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CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1034--1036

Rash Decisions in Neurology: A Case Report of Brachioradial Pruritus Secondary to Cervical Intramedullary Lesion

Dhananjay Gupta, Nikith Shetty, Akhil Shivaprasad, Mahendra Javali, Rangaiah Pradeep, Anish Mehta, Purushottam T Acharya, Rangasetty Srinivasa 
 Department of Neurology, Ramaiah Medical College, Bengaluru, Karnataka, India

Correspondence Address:
Mahendra Javali
Department of Neurology, Ramaiah Medical College and Hospitals, Bengaluru - 560 054, Karnataka
India

Abstract

Brachioradial pruritus (BRP) is an enigmatic condition often encountered by dermatologists and passed off as a benign itch. It is an “idiopathic” pruritus, presenting as severe itching on the radial aspect of the elbow. The physical examination may be unremarkable except for mild pruritic lesions. Hence, the patient is treated with local applications of sunscreens, anti-inflammatory agents, anti-histamines and steroids, most of which prove to be ineffective. Dermatomal localization of localization of pruritis has suggested cervical myeloradiculopathy as a novel aetiology and this has been elucidated in recent studies. Here we report a young man, who presented with brachioradial pruritus and was diagnosed to have a C6-7 intramedullary cervical cord lesion.



How to cite this article:
Gupta D, Shetty N, Shivaprasad A, Javali M, Pradeep R, Mehta A, Acharya PT, Srinivasa R. Rash Decisions in Neurology: A Case Report of Brachioradial Pruritus Secondary to Cervical Intramedullary Lesion.Neurol India 2021;69:1034-1036


How to cite this URL:
Gupta D, Shetty N, Shivaprasad A, Javali M, Pradeep R, Mehta A, Acharya PT, Srinivasa R. Rash Decisions in Neurology: A Case Report of Brachioradial Pruritus Secondary to Cervical Intramedullary Lesion. Neurol India [serial online] 2021 [cited 2021 Oct 27 ];69:1034-1036
Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1034/325376


Full Text



Brachioradial pruritus (BRP) is a poorly understood phenomenon, which was first described by Waisman in 1968 as an intense itching on the lateral aspect of the elbow.[1] Most of the patients present with burning, stinging or tingling sensation over the dorsolateral aspect of the elbow, extending up to the arm or forearm. Classically, the symptoms are more prominent at night and are aggravated during the summer months. Patients have severe itching with skin excoriations. Other than the pruritic lesions, the physical examination is usually normal. Initially it was thought to be a benign lesion due to chronic sun exposure, however, the current understanding includes compressive lesions of the lower cervical spine as a contributing factor.[2],[3],[4],[5],[6],[7] Whether the association between spine lesions and brachioradial pruritis is causal or merely co-incidental is still debatable.

 Case Report



A 30-year-old man complained of multiple itchy lesions over the right arm for 7 months prior to presentation. It was associated with intermittent burning sensation over the outer aspect of the arm. He did not report any weakness of limbs. On examination vitals were stable. There were multiple erythematous papular lesions arranged in a linear fashion over the extensor aspect of the arm – in the distribution of C7 dermatome [Figure 1]. There were no vesicles or excoriations. Neurological examination revealed reduced power in the right triceps muscle - 4+/5 and an absent triceps jerk. A dermatological evaluation was also suggestive of pruritic lesions. Routine metabolic workup was normal. MRI cervical spine showed a heterogeneous signal intensity intra-medullary lesion in the C6-C7 region. The lesion was T2-hypointense with a hyperintense center and showed blooming on SWI. There was no post-contrast enhancement. The MRI features were consistent with a diagnosis of cavernoma of the cervical cord [Figure 2].{Figure 1}{Figure 2}

 Discussion



Morris Waisman, a dermatologist in Florida, USA reported few patients with intense localized pruritus of the extensor aspect of elbow, roughly corresponding to the proximal Brachioradialis muscle. The lesions occurred on the arm exposed directly to the sun and showed summer exacerbations. Hence, he named the condition as “Brachioradial Summer Pruritus”. The risk factors included blue-eyed, fair-to-moderate complexion patients, involved in outdoor activities- often working bare-armed or wearing short-sleeved shirts.[1] For the next two decades, it was thought to be a photo-dermatitis secondary to UV exposure and treatment included sunscreens and topical steroids. In 1983, Heyl described 14 patients of brachioradial pruritus from the temperate climate of Transvaal, South Africa. In 4 of them, degenerative and osteoarthritic changes of the lower cervical vertebrae (C4-7) were found and thus cervical radiculopathy was proposed as an aetiology.[2] Subsequently, authors have reported presence of brachioradial pruritus in patients with cervical disk herniation,[3] neural foraminal stenosis[4] and cervical ependymoma.[5] Amr Gohar reported a middle-aged man with localized pruritus of the right hand, which was initially misdiagnosed as scabies. Subsequently patient developed numbness of the right upper and lower limbs and underwent MRI spine which showed a C5-6 disk prolapse with hypertrophied ligamentum flavum.[6] Researchers in University of Massachusetts retrospectively analyzed 22 patients with brachioradial pruritus. 11 of these patients underwent cervical spine radiographs on basis of clinical suspicion. A cervical spine lesion, correlating with the location of pruritus was found in all of them.[7] A similar prospective trial undertaken in University Hospital Munster in Germany found detectable cervical MRI changes in all the 42 patients with brachioradial pruritus. In 80.5% of these patients, a disk protrusion or stenosis of the intervertebral foramina led to nerve compression, which correlated significantly with the dermatomal localization of the pruritus.[8]

The exact pathophysiology of cervical lesions causing brachioradial pruritus is uncertain, though similar localized neuropruritic lesions have been described with compression of posterior rami of T2-T4 (notalgia parasthetica) and lumbosacral radiculopathy (anogenital pruritus). Itching has also been described in myelitis associated with multiple sclerosis and Neuro-myelitis optica, both as an index symptom and as a presentation of relapse of the disease.[9] Traditionally, pain and “Itch” were considered to be carried by the same unmyelinated group C fibers. The “Intensity theory” hypothesized that the milder, subliminal stimuli are perceived as “itching” and the moderate-to-severe intensity stimuli cause pain with nocifensive behaviour in form of withdrawal of the limb. More recently, the “Specificity theory” has replaced the intensity theory and researchers have been able to delineate distinct histamine-sensitive “itch” receptors[10] and 'itch-selective' neurons[11] within the central spinothalamic tract. Thus, it can be proposed that there is a complex interaction between the nociceptive and pruritoceptive neurons in the spinal cord as a result of compressive lesions, which ultimately leads to predominance of either the itch sensation or the pain sensation. Association with other sensory-motor signs and symptoms and radiographic lesions in the corresponding dermatomal distribution suggest a neuropathologic basis of the pruritus. The successful treatment with anticonvulsants like Gabapentin and Pregabalin further establish a neurogenic cause of itching.

 Conclusion



Our case highlights the importance of suspecting a cervical cord lesion in patients with unexplained itching and pruritus, especially in an upper limb dermatomal distribution. Imaging with plain radiographs and MR imaging of the cervical spine should be sought in all cases of BRP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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