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LETTER TO THE EDITOR
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 421
 

Response to the letter to the editor


Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission23-Apr-2016
Date of Decision28-Apr-2016
Date of Acceptance28-Apr-2016
Date of Web Publication25-Jul-2016

Correspondence Address:
S A Jabeen
Department of Neurology, Millennium Block, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.186858

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How to cite this article:
Jabeen S A, Sandeep G, Mridula R, Meena A K, Borgohain R. Response to the letter to the editor. Ann Indian Acad Neurol 2016;19:421

How to cite this URL:
Jabeen S A, Sandeep G, Mridula R, Meena A K, Borgohain R. Response to the letter to the editor. Ann Indian Acad Neurol [serial online] 2016 [cited 2019 Dec 8];19:421. Available from: http://www.annalsofian.org/text.asp?2016/19/3/421/186858


Sir,

I thank Mahjoub et al. for showing interest in our article about a patient with suspected Leigh's disease.

We arrived at the diagnosis of mitochondrial disease and in particular Leigh's disease in a 37-year-old female due to the following reasons.

In her first presentation, the patient presented with unexplained vomiting followed by acute brainstem syndrome, which was diagnosed as Wernicke's encephalopathy in view of the horizontal gaze-evoked nystagmus and ataxia with imaging evidence of dorsal brainstem lesions. In the first admission, investigations to evaluate for the cause of recurrent vomiting were done including endoscopy and colonoscopy, which were normal. Retrospectively, the reason for unexplained gastrointestinal (GI) symptoms [2] is probably mitochondrial disease as the patient is completely asymptomatic after using mitochondrial regimen (thiamine and coenzyme Q).

The patient stopped thiamine after discharge and she relapsed back with severe symptoms. The shock was not due to sepsis as the total white blood cell count and serum procalcitonin including blood and urine cultures were normal. A normal central venous pressure with normal two-dimensional echo, lack of elevation of creatinine kinase, and troponin levels also rules out the possibility of takotsubo cardiomyopathy or any cardiac cause for the ventilatory failure or shock. [1] The most plausible cause for respiratory failure was brainstem involvement as she had associated bulbar palsy. The patient was fully conscious even in the presence of severe lactic acidosis making the possibility of underlying status epilepticus less likely. Moreover, the patient improved without any antiepileptic drug.

We agree with Mahjoub et al. that the investigations to establish the molecular diagnosis of mitochondrial disease were incomplete due to unavailability of nuclear DNA analysis for mitochondrial genes and electron microscopy. Regarding the course of the disease in adult-onset Leigh's disease as they pointed out, it ranges from sudden death shortly after onset to recovery and long-term survival. [2],[3] Our patient, at the time of this writing, is doing well and continuing to take coenzyme Q and thiamine supplements. Although the molecular diagnosis could not be established, the clinical profile of the patient (unexplained GI symptoms, unexplained elevation of serum and cerebrospinal fluid lactate, imaging picture, supportive features on muscle biopsy, the dramatic response to thiamine and other mitochondrial cocktail strongly favors a mitochondrial disease, most likely Leigh's disease. [4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Finsterer J. Leigh and Leigh-like syndrome in children and adults. Pediatr Neurol 2008;39:223-35.  Back to cited text no. 1
[PUBMED]    
2.
Malojcic B, Brinar V, Poser C, Djakovic V. An adult case of Leigh disease. Clin Neurol Neurosurg 2004;106:237-40.  Back to cited text no. 2
[PUBMED]    
3.
Wick R, Scott G, Byard RW. Mechanisms of unexpected death and autopsy findings in Leigh syndrome (subacute necrotising encephalomyelopathy). J Forensic Leg Med 2007;14:42-5.  Back to cited text no. 3
[PUBMED]    
4.
Baertling F, Rodenburg RJ, Schaper J, Smeitink JA, Koopman WJ, Mayatepek E, et al. A guide to diagnosis and treatment of Leigh syndrome. J Neurol Neurosurg Psychiatry 2014;85:257-65.  Back to cited text no. 4
    




 

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