Neurorecurrence

NEURORECURRENCE, a term given by Ehrlich (P. Ehrlich) to inflammations and paralyses, mainly of cranial nerves, less frequently of spinal nerves, which are particularly often observed in patients with fresh syphilis shortly after completion of their salvarsan treatment. According to Malaise, "here we are dealing with those paralyses of the cranial nerves that appear in patients in the primary and secondary stages of syphilis after the administration of salvarsan; in this case, the same nerves are predominantly affected and in exactly the same order as in the obvious manifestations of early neurosyphilis." At present, this term is not recognized by many authors. Thus, Steiner points out that in so-called neurorecurrence, as a rule, we are not dealing with a true recurrence in the nervous system, but with an intensified under the influence of treatment specific lesion in the central nervous system; therefore, he proposes to call these lesions meningoneuritis. Jahnel suggests abandoning the term N., since the lesions designated as N. occur in sufficient numbers in the early stages of syphilis without any preceding therapy. Ehrlich's neurorecurrences are observed almost exclusively in the early stages of syphilis, usually within the first year after infection; significantly less frequently within the second year; in the third year and later, N. are a great rarity. Those observed particularly frequently at the beginning of the salvarsan era were initially considered by some authors, especially Finger, as an expression of a special neurotropism of salvarsan preparations acting on weakened by the syphilitic virus cranial nerves. However, Ehrlich from the very beginning considered N. truly syphilitic diseases, which was later confirmed by 1) the presence in some cases of N. of pathological cerebrospinal fluid; 2) the reverse development of lesions under the influence of vigorous combined (mercurial-salvarsan) therapy. At present, it is precisely established that N. can occur without any therapy. Steiner in this connection divides meningoneuritis into 2 groups: 1) developed without any specific therapy and 2) occurring after specific treatment. Thus, Rigaud in 61 out of 581 cases of secondary syphilis found early or late labyrinthitis. Beck and others point to the greater frequency of lesions of the vestibular and cochlear parts of the inner ear in syphilitics. Fehr in 2,636 secondary syphilitics found 317 times eye lesions before the start of treatment. These lesions of syphilitic nature respond excellently to specific therapy. N. were also observed in the pre-salvarsan era. Benario published 122 cases of N. occurring after mercury therapy, and after the introduction of bismuth into the treatment of syphilis, cases of N. after purely bismuth therapy have been described (Nathan, Koenigsberg). Rothschild observed 36 N.: after mercury-0, after "606"-2, "914"-1, Silbersalvarsan or Neosilbersalvarsan-9, mercury + salvarsan-17, after bismuth + salvarsan-2. Zarkhi found on the material of the syphilitic department of the State Venereal Institute from 1922 to 1925 18 cases of N., and in 6 cases they developed without preceding therapy. At the beginning of the salvarsan era, N. were observed very frequently (in Finger's clinic in 500 syphilitics-44 times); then they are noted significantly less frequently; according to the statistics of a special German commission (1920), which investigated side effects during salvarsanotherapy, out of 225,780 injections, 18 cases of neurorecurrences were registered. The etiological factor of N. is insufficient, especially salvarsan therapy (Jadassohn). Some authors believe that N. can occur when using fractional doses of specific means with large intervals. According to Ehrlich's indications, one should distinguish those lesions of the nervous system that develop soon (within 24 hours) after the administration of salvarsan from those that are detected several weeks after the end of the course of treatment. In the first case, we are dealing with the Jarisch-Herxheimer reaction, and the developed nervous manifestations quickly yield to continued without delay specific therapy. In the second case, N. develop in the true sense of the word. The late time of their appearance Ehrlich explains by the insufficient vascularization of the nerves, as a result of which salvarsan does not penetrate in sufficient quantity into the nervous tissue and cannot destroy all the spirochetes present there; the remaining foci of them, multiplying later, lead to the formation of N. According to Hantke, spirochetes abundantly penetrate into the base of the brain and the nerves emerging from it due to the well-developed lymphatic pathways here, while salvarsan, according to Werther's research, with difficulty penetrates through the meninges and therefore is unable to fully affect the foci of spirochetes, which results in N. In N., we are dealing with a predominant lesion of the auditory, visual, facial, oculomotor, abducens, trochlear, and trigeminal nerves. These nerves are more often affected in isolation and less frequently in various combinations; especially often combined are lesions of the auditory and facial nerves, less frequently - trigeminal and abducens, oculomotor and abducens, auditory, facial and visual. According to Benario's statistics, combined lesions are observed only in 25%, in 75% - isolated N. in the following sequence: auditory-43%, visual-26%, facial-15.9%, oculomotor-7.6%, abducens, trochlear and trigeminal nerves - each in 2.5%. Zarkhi in 18 cases of N. found lesion of the auditory and visual nerves 7 times each, facial-6 times, hypoglossal-3 times and oculomotor-2 times. Clinically, in addition to the lesion of the indicated nerves, paralyses of bulbar nerves can be observed. In other cases, hemiplegias, epileptiform seizures, paraparesis of the lower extremities, disorders of urination, polyneuritis (Malaise) may occur. In cases where N. develop gradually, over several weeks, they may be preceded by headaches, dizziness, noise in the ears, however, they can also occur suddenly without any prodromal phenomena. - The auditory nerve can be affected in its entirety; however, isolated lesions of its cochlear or vestibular part can be encountered; paralyses and pareses can be unilateral and bilateral. Clinically, the lesion manifests itself as noise in the ears, dizziness with certain movements, disturbance of equilibrium with nausea, hearing loss, sometimes up to complete deafness. - Diseases in the eye area are extremely diverse. According to Gilbert, "in the eye they proceed in the form of extremely strong swelling of the papilla, which protrudes by several diopters and produces the impression of a severe congestive papilla; the swelling is accompanied by hemorrhages into the nerve papilla and its surroundings and clouding of the vitreous body." In addition to the congestive papilla, neuritis optica is often observed. Diseases of the optic nerve occur unilateral and bilateral. As a result of paralysis of the oculomotor nerve, ophthalmoplegia externa and interna can develop. Paralyses of the facial nerve in the overwhelming majority of cases are unilateral. - N. are often accompanied by changes in the cerebrospinal fluid, in which pleocytosis is most often encountered with fluctuations in very wide limits: from normal to 1,000 cells (Gennerich); the phase of the 1st reaction of Nonne-Appelt can be positive and negative; the Wassermann reaction in the fluid in fresh cases is usually negative, in older cases it can be positive. The question of the connection of N. with the phenomena of tabes and progressive paralysis at present remains open. Individual authors describe cases where progressive paralysis and tabes developed in patients suffering from N. during secondary syphilis. However, most researchers (Mattauschek, Finger, Kyrle) do not find it possible to establish a connection between N. and these diseases, since the number of early lesions of the central nervous system is 50-80%, while late ones (tabes and progressive paralysis) occur on average in 12%, and despite the significant increase in N. in the first years of the use of salvarsan, there was no associated increase in cases of progressive paralysis and tabes. The therapy of N., according to the opinion of most authors, should be reduced to vigorous specific, preferably combined treatment: bismuth or mercury + salvarsan. - Prevention of N. follows from the fact that the vast majority of them develop due to insufficient treatment. Therefore, to prevent N., vigorous specific treatment is necessary, which should first of all consist in the correct dosing of salvarsan preparations (especially one should avoid excessively small doses of the drug); before the use of salvarsan, the patient is recommended to have several injections of mercury or bismuth. - The prognosis in N. is as a rule favorable. Steiner points to their great tendency to spontaneous reverse development. In individual cases, despite all measures, it was not possible to achieve complete recovery.