromperipheralneuropathy,whichpredominantly affectsthelowerlimbs.Theyare,therefore,potential sur-gicalcandidates.
In recent years, and mainly the result of thematic review articles or case reports in endemic regions, we havesoughttounderstandtheimplicationsandanesthetic needsofthesepatients,avoidexacerbations/crisisor post-surgical complications. Thus, the anesthetic management of these patients should take into account some special features.
Manyofthesepatientsareunderdailycorticosteroids,4 andneedtokeepdosesnotbelowtheusualduringthe peri-operative period (hydrocortisone 200mg in major surgery
and100mginminorsurgery)duetotheriskofleft ventri-culardysfunctionandrefractoryhypotension.
Classically, the neuraxial anesthetic approach is con-traindicated in patients with active disease or active neurologicalsymptoms.However,thereareseveralreports ofneuraxialanesthesiainpatientswithTSP,without dete-riorationofneurologicalsymptoms,oraccelerateddisease progression.3
Someauthorshavereportedthattheinductiondosesof propofol(2---3mg.kg−1)causesdecreasedelectromyographic
activity(about20%)inpatientswithTSP,without,however, decreasedmusclestrengthorneuronalconductionvelocity.5 The choice of neuromuscular relaxant to use in such patients is also a subject of great controversy.The pres-enceofahighnumberofmusclecholinergicreceptorsoutof theneuromuscularplateonthesepatientsgreatlyincreases thesensitivitytoacetylcholine.Thus,theuseof depolariz-ingmusclerelaxants,suchassuccinylcholine,carriesahigh riskofseverehyperkalemia(increaseofabout3mmol.L−1)
that mayresult in cardiac arrest. Ifnecessary, the group of nondepolarizing muscle relaxants should be preferred, although thesepatients often exhibit a prolonged action. Thus,neuromuscularblockmonitoringisessential.
Thechoiceof thetechniqueandanestheticprotocolin thispatienttookintoaccountthecurrentrecommendations forpatients withknownmyelopathy. Neuraxial anesthesia was discarded due to coagulopathy and risks of exacer-bation/disease progression. The selected drugs, notably inducingand relaxing drugs, minimize the risk of serious perioperativecomplications.
Conclusions
Tropicalspastic paraparesis is a rareneurological compli-cationofHTLV-1infection,isendemicinJapan,Colombia, BrazilandCaribbeancountries.Itischaracterizedbyslow andprogressivespasticity, hyperreflexia,muscleweakness mainlyinthelowerlimbs,bladderdisorders,andchangesin sensitivity.
The managementofthesepatients ischallenging. Usu-ally, general anesthesia is selected at the expense of neuraxialanesthetictechniquesduetothepossibilityof dis-ease exacerbation. The choice of the induction drug and especiallythemusclerelaxant(whereverpossible,avoidthe depolarizingrelaxants)isessentialtopreventmajor periop-erativecomplicationsthatprolonghospitalizationandresult intheprogressionofdiseaseactivity.Carefulmonitoringof theneuromuscularblockisessentialandindisputable.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
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4.Ribas JG, Melo GC.Mielopatia associadaao vírus linfotrópico humanodecélulasTdotipo1(HTLV-1).RevSocBrasMedTrop. 2002;35:377---84.
