Abstract
Study Objectives Idiopathic diaphragm paralysis is probably more common and responsible for more morbidity than generally appreciated. Bell’s palsy, or idiopathic paralysis of the seventh cranial nerve, may be seen as an analogous condition. The roles of zoster sine herpete and herpes simplex have increasingly been recognized in Bell’s palsy, and there are some data to suggest that antiviral therapy is a useful adjunct to steroid therapy. Thus, we postulated that antiviral therapy might have a positive impact on the course of acute idiopathic diaphragm paralysis which is likely related to viral infection. Methods Three consecutive patients with subacute onset of symptomatic idiopathic hemidiaphragm paralysis were empirically treated with valacyclovir, 1,000 mg twice daily for 1 week. Prior to therapy, diaphragmatic function was assessed via pulmonary function testing and two-dimensional B-mode ultrasound, with testing repeated 1 month later. Diaphragmatic function pre- and post-treatment was compared to that of a historical control group of 16 untreated patients. Results All three subjects demonstrated ultrasound recovery of diaphragm function 4–6 weeks following treatment with valacyclovir. This recovery was accompanied by improvements in maximum inspiratory pressure (PImax) and vital capacity (VC). In contrast, in the untreated cohort, diaphragm recovery occurred in only 11 subjects, taking an average of 14.9 ± 6.1 months (mean ± SD). Conclusions The results of this small, preliminary study suggest that antiviral therapy with valacyclovir may be helpful in the treatment of idiopathic diaphragm paralysis induced by a viral infection.
References
Holland N, Weiner G (2004) Recent developments in Bell’s palsy. BMJ 329:553–557. doi:10.1136/bmj.329.7465.553
Axelsson S, Lindberg S, Stjernquist-Desatnik A (2003) Outcome of treatment with valacyclovir and prednisone in patients with Bell’s palsy. Ann Otol Rhinol Laryngol 112(3):197–201
Hato N, Matsumoto S, Kisaki H, Takahasi H, Wakisaka H, Honda N, Gyo K, Murakami S, Yanagihara N (2003) Efficacy of early treatment of Bell’s palsy with oral acyclovir and prednisolone. Otol Neurotol 24:948–951. doi:10.1097/00129492-200311000-00022
Hato N, Yamada H, Kohno H, Matsumoto S, Honda N, Gyo K, Fukuda S, Furuta Y, Ohtani F, Aizawa H, Aoyagi M, Inamura H, Nakashima T, Nakata S, Murakami S, Kiguchi J, Yamano K, Takeda T, Hamada M, Yamakawa K (2007) Valacyclovir and prednisolone treatment for Bell’s palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol 28:408–413. doi:10.1097/01.mao.0000265190.29969.12
Sullivan FM, Swan IRC, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD, Clarkson JE, Hammersly V, Hayavi S, McAteer A, Stewart K, Daly F (2007) Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med 357(16):1598–1607. doi:10.1056/NEJMoa072006
Gilden DH, Tyler KL (2007) Bell’s palsy—is glucocorticoid treatment enough? N Engl J Med 357:1653–1655. doi:10.1056/NEJMe078188
Tsairis P, Dyck PJ, Mulder DW (1972) Natural history of brachial plexus neuropathy. Report on 99 patients. Arch Neurol 27:109–117
Chan CK, Loke J, Virgulto JA, Mohsenin V, Ferranti R, Lammertse T (1988) Bilateral diaphragmatic paralysis: clinical spectrum, prognosis, and diagnostic approach. Arch Phys Med Rehabil 69:976–979
Mulvey DA, Aquilina RJ, Elliot MW, Moxham J, Green M (1993) Diaphragmatic dysfunction in neuralgic amyotrophy: an electrophysiologic evaluation of 16 patients presenting with dyspnea. Am Rev Respir Dis 147:m66–m71
Hughes PD, Polkey MI, Moxham J, Green M (1999) Long-term recovery of diaphragm strength in neuralgic amyotrophy. Eur Respir J 13(2):379–384. doi:10.1183/09031936.99.13237999
Kumar N, Folger WN, Bolton CF (2004) Dyspnea as the predominant manifestation of bilateral phrenic neuropathy. Mayo Clin Proc 79(12):1563–1565
Lahrmann H, Grisold W, Authier FJ, Zifko UA (1999) Neuralgic amyotrophy with phrenic nerve involvement. Muscle Nerve 22:437–442. doi:10.1002/(SICI)1097-4598(199904)22:4<437::AID-MUS2>3.0.CO;2-F
Summerhill EM, Abu El-Sameed Y, Glidden TJ, McCool FD (2008) Monitoring recovery from diaphragm paralysis with ultrasound. Chest 133:1–7. doi:10.1378/chest.07-2200
Chetta A, Rehman AK, Moxham J, Carr DH, Polkey MI (2005) Chest radiography cannot predict diaphragm function. Respir Med 99:39–44. doi:10.1016/j.rmed.2004.04.016
Wilcox PG, Pardy RL (1989) Diaphragmatic weakness and paralysis. Lung 167:323–341. doi:10.1007/BF02714961
Wait JL, Nahormek PA, Yost WT, Rochester DP (1989) Diaphragm thickness-lung volume relationship in vivo. J Appl Physiol 67:1560–1568
Cohn D, Benditt JO, Eveloff S, McCool FD (1997) Diaphragm thickening during inspiration. J Appl Physiol 83:291–296
Gottesman E, McCool FD (1997) Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med 155:1570–1574
ATS/ERS Task Force (2005) Standardisation of spirometry. Eur Respir J 26:319–338. doi:10.1183/09031936.05.00034805
ATS/ERS Task Force (2005) Standardisation of the measurement of lung volumes. Eur Respir J 26:511–522. doi:10.1183/09031936.05.00035005
ATS/ERS (2002) Statement on respiratory muscle testing. Am J Respir Crit Care Med 26:511–522
Verhey P, Gooselin M, Primack S, Kraemer A (2007) Differentiating diaphragmatic paralysis and eventration. Acad Radiol 14(4):420–425. doi:10.1016/j.acra.2007.01.027
Similowski T, Strauss C (2004) Iatrogenic-induced dysfunction of the neuromuscular respiratory system. Clin Chest Med 25:155–166. doi:10.1016/S0272-5231(03)00142-4
Halpern SL, Covner A (1949) Motor manifestations of herpes zoster. Arch Intern Med 84:907–916
Anderson JP (1970) Paralysis in herpes zoster. BMJ 3:357
Melcher WL, Dietrich RA, Whitlock WL (1990) Herpes zoster phrenic neuritis with respiratory failure. West J Med 152:192–194
Fujimoto S, Matsuno O, Matsumoto T, Kumamoto T, Tsuda T (1996) A case of diaphragmatic paralysis following herpes zoster. Rinsho Shinkeigaku 36(2):345–347
Pellas F, Olivares JP, Zandotti C, Delarque A (1993) Neuralgic amyotrophy after parvovirus B19 infection. Lancet 342:503–504. doi:10.1016/0140-6736(93)91635-Y
Maas JJ, Beersma MFC, Haan J, Jonkers GJPM, Kroes ACM (1996) Bilateral brachial plexus neuritis following parvovirus B19 and cytomegalovirus infection. Ann Neurol 40:928–932. doi:10.1002/ana.410400618
Misamore GW, Lehman DE (1996) Parsonage-Turner syndrome (acute brachial neuritis). J Bone Joint Surg Am 78:1405–1408
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Crausman, R.S., Summerhill, E.M. & McCool, F.D. Idiopathic Diaphragmatic Paralysis: Bell’s Palsy of the Diaphragm?. Lung 187, 153–157 (2009). https://doi.org/10.1007/s00408-009-9140-z
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DOI: https://doi.org/10.1007/s00408-009-9140-z