Modafinil for treatment of fatigue in post-polio syndrome: A randomized controlled trial
Richard A.Rison, Neurology Consultants Medical Group, 12291 E. Washington Blvd. Suite #303, Whittier, CA 90606rison@usc.edu
Submitted September 09, 2007
I read with interest the article by Vasconcelos et al on the use of modafinil for the treatment of fatigue in post-polio syndrome. [1] Like many clinicians caring for post-polio patients, the overall negative results and expanding list of past failures are disappointing.
Poliomyelitis has recently been identified as a cause of muscle weakness in patients with West Nile virus (WNV) infection, and a syndrome of acute asymmetric flaccid paralysis (AFP) has been described in numerous patients. [2] This acute asymmetric flaccid paralysis resembles that of the anterior horn cell poliomyelitis seen in polio victims and is often associated with disabling fatigue and frequently hinders physical therapy and rehabilitation efforts. I am unaware of any reported medication trials in WNV-AFP patients for symptomatic relief of disabling fatigue.
In the summer of 2003, WNV invaded Southern California and then dispersed to every county in the state. [3,4] Shortly thereafter in my community, we started seeing our first cases of WNV-induced neurologic complaints including monoplegic patients. Following workup on the medical floors including serologies, cerebrospinal fluid analysis, and electrodiagnostic studies, they all eventually completed rehabilitation stays that were plagued with fatigue. I treated with both pyridostigmine and modafinil in varying doses in these patients (n=3) with mixed and overall discouraging results.
West Nile virus is the leading cause of arboviral encephalitis in the United States and surveillance data for 2006 suggest a 14% increase in cases of WNV neuroinvasive disease from 2005 and the largest number reported since 2003. [5] Therefore, it is probable that the number of WNV-AFP patients that will increase.
Given the overlapping similarities of neuromuscular manifestations in the anterior horn cell poliomyelitis of WNV-AFP and polio/post-polio disease, clinicians should all be aware of and monitor for the development of any “post-West Nile virus” fatigue syndrome.
This letter is a call for randomized controlled medication trials in WNV-AFP patients with fatigue as has been so aptly done in post-polio patients. Wishful thinking and my “n=3” aside, perhaps this time the list of failures will be shorter.
References
1. Vasconcelos OM, Prokhorenko OA, Salajegheh MK, et al. Modafinil for treatment of fatigue in post-polio syndrome: A randomized controlled trial. Neurology 2007;68;1680-1686.
2. Leis AA, Stokic DS, Webb RM, Slavinski SA, Fratkin J. Clinical spectrum of muscle weakness in human West Nile virus infection. Muscle Nerve 2003;28:302-308.
3. Reisen W, Lothrop H, Chiles R, et al. West Nile virus in California. Emerg Infect Dis. 2004;10:1369-1378.
4. Reisen WK, Fang Y, Lothrop HD, et al. Overwintering of West Nile virus in Southern California. J Med Entomol 2006;43:344-355.
5. West Nile virus activity--United States, 2006 MMWR Morb Mortal Wkly Rep. 2007;56:556-559.
Disclosure: The author reports no conflicts of interest.
I read with interest the article by Vasconcelos et al on the use of modafinil for the treatment of fatigue in post-polio syndrome. [1] Like many clinicians caring for post-polio patients, the overall negative results and expanding list of past failures are disappointing.
Poliomyelitis has recently been identified as a cause of muscle weakness in patients with West Nile virus (WNV) infection, and a syndrome of acute asymmetric flaccid paralysis (AFP) has been described in numerous patients. [2] This acute asymmetric flaccid paralysis resembles that of the anterior horn cell poliomyelitis seen in polio victims and is often associated with disabling fatigue and frequently hinders physical therapy and rehabilitation efforts. I am unaware of any reported medication trials in WNV-AFP patients for symptomatic relief of disabling fatigue.
In the summer of 2003, WNV invaded Southern California and then dispersed to every county in the state. [3,4] Shortly thereafter in my community, we started seeing our first cases of WNV-induced neurologic complaints including monoplegic patients. Following workup on the medical floors including serologies, cerebrospinal fluid analysis, and electrodiagnostic studies, they all eventually completed rehabilitation stays that were plagued with fatigue. I treated with both pyridostigmine and modafinil in varying doses in these patients (n=3) with mixed and overall discouraging results.
West Nile virus is the leading cause of arboviral encephalitis in the United States and surveillance data for 2006 suggest a 14% increase in cases of WNV neuroinvasive disease from 2005 and the largest number reported since 2003. [5] Therefore, it is probable that the number of WNV-AFP patients that will increase. Given the overlapping similarities of neuromuscular manifestations in the anterior horn cell poliomyelitis of WNV-AFP and polio/post-polio disease, clinicians should all be aware of and monitor for the development of any “post-West Nile virus” fatigue syndrome.
This letter is a call for randomized controlled medication trials in WNV-AFP patients with fatigue as has been so aptly done in post-polio patients. Wishful thinking and my “n=3” aside, perhaps this time the list of failures will be shorter.
References
1. Vasconcelos OM, Prokhorenko OA, Salajegheh MK, et al. Modafinil for treatment of fatigue in post-polio syndrome: A randomized controlled trial. Neurology 2007;68;1680-1686.
2. Leis AA, Stokic DS, Webb RM, Slavinski SA, Fratkin J. Clinical spectrum of muscle weakness in human West Nile virus infection. Muscle Nerve 2003;28:302-308.
3. Reisen W, Lothrop H, Chiles R, et al. West Nile virus in California. Emerg Infect Dis. 2004;10:1369-1378.
4. Reisen WK, Fang Y, Lothrop HD, et al. Overwintering of West Nile virus in Southern California. J Med Entomol 2006;43:344-355.
5. West Nile virus activity--United States, 2006 MMWR Morb Mortal Wkly Rep. 2007;56:556-559.
Disclosure: The author reports no conflicts of interest.