|Year : 2017 | Volume
| Issue : 5 | Page : 7-31
|Date of Web Publication||20-Mar-2017|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Abstracts. Ann Indian Acad Neurol 2017;20, Suppl S1:7-31
| Poster Session I;|| |
Friday, 24 March 2017; 13:30-14:30 Hrs
I 1: Tubercular meningitis presenting as cerebral venous sinus thrombosis: A rare association
Ojha P, Sardana V
Department of Neurology, Government Medical College, Kota, Rajasthan
Background: Central Nervous system Tuberculosis is a serious infection commonly found to occur in the developing countries endemic to tuberculosis. It may manifest as meningitis, meningoencephalitis, tuberculoma, tubercular abscess, hydrocephalus, stroke due to tuberculous vasculitis and encephalopathy. Cerebral venous sinus thrombosis (CVT) is a type of cerebrovascular disease that occurs due to thrombosis of the intracranial veins and sinuses. Rarely, Tubercular meningitis (TBM) can predispose to cerebral venous sinus thrombosis (CVT). Here we report a young man, who initially presented as cerebral venous sinus thrombosis and was found to have Tubercular Meningitis. Case: A 28-year-old male patient was admitted in Neurology department with complaints of high-grade continuous fever with diffuse headache and vomiting for 7 days prior to admission. On admission, patient was febrile, had stable vitals and was drowsy with occasionally responding to verbal commands. Cranial nerve examination was within normal limits except for the presence of bilateral early papilloedema. Neck stiffness was present along with positive Kernig sign. Rest of the neurological examination was within normal limits. Non contrast Computed tomography of Brain was suggestive of abnormal hyperdensity in the region of Superior sagittal sinus. Magnetic Resonance Venogram was suggestive of thrombosis of Superior sagittal sinus and right transverse sinus. CSF examination was suggestive of Tubercular Meningitis. Patient was started on antitubercular treatment and Low molecular weight heparin followed by oral anticoagulants. The patient responded to medications during hospitalisation, was discharged in a haemodynamically stable condition and was advised to continue oral anticoagulant for 6 months with regular INR monitoring along with antitubercular treatment and tapering dose of oral steroids. Conclusion: Cerebral venous sinus thrombosis is a disease which can rarely be associated with tuberculous meningitis. A very high index of suspicion is required to correctly diagnose the complication as its timely aggressive treatment has an excellent outcome.
I 2: Tubercular meningitis in a tropical setting: A case of TBM presenting as brainstem stroke
Sachan M, Kushwaha S, Gupta A, Tarfarosh SFA
Department of Neurology, IHBAS, Delhi
Introduction: Stroke occurs in 20% of patients with TBM, underlying vascular damage and infarction are much more extensive. A vast majority of the strokes in TBM are situated in the 'tubercular zone', i.e., basal ganglia, and are bilateral and multiple in number. We here present an unusual case of TBM presenting as brainstem stroke. Case report: A 78 year old female presented with high grade fever for two days, acute onset of weakness of right upper and lower limbs followed by altered sensorium since 1 day. There was no history of headache, vomiting, decreased appetite, weight loss, or any seizure like activity. Patient was a non-diabetic, non-hypertensive and a non-smoker. On examination, the blood pressure of the patient was 160/100 mmHg, pulse rate was 64/minute, temperature was 100°F, and respiratory rate was 32/minute. The GCS of the patient was 8/15 (E2V2M4). Neurological examination revealed a bilateral pinpoint pupil not reacting to light. The assessment of motor and sensory system could not be done as the patient was in altered sensorium. DTRs were absent on the right side and +2 on lt side. Bilateral planter Extensor. The MRI findings showed acute infarct in right and left ventral pons, and partially extending into left ventral medulla. Patient was investigated in detail to rule out all secondary causes of fever. Patient was intubated and kept on mechanical ventilator support. Nevertheless, the patient's sensorium did not improve and, so we did a lumbar puncture on the 3rd day of admission and to our surprise, CSF examination ZN staining and culture were positive for M. tuberculosis. We started ATT along with dexamethasone. Patient improved after 20 days and was discharged from the hospital. Conclusion: TBM is the most feared extrapulmonary complication of TB. Among Cerebral infarction caused by TBM, brainstem stroke may be one of the manifestations.
I 3: Infarcts in tuberculous meningitis patients reported from a tertiary care neuro-psychiatry hospital in North India
Bhirud LB, Kushwaha S, Khurana S, Gupta R
Department of Neurology, Zydus Hospital, Anand, Gujarat
Objective: To Study the clinical and radiological characteristics of infarct in Tuberculous Meningitis (TBM) patients. Background: Tuberculous meningitis is the most common cause of meningitis in adults in tropical countries. The present study is an endeavour to find out the clinical and radiological characteristics of infarct in Tuberculous Meningitis patients and outcome of such patients. Methods: The present study is an observational study conducted at Institute of human behaviour and allied sciences (IHBAS), Delhi. The study is combination of Retrospective and Prospective case series of Tuberculous Meningitis patients. Clinical History, Neurological Examination, investigations including CSF study and Neuroimaging was documented and the data was compiled and analysed using appropriate statistical methods in SPSS 17. Results: Total 49 patients in prospective and 111 patients in retrospective study of TBM were enrolled after taking informed written consent in prospective case series and after applying set inclusion and exclusion criteria made for study protocol. Focal motor deficit i.e. hemiparesis or paraparesis was seen in 10% patients of TBM. Contrast enhancing CT Brain or MRI Brain done shows apart from meningeal enhancement and tuberculomas, other complications of TBM were hydrocephalus which was seen 25% patients and infarcts were seen in 20% patients of TBM for which most common site was basal ganglia. Conclusions: In this observational study, we found 20% patients had infarct on Neuroimaging of TBM patients and the most common site was basal ganglia.
I 4: Clinicoradiological profile of central nervous system tuberculomas in a tertiary level hospital in North West India- A case series of ten patients
Sulena S, Garg S, Vidhi, Garg R, Paramdeep
Department of Neurology, GGS Medical College, Faridkot, Punjab
Introduction: Tuberculoma of Central Nervous System (CNS) is a rare manifestation of Tuberculosis and accounts for 0.2% of Intracranial Space occupying lesions. Due to its similarity with many infectious and non-infectious entities, diagnosis is difficult. This study was planned as a pilot study to see the clinicoradiological profile of CNS tuberculomas presenting to our hospital. Material and Method: This was a prospective study where 10 consecutive patients diagnosed as CNS tuberculomas presenting to Neurology department were enrolled. Detailed history and neurological examination was done followed by neuroimaging and clinicoradiological profile was assessed. Results: Ten consecutive cases diagnosed as CNS tuberculomas were enrolled in the study. There were 8 males and 2 females. The age group ranged from 9 years to 52 years with mean age of 27.7 years. Out of 10 patients one had coexisting pulmonary tuberculosis, one had celiac disease and none of them was HIV positive. Triad of headache, vomiting and fever was present in 3 patients and all patients had focal or cranial neurological deficits. Two patients had presented with partial seizure with secondary generalisation. Neuroimaging (CECT/CE- MRI) had shown supratentorial, infratentorial, both supra and infratentorial leions in 4, 2, 4 patients respectively. All the lesions were multiple, conglomeration was seen in 3 patients and 8 had ring enhancing lesions and 2 had nodular lesions. Associated findings (hydrocephalous, meningeal enhancement, infarcts) were seen in 2 patients. All patients were put on antitubercular drugs. Follow up scan has been done for 4 patients and all have shown regression in the size and number of lesions. Conclusions: CNS Tuberculomas presents at a young age and predominantly in males and has a variable clinical and radiological presentation.
I 5: Persisting tuberculomas: When to stop therapy?
Kulkarni R, Pujari S, Atre A
Department of Neurology, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra
CNS tuberculoma is not uncommon disease in India. Clear guidelines are lacking about its treatment duration. Tuberculoma is known to grow in size while being on therapy. Some enhancing tuberculomas may persist for longer period in spite of adequate anti-tubercular therapy (ATT). One study showed that about 70% patients had residual lesions after 18 months of treatment. We present 6 cases of tuberculomas which were diagnosed clinically and radiologically. They were treated for a period >1 year and were followed with serial imaging. They had shown clinical improvement but the enhancing lesions had persisted. ATT was stopped if a patient was clinically asymptomatic and last 2 MRI did not show any change. All 6 patients were followed up later clinically and radiologically for >1 year after stopping treatment. They did not get any new symptoms except seizures in 1. The MRI did not show any new lesion or worsening of lesions except perilesional edema in the patient with seizure. CT scan showed calcification of the enhancing lesion in 3 patients. Many tuberculomas shrink and disappear with therapy over time. However, some lesions may become necrosed or calcified and may not disappear at all. If the patient has received correct ATT regimen for 12 to 18 months and is clinically asymptomatic or has no new signs/symptoms and if there are no new lesions on last 2 imaging, then therapy can be stopped. Clinical and radiological follow up is advised. The disappearance of lesion on imaging cannot be considered as end-point of treatment in all patients.
I 6: Tuberculosis of the CNS: A survey of patterns of practice
Kadam ND, Kulkarni R, Meshram C, Kadam N
Department of Neurology, Dr. Satish Khadilkar: JJ Hospital, Mumbai, Maharashtra
Aims and objectives: This questionnaire based survey of neurologists is aimed at understanding the patterns of practice implemented by neurologists in diagnosing and treating CNS tuberculosis. Materials and methods: All neurologists practicing in Maharashtra state were surveyed. To reach wide number of neurologists, survey was carried out online. A total of 20 questions were included. [Appendix A]. Results: 78 out of 156 (50%) neurologists responded to the questionnaire. There was no consensus of opinion on lowest CSF cell count (52% opined for 10-25 cells, 27% for 25-50 cells), lowest protein count (52% opined for 75-100 mg/dl, 37% for 50-75 mg/dl, CSF ADA levels (55% do not use, 45% use), contents and duration of ATT used (51% uses HRZE+ HR as the primary ATT regimen.51% prefer duration of 18 months for TBM and 46% prefer duration of 12-18 months for tuberculoma), follow up of the cases (42% opine for neuroimaging 3 monthly during the course till resolution). Consensus opinion was seen on contact history (not present in 82%), use of CSF TB PCR (75% use it), strategy to stop ATT (clinical and radiological improvement both by 88% neurologists), use steroid in all cases of TBM (72% uses) and proportion of drug resistant cases (<25%). Conclusions: The striking feature of this study was of the lack of uniformity in diagnostic (CSF cell &protein counts, ADA levels) and therapeutic (primary drug regimen and duration and follow up) aspects of dealing with tuberculosis of the CNS. On the other hand, majority consensus was seen on neurological presentation of CNS TB, Use of TB PCR in CSF and use of steroids. This study underscores the urgent need of uniform practical guidelines for treatment of CNS tuberculosis. Appendix A- Questionnaire.
I 7: Dilemma in the treatment of CNS tuberculosis: 2 cases
Bolegave VS, Benny R, Singh R, Shah S, Banerjee D, Pai P
Department of Neurology, Fortis Hospital Mulund, Mumbai, Maharashtra
Aim was to highlight the problem of vasculitis due to CNS tuberculosis (TB) and persistent CNS tuberculoma in spite of adequate therapy. Case 1: A 25 year old female presented with constitutional symptoms (fever & anorexia of 3 week duration). On evaluation she was found to have sputum negative military tuberculosis for which she was started on Anti Tuberculous therapy. She had one episode of of seizure 2 weeks later. On further evaluation, she was found to have multiple tiny ring enhancing lesions suggestive of tuberculomas on her MRI brain. Her CSF was reactive. She was started on intra venous (IV) steroids and anti- epileptics. She improved over the next 2 weeks and was re admitted with worsening of her neurological symptoms in the form drowsiness and left sided weakness in spite of 24 mg per day of dexamethasone. Repeat imaging showed vasculitic infarcts in the thalamus and brain stem. Her dose of IV dexamethasone was stepped up to 32 mg and ecosprin was added. Her neurological condition worsened dramatically with further increase in infarct size and number. Thalidomide was added. Despite all efforts patient worsened and succumbed to her illness. Case 2: A 47 year male presented with headaches of 6 weeks duration without any focal signs or constitutional symptoms. On evaluation he was found to have a ring enhancing lesion on the left temporal lobe with perilesional edema. CSF was reactive. He was treated with AKT and steroids. Despite completing 1 year of treatment his MRI showed increase in lesion size but there was no neurological worsening. Hence steroid therapy was extended but repeat imaging after another 6 months showed further increase in the size of lesion & perilesional edema. Stereotactic biopsy of the lesion confirmed it to be TB.
I 8: Comparison of sensitivity and specificity of CSF ADA and TB-PCR DNA for diagnosis of CNS tuberculosis
Ghosh S, Purandare R, Mondal GP
Department of Neuromedicine, Calcutta National Medical College, Kolkata, West Bengal
Background: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with extremely varied clinical presentations, predisposing factors, imaging findings, and outcomes. We conducted a prospective study of 50 patients of CVT admitted in our department for a period of 1 year. Results: The mean age of presentation was 35 years and there was a male preponderance (3:2). Headache was the most common presenting feature (80%) followed by seizures, altered sensorium, hemiparesis, cranial nerve deficits. The predisposing factors were predominantly noninfective and included inherited thrombophilias like protein C and S deficiencies, pregnancy, hyperhomocystinemia, malignancies. Infective cases were mostly bacterial meningitis. Investigations: MR Venography is the most definitive imaging modality and revealed lack of flow due to thrombosis in venous sinuses most notably in superior saggital sinus. CT Scans revealed delta sign, cord signs in few cases. D-dimer was elevated in another few cases (25%). Treatment: Anticoagulation is the cornerstone of treatment. LMW Heparin was given in all patients for 14 days and was followed by oral anticoagulant, mostly warfarin and in few cases by Dabigatran especially in protein C and S deficient patients. Appropiate antibiotics were used in selected cases where infection was the etiology. Interventional procedures like decompressive hemicraniectomy or endovascular thrombolysis were not required in any of the cases. Outcome: Only 2 patients (4%) died within 7 days of the illness despite initiation of therapy. Out of the surviving 48 patients, 8 (12.5%) are recovering from residual disability and the rest are doing well.
I 9: Multi drug resistant and heteroresistant mycobacterium tuberculosis with associated gene mutations from tuberculous meningitis patients in India
Gupta R, Thakur R, Kushwaha S, Jalan N, Rawat P
Department of neurology, Institute of Human Behavior and Allied Sciences, Delhi
Background: Heteroresistant Mycobacterium tuberculosis (MTB) strains (mixture of susceptible and resistant subpopulations) are major challenges for detection by available drug susceptibility testing (DST) methods and successful therapy. The aim of this study was to detect MDR and heteroresistant tuberculosis strains with the associated gene mutations from patients of tuberculous meningitis (TBM). Materials and Methods: A total of 197 MTB isolates from 478 patients of TBM were collected from July 2012 to July 2015 and subjected to DST by BACTEC MGIT and line probe assay. Hetero resistance was defined as presence of both WT and mutant genes in LPA. Results: Of 197 MTB isolates, 11 (5.6%) were MDR, 23 (11.6%) were mono resistant to INH and 1 (0.5%) isolate was mono resistant to RMP. Out of 34 INH resistant and 12 RMP resistant isolates by MGIT hetero resistance was detected in 8 (23%), 2 (2.3%) isolates respectively. Rifampicin heteroresistant strains had WT bands along with mutation band S531L whereas INH heteroresistant strains had WT bands with mutation band S315T1. Additional 10 INH resistant and 4 RIF resistant isolates by MGIT were detected sensitive by LPA which could be either due to presence of very few resistant bacteria or due to mutations in genes not detected by LPA. Additionally one MTB isolate was sensitive in MGIT but had C15T mutation depicting failure of MGIT DST to detect mutations in the promoter region of inhA. Conclusion: The prevalence of MDR M. tuberculosis was 5.5% in TBM patients with the most common mutation being ΔWT band with S531T for Rifampicin and ΔWT band with S315T1 for INH. Heteroresistance was detected in 8 (23.5%), 2 (16.6%) isolates for INH and Rifampicin respectively. MGIT DST is more sensitive for detecting resistance in MTB but for detection of heteroresistance both the phenotypic and genotypic method is recommended.
I 10: Craniovertebral junction tuberculosis: A rare presentation of tuberculosis revisited
Bajaj BK, Gupta S, Singh R, Singh R
Department of Neurology, PGIMER, Dr. RML Hospital, New Delhi
Cranio-vertebral tuberculosis is a rare manifestation of tuberculosis. It accounts for 1-5% of tubercular spondylitis. It is a life threatening condition with risk of severe neurological deficit and is known to occur in the absence of any other recognizable tubercular focus at the time of presentation. It is critical to diagnose and treat it early. In this presentation we will discuss the case of a sixty five year old female who remained undiagnosed for 6 months despite being symptomatic. She was finally provisionally diagnosed as cranio-vertebral junction tuberculosis after extensive investigations. The patient presented to us with initially aching, non-radiating pain in occipito-nuchal region aggravated by carrying weights overhead for 6 months. Her symptoms worsened gradually and she developed restriction of neck movement even on slight movements of neck. There was no history suggestive of neurological deficit. There was no history of fever, weight loss or decreased appetite. Detailed physical examination of the patient did not reveal any abnormality except for restriction of neck movements due to pain. She was comprehensively investigated for malignancy before final diagnosis of cranio-vertebral region tuberculosis was entertained and was treated conservatively with anti-tubercular drugs. We present the dilemmas we faced and, review the literature about cranio-vertebral tuberculosis and its management in this paper.
I 11: Cns blast crisis of CML misdiagnosed as tubercular meningitis
Saini PK, Sharma CM, Kumawat BL, Vyas A, Garg A, Kumar K
Department of Neurology, SMS Medical College, Jaipur, Rajasthan
Chronic myeloid leukemia is a Myeloproliferative disorder characterized by three phases: chronic, accelerated and blastic. In rare cases, isolated CNS blast crisis can occur. We report an unusual case of a patient with CML who, despite in complete cytogenetic remission of bone marrow for several years, experienced CNS blast crisis, initially misdiagnosed as tubercular meningitis. A 22 year old male, diagnosed with chronic phase CML five years back on Imatinib 400 mg daily and achieved hematological and cytogenetic remission, till six months back when he developed acute onset headache, vomiting with meningeal signs, subsequently suspected to have tubercular meningitis on basis of mild hydrocephalus in MRI Brain and lymphocytic pleocytosis, high proteins and low glucose in CSF analysis, for which steroids and anti- tubercular medications were started. Afterwards patient had mild improvement in symptoms which was transient and he continued to be deteriorated even after VP shunt surgery for increasing hydrocephalus and presented with persistent headache and vomiting, recurrent seizures and altered sensorium. Neurological examination revealed a drowsy and disoriented patient with positive meningeal signs.MRI brain showed confluent subcortical hyper intensities with meningeal enhancement but no hydrocephalus. Repeat CSF analysis showed similar biochemical picture but with positive cytospin for myeloid blasts on Myeloperoxidase staining.CSF TB PCR was negative. Patient was still in hematological remission. A diagnosis of isolated CNS blast crisis was made and patient was transferred to hemato oncological facility where chemotherapy was started and patient started to recover. In patients with treated CML, the rare case of an isolated CNS blast crisis has to be taken into account if neurological symptoms evolve and CSF biochemistry can mimic tubercular meningitis which is rather common entity. So this case report highlights the relevance of cytological study of CSF in patients of CML if suspected to have CNS blast crisis clinically.
I 12: Primary Multiple Intracranial Hydatidosis (MIH): A glance of a rare presentation
Gupta A, Kushwaha S
Department of Neurology, IHBAS, Delhi
Introduction: Culprit behind the causation of a zoonotic hydatid cyst is tape worm of genus Echinococcus. Incidence in Indian endemic zone is of 0.2%. Primary multiple intracranial hydatidosis is rarely reported in literature. Here we report a 19 year old male with multiple primary intracranial hydatid cystic lesions. Case report: We report a 19 years old male presented with complaints of refractory generalized tonic clonic seizures. There was no history of preceding fever, loose stools, chronic cough, any metabolic derangements, head trauma or any immunocompromised state. Patient was managed aggressively in emergency and loaded with valproate dose as per status epilepticus protocol and shifted to Intensive care unit. Routine hematological investigations were non-revealing. An urgent NCCT head was obtained which showed multiple hypodense lesions of varying sizes spread over both cerebral hemispheres. MRI Brain with contrast showed the presence of same lesions with small lesions in other areas. Extensive workup of the patient failed to reveal any evidence of primary disease in other organs. A MR Spectroscopy (MRS) of the lesions was was obtained to rule out the differentials. MRS revealed well resolved lipid lactate peak at 1.3 ppm with pyruvate peak at 2.48 ppm. In corroboration with MRI findings a diagnosis of hydatid cysts was confirmed. The cysts were later confirmed on histopathological examination by sampling one of the superficial cysts. The patient was started on steroids and anticonvulsants. Discussion: Intracranial hydatosis is rare, contributing only 1-2% of space occupying lesion in endemic regions while intracranial incidence in India is 0.2%. These manifest as solitary cystic lesions and occurrence of multiple intracranial hydatosis is an extremely rare phenomenon. Dealing with multiple cystic intracranial lesions, a diagnosis of intracranial hydatidosis to be kept in differentials specially in tropical countries.
I 13: Varicella Zoster Encephalitis: Clinical and radilogical profile
Osman S, Reddy MY, Chaudhary NV, Jaiswal SK, Parida S, Murthy JMK
Department of Neurology, Care Hospital, Banjara Hills, Hyderabad, Telangana
Background: Varicella Zoster Virus (VZV) is an uncommon cause of acute viral encephalitis, accounting for 10% of cases. However, the clinical and radiological characteristic of VZV-encephalitis has not been well studied. Material and Methods: Retrospective analysis of case records of patients with VZV-encephalitis admitted between April 2014 and October 2016. Diagnosis VZV-encephalitis was based on presence of VZV antigen in CSF or VZV antibodies in serum (IgM) and clinical evidence of herpetic skin lesions. Results: During the study period seven patients (mean age 67.5 years; range 55-77 years; M: F: 3:4) were admitted. Duration of the symptoms ranged between 4 and 25 days. The predisposing factors included: diabetes (4), rheumatoid arthritis (1) and ulcerative colitis (1).. Presenting features included: fever (3); headache (1); altered sensorium (4); seizures (2); ataxia (2), headache and decreased hearing acuity (1). The clinical syndromes were: meningoencephalitis in 6 (one with deafness and 2 with cranial neuropathies) and cerebellitis in one. MRI findings were leptomeningeal and seventh nerve enhancement in one patient and leptomeningeal and patchy parenchymal enhancement in three patients. All patients had abnormal CSF: pleocytosis and elevated protein. All patients received IV acyclovir for 14 days and had favorable outcome. Conclusion: VZV-encephalitis is potentially treatable encephalitis and should be considered in patients with encephalopathy and CSF pleocytosis.
I 14: Pyogenic meningitis in adults! please check for CSF leak!
Duberkar DR, Jawale R, Modagi R. Jawale R, Modgi R
Department of Neurology, Wockhardt Hospital, Nashik, Maharashtra
Objective: To highlight importance of active search for CSF leakage in adult patients with pyogenic meningitis. Background: In Modern antibiotic era Pyogenic meningitis in immunocompetent patients is rare and underlying mechanism leading to this serious infection must be sought in every patient. Out of 10 immunocompetent patients of pyogenic meningitis admitted to our hospital from December 2014 to November 2016 we demonstrated CSF leakage in 6 patients on CT cysternography. This emphasizes the importance of CT cysternography in patients with pyogenic meningitis where underlying mechanism is not clear. Patients and Methods: In last 2 year (December 2013 to November 2015), 10 patients with pyogenic meningitis (CSF study proven) were analysed. In 6 patients the underlying mechanism was not clear and hence we performed CT cysternography in these patients. 2 patients had history of CSF rhinorrhoea. 2 patients had past history of head injury and out of that one had undergone surgery for head injury. 1 patient had past history of acoustic schwanoma operated 5 years back. One patient had congenital bony defect producing CSF leakage. All 6 patients underwent corrective surgery. One patient had recurrence of CSF rhinorrhoea and pyogenic meningitis. Results: We demonstrated CSF leak in 6 patients with pyogenic meningitis who did not have any other significant risk factor or pyogenic meningitis. CSF leak closure prevented further episodes of pyogenic meningitis in 5 patients. Conclusions: Active search for CSF leak should be done in patients with pyogenic meningitis where mechanism responsible for susceptibility is unknown.
I 15: Neurological Lyme's disease from India: A case report
Shembalkar PK, Shembalkar S
Department of Neurology, Getwell Hospital & Research Institute, Nagpur, Maharashtra
Lyme's disease is rarely reported from India. Although, Lyme's disease outbreak is reported in lay press, there are no reports of neurological Lyme's disease. We report a young male who presented with acute right facial weakness. He has history of headaches and numbness in finger tips and toes in preceding week. Examination revealed right lower motor neuron facial weakness and impaired sensations in the fingers and toes. EMG & NC study showed asymmetrical axonal sensory neuropathy. MRI brain with contrast was normal, CSF showed raised proteins and normal cellularity. He was evaluated as asymmetrical neuropathy. ANA immunoblot, Serum ACE levels, and HIV were negative. Serum IgM for Lyme's disease was positive. He was treated with doxycycline and steroids. He recovered completely. The possible mode of acquiring infection was handling of deer. In India, Lyme's disease should be suspected in patients presenting with neurological symptoms and who reside near forests where considerable deer population is present.
I 16: Facial chorea as a presenting symptom of cerebral toxoplasmosis in an immunocompromised (HIV) patient : A case report
Sharma SK, Sardana V, Ojha P, Maheshwari D, Bhushan B
Department of Neurology, GMC, Kota, Rajasthan
Background: Neurological manifestations, as a presenting symptom of HIV infection, are present in approximately 10-20% cases, whereas about 60% of patients with advanced HIV disease have some neurologic dysfunction. The incidence of movement disorders in HIV infected population is only 2–3%, which may be tremors, chorea-ballismus, dystonias, myoclonus, paroxysmal dyskinesias and Parkinsonism More Details. In majority of the patients, hyperkinesias result from lesions caused by opportunistic infections such as toxoplasmosis. Facial chorea preceeding hemichorea-hemiballismus has been observed as an extremely uncommon manifestation in HIV patients. Nath et al (1993) reported a case with involuntary facial movements preceding the appearance of hemichorea–hemiballismus secondary to Cerebral Toxoplasmosis. We also present a case of Lt. hemichorea –hemiballismus in HIV patient, starting from the left half of face. Case - A 35 year old heterosexual, HIV positive male, diagnosed 2 years back, presented with 1 month history of Left hemichorea-hemiballismus preceded by left facial nonrhythmic, intermittent, spasmodic asynchronous movements in the upper lip, lower lip, and the platysma for 10 days without any history of limb weakness, altered sensorium or fever. Investigations revealed recent CD4 count of 123/mm3. MRI brain with contrast was suggestive of space occupying lesions of 8mm×9mm involving Rt. Crus cerebri and adjacent area of Rt. Thalamus, displaying thin peripheral rim enhancement with central non-enhancing necrotic area. Initially posiibility of Tuberculoma was considered. On further investigations, presumptive diagnosis of cerebral Toxoplasmosis was considered, based on radiological findings and positive serology [sensitivity≈90%, Specificity≈85%] -anti Toxoplasma antibody IgG = 300 and response to therapy. Pathogenesis was considered to be due to damage/pressure effect over subthalamic nucleus or its efferent pathways. Patient responded to Tetrabenazine, Trimethoprim-sulfamethoxazole (TMP-SMX) and HAART. Conclusion: Hemichorea - hemiballismus preceded by Facial chorea as presenting symptom of cerebral toxoplasmosis in HIV patients is a rare entity. Cerebral Toxoplasmosis should be suspected in HIV positive patient with hemichorea - hemiballismus since it is potentially treatable condition.
I 17: Comparative analysis of subclinical involvement of cranial neuropathy through electrophysiological studies (BAEPS, VEPS & EMG) in leprosy
Maheshwari PK, Kaushik S, Tripathy S, Gupta UN, Singh AK, Agarwal P
Department of Neurology, SN Medical College, Agra, Uttar Pradesh
Leprosy is a nonfatal, chronic systemic infectious disease, the clinical manifestations of which are primarily confined to skin and peripheral nervous system. Nerve involvement is prior to any clinical manifestation and it is usually segmental demyelinating in nature, which later on is followed by axonal degeneration. Few reports have suggested involvement of brainstem and cranial nerves in this disease. A method to detect asymptomatic neuropathy of cranial nerves electrophysiologically could be valuable to identify patients at high risk for symptomatic disease. This inspired us to study the involvement of facial, trigeminal, optic nerve and stato-acoustic nerve in leprosy. The present study was undertaken in Postgraduate Department of Medicine and Neurology Division of S.N. Medical College, Agra. A total of 50 cases (diagnosed patients of leprosy without any symptomatic cranial neuropathy) and 50 controls of 20-50 age groups were taken. BAEPs, VEPs, Blink reflex testing and facial motor conduction studies were performed on all subjects. Results were analyzed and compared; Student's t test was used. In this study the most important abnormalities on BAEPs, were the delayed peak latencies of wave III, wave V and interpeak latencies of wave I- III, wave III-V and wave I-V. The important observation on VEPs were the delayed peak latency of major positive potential (P100) in significant number of cases. On blink reflex testing significant delay in latency of R1, R2 (ipsilateral and contralateral) were observed. On facial motor conduction testing delay in maximum onset latency were observed in significant number of cases. In our study the delayed peak latencies and interpeak latencies indicate the subclinical involvement of facial and trigeminal in 80%, peripheral part of facial in 74%, optic nerve in 68%, and & stato-acoustic nerve in 52% of cases. This provides us with evidence for subclinical central or brainstem and peripheral demyelination in leprosy.
I 18: Herpes simplex encephalitis presenting with Kluver Bucy syndrome and Akinetic Mutism
Singh AK, Kulshreshtha D, Maurya PK, Thacker AK, Thakkar MD, Tiwari A
Department of Neurology, Dr. RMLIMS, Lucknow, Uttar Pradesh
Introduction: The Kluver Bucy syndrome (KBS) is a neurobehavioral syndrome with constellation of symptoms including visual agnosia (i. e., inability to recognize familiar objects or people), hypersexuality, emotional behavioral alteration (particularly placidity), hyperorality, hypermetamorphosis (i. e., strong impulse to react and explore to every visual stimulus) and memory deficits. The syndrome is seen in pathological states which destroy temporal lobes bilaterally. Herpes Simplex Encephalitis (HSE) is one of the common causes of this syndrome. Case report: A 40 yrs old gentleman came with 7 days history of fever, seizures and worsening sensorium. He presented with akinetic mutism at admission. He was evaluated in detail and found to have HSV-1 encephalitis on basis of CSF HSV-1 PCR positive result and MRI brain showing T2 WI & T2 Flair hyperintenstities in bilateral orbitofrontal and medialtemporal region with leptomeningeal enhancement. He was started on standard treatment with i.v acyclovir 20mg/kg for 14 days with phenytoin for seizures and other supportive management. After five days of treatment he began exhibiting strange behavioral abnormalities as follows: pelvic thrusting movements which increased whenever anybody approached him; hyperorality in form of chewing his ryles tube, blanket, clothes, thumb; exhibiting diminished fear responses or reacting with unusually low aggression to others in spite of beaten by them; repeatedly asking for food with gestures, but not identifying any person. On follow up he was ambulatory without support but didn't recognize his family members, language was limited to few words for asking food, had increased appetite, insomnia and hypermetamorphosis. He was continued with carbamazepine and clonazepam and advised for regular follow up. Conclusion: HSE is the most common infective cause of KBS though complete KBS is rarely seen in humans. No large studies have been carried out to determine the exact incidence of KBS in HSV encephalitis.
I 19: Utility of high resolution ultrasound in the diagnostic evolution of ulnar neuropathy with particular emphasis in leprosy neuropathy
Reddy MY, Chaudary NV, Jaiswal SK, Kumar S, Murthy JMK
Department of Neurology, Institute of Neurological Sciences, Care Hospital, Banjara Hills, Hyderabad, Telangana
Background: High Resolution Ultrasound (HRUS) is increasingly being used in the diagnostic evaluation of mononeuropathies. Of the mononeuropathies, ulnar neuropathies are the most common mononeuropathies seen in neuromuscular clinics. This study aims to define the role of HRUS in the etiological diagnosis of ulnar neuropathies. Material and Methods: This study was conducted at tertiary care hospital, Hyderabad, South India between May 2015 and October 2016. HRUS was performed using Philips HD15 with linear 12-3 probe. The cohort comprised of 31 patients with ulnar neuropathies. Mean cross sectional area (CSA) at specific sites, fascicular architecture and color flow were studied in 40 ulnar nerves from thirty one patients. Results: The etiological spectrum of ulnar neuropathy included: neuritic form of leprosy in 21; nerve tumors in 3; and ulnar neuropathies at cubital tunnel in 7 patients. In patients with neuritic leprosy, median CSA of ulnar nerve below, at and above elbow was 10.2 mm 2, 13.5 mm 2 and 14.75 mm 2 respectively. Fascicular architecture was distorted in all the 21 (100%) patients and colour flow in 7 (26%). In patients with cubical tunnel syndrome the median CSA of lunar nerve below, at and above elbow was 3.86 mm 2, 14.2 mm 2 and 5.95 mm 2 respectively. Fascicular architecture was lost in 4 (60 %) and color flow was absent. All the 3 patients with tumors had focal enlargements ranging between 60 mm 2 to 94.4 mm 2 and variable architecture. Conclusion: Long segment enlargement (> 10 cm) with maximum CSA in the above elbow segment with distorted fascicles favor leprosy. Short segment enlargement (< 5 cm) with maximum CSA at elbow favour cubital tunnel syndrome. Huge focal enlargements with variable architecture favour tumorous pathology.
I 20: Neurological involvement in melioidosis
Rynjah GL, Alexander M, Prabhakar AT, Babu SP
Department of Neurology, CMC, Vellore, Tamil Nadu
Introduction: Burkholderia pseudomallei nfection of the central nervous system is rare. We describe two cases of melioidosis presenting without predisposing factors. Case Reports: 32 year old lady presented with fever, headache, vomiting and progressive drowsiness with history of drainage of an abcess over the forehead 2 weeks prior. At presentation, she was drowsy with a swelling over the left eyelid. She had signs of meningeal irritation with a left lower motor neuron facial palsy. MRI of the brain showed an abscess in the left middle cerebellar peduncle with edema extending throughout the brainstem and into the cervical cord. Culture of the pus grew Burkholderia pseudomallei and she was started parenteral Meropenem. She developed septic shock with evidence of disease progression on serial imaging and expired 13 days after admission. 49 year old gentleman presented with 3 week history of neck pain radiating to the left upper limb and subsequent weakness of the left upper limb progressing to involvement of all 4 limbs and urinary retention. He was stupourose at admission and required mechanical ventilation and inotropic support. Imaging showed a left thalamic abscess and long segment spinal cord involvement from the midbrain to the thoracic cord. Blood culture and CSF cultures grew Burkholderia pseudomallei. He received parenteral Meropenem but expired 7 days after admission. Discussion: Melioidosis is increasingly described from India though CNS involvement is rare with rates ranging from 1.5-3%. Pathogenic mechanisms described are direct invasion, embolic spread as well as a neurotrophic exotoxin. Risk factors for acquiring the infection include Diabetes, CKD and malignant disease. This infection should be considered as a differential in patients with focal suppurative lesions as well as encephalomyelitis even in patients without these predisposing factors in endemic regions. Aggressive antibiotic therapy is required for management though mortality and morbidity rates remain high.
I 21: A rare presentation of herpes zoster infection
Subir A, Krshnadas CK, Gafoor F, Rafeeque, Girija
Department of Neurology, MES Medical College, Kolathur, Perinthalmanna, Kerala
59 years old male patient presented with acute onset paraplegia with a definite sensory level and associated urinary retention. His symptoms had developed nearly one month after the development of rashes over his left T7 dermatome consistent with herpes zoster. There was grade zero power in both lower limbs. Investigations revealed a demyelination in the spinal cord at the T 7 -T8 level and CSF study was positive for HZV immunoglobulin. He did not respond to steroids. Herpes zoster myelitis in an immunocompetent adult is rare. Even rarer is its presentation as an acute onset symmetrical paraplegia with a sensory level and usually will recover but that was not the situation in our case. Because of the rarity of this kind of presentation of herpes zoster myelitis I would like to present it in this forum.
I 22: Spectrum of neurological complications in chikungunya fever
Anand KS, Agrawal AK, Garg J, Dhamija RK, Mahajan RK
Depatments of Neurology & Microbiology, PGIMER and Dr Ram Manohar Lohia Hospital (RMLH), Lady Hardinge Medical College (LHMC), New Delhi
Introduction: Chikungunya is a mosquito-borne viral disease belonging to alphavirus genus of the Togaviridae family, spread mostly by Aedes aegypti mosquito. The outbreaks have been reported from various parts of India. The present study was conducted during the recent outbreak in 2016 in Delhi. Objective: To study the spectrum of neurological complications and their outcome in patients of Chikungunya. Methods: This prospective case study was conducted at Departments of Neurology, PGIMER & Dr RMLH and LHMC, New Delhi from July 2016 to October 2016. Patients presenting with typical picture of Chikungunya fever with positive serology and developing neurological complications were enrolled. Results: A total of 40 cases of Chikungunya fever (M: F= 14:26; age range = 21-90 yrs). All patients had typical features of fever and joint pains with twelve (30%) of them developing rash. All the cases were reactive for IgM antibodies in MAC-ELISA. A large spectrum of neurological complications was observed among patients involving almost whole of the neuraxis. The neurological manifestations included encephalopathy-12 (30%), cranial neuropathy-3 (7.5%), myelopathy-1(2.50%), radiculoneuropathy- 3(7.50%), mononeuropathy- carpel tunnel syndrome-9 (22.50%), extrapyamidal -tremors-1(3.85%). Ten patients reported worsening of preexisting diabetic peripheral neuropathy (4) & carpal tunnel syndrome (6) symptoms. One patient had aggravation of myasthenia gravis lending into respiratory failure. Patients developing encephalopathy had normal MRI in 7 & abnormal in 5. CSF showed mild lymhocytosis with raised protein and normal glucose. EEG showed diffuse theta and delta activity. Patients developing neuropathy had abnormal NCS. Imaging was normal in patient developing tremor. Death was seen in 4 (10%) patients, all from encephalopathy group. Conclusion: Chikungunya can affect almost all parts of nervous system including brain parenchyma, extrapyramidal system, brainstem, spinal cord, radicals, neuromuscular junction and peripheral nerves. Poor prognosis was observed in elderly particularly those with multiple co-morbidities.
I 23: Acute hemorrhagic encephalitis: A rare presentation of scrub typhus
Gupta S, Anand KS, Agrawal AK, GargJ, Mahajan RK
Departments of Neurology & Microbiology, PGIMER and Dr Ram Manohar Lohia Hospital (RMLH), New Delhi
Introduction: Scrub typhus is an acute febrile illness caused by infection with Orientia tsutsugamushi shi transmitted by trombiculid mites. The disease is widespread, extending from Japan to Australia and from India to the Pacific. It is prevalent in many parts of India and has been reported in the east, south and the Himalayas. Scrub typhus continues to be a public health problem in Asia. Case Report: A 19-years-old female admitted with history of travel to Himachal Pradesh for a scout camp following which she developed headache, multiple episodes of projectile vomiting for 7 days, fever for 4 days and altered sensorium for 2 days. At the time of admission GCS was E1M1V1, she was febrile, pulse rate 110/min, BP -116/64 mm Hg, R/R- 24/min, SPO2 90%. Bilateral conducted sounds were present in lower lung fields, pupils were 4 mm in size, round and sluggishly reacting to light, Doll's eye, corneal and conjunctival reflexes were normal. Fundus was normal. There was no response to deep painful stimulus. Deep tendon reflexes were normal and bilateral plantars were non elicitable. Hematologic parameters were suggestive of anemia, neutrophilic leucocytosis, dyselectrolytemia, deranged urea, creatinine, raised bilirubin, transaminases. Chest skiagram revealed bilateral pneumonitis, HBsAg, HCV, HIV I&II were nonreactive. Malarial parasite (EDTA, immunochromatography), typhoid, dengue, chikungunya, IgM for Japanese encephalitis, leptospira, Herpes simplex virus were negative. IgM ELISA for scrub typhus was positive. NCCT head was normal. MRI brain showed acute hemorrhagic encephalitis (T2/FLAIR hypertintense, T1 hypointense signal without contrast enhancement in bilateral external capsule, internal capsule, lentiform nuclei, thalamus, midbrain, pons, cerebellar peduncles, part of medulla, with restricted diffusion on DWI and blooming on SWI in bilateral external capsule and pons). She was managed with doxycycline, azithromycin, symptomatic and supportive management but further deterioration of general condition and hematologic parameters was seen. Patient developed myocarditis during course of hospitalisation following which she was started on steroids. Conclusion: Scrub typhus presenting as acute hemorrhagic encephalitis is a rare entity and should always be considered in differential diagnosis of acute encephalitic syndrome in tropical countries like India.
I 24: CNS infection with Listeria monocytogenes nes in a tertiary care centre from 2009-2016: incidence, clinical features and outcomes
Patil LN, Munshi M, Sanghvi D, Mani J, Kulkarni N, Bhatt M, Singhal T, Aggarwal A
Department of Neurology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra
Introduction: Listeria Monocytogenes is a gram positive coccobacillus that predominantly affects immunocompromised patients. CNS infection is associated with high mortality. We report the incidence, clinical spectrum, radiological features and risk factors of listeriosis in a tertiary care center. Methods: Over 7 year period 2009-2016, 3 patients were diagnosed with listeriosis in our hospital. All 3 patients had neurological involvement. Case 1: 56year immunocompetent women presented with rhombencephalitis. Serial Brain MRIs showed brainstem and basal ganglia lesions, CSF multiplex PCR assay was positive for Listeria. Patient improved with ampicillin and gentamicin for 6 weeks with only residual diplopia. Case 2: 13year immunocompromised (SLE on oral corticosteroids) girl presented with acute meningitis, cerebral abscess, and hydrocephalus. CSF cultures were positive for listeria. She recovered with residual hemiplegia after 6 weeks treatment with ampicillin and gentamicin. Case 3: 54year immunocompromised (chronic renal failure and multiple myeloma) women presented with acute meningitis. CSF analysis with VITEK was positive for Listeria. She died despite treatment for listeriosis. Conclusion: Listeriosis is rare infection even in tertiary care hospital. There should be high degree of suspicion in immunocompromised patients as early diagnosis and prompt treatment can yield good results.
I 25: Chikungunya encephalitis and "Diffusion Dot Sign''
Jagtap SA, Kulkarni R, Pujari S, Joshi A
Department of Neurology, Bharati Vidyapeeth, Deenanath Mangeshkar Hospital, Pune, Maharashtra
Background:Chikungunya virus from family of alpha viruses causes an acute viral infection characterized by fever, rash, and arthralgia and infrequently neurological involvement like meningoencephalitis, which many times undiagnosed or misdiagnosed with other viral meningoencephalitis. Very few studies have described clinical and imaging characteristics of Chikungunya. Objective: To study the neurological complication and magnetic resonance imaging (MRI) characteristics of Chikungunya. Method: We prospectively studied patients of Chikungunya with neurological manifestations and followed up for improvement and any permanent damage or death admitted in Deenanath Mangeshkar Hospital, Pune from Jan 2016 to October 2016. Results: Twenty four patients were admitted with chickengunya of 6 had neurological manifestation in the form of altered sensorium, limb weakness and urinary retention. The mean age was 55.3 years (range 5-82) while in encephalitis group 77.5 (range 59-82). All patients had altered mental functions lasting for one day to one week and requiring ICU stay up to 2 weeks. All patients had urinary retention, initially or during the course of illness. Only one patient had lower limb weakness and seizures in none. CSF was done in all which showed CSF protein from 27-100, cells 2-100, predominantly lymphocytes and positive PCR for Chikungunya. MRI Brain was done in all patients which showed characteristic bilateral fronto-temporal white matter lesions with restricted diffusion, which we called as “diffusion dot sign'' which enhanced on post contrast T1-weighted (T1WI) fat saturated image with resolution on follow up MRI. The average hospital stay was 21 days (range 7-40) with near complete improvement in all except one who succumbed to his illness. Conclusion: Typical clinical history of Chikungunya infection, neurological manifestation with associated MRI finding of “diffusion dot sign'' helps to confirm the diagnosis of Chikungunya Encephalitis, supportive management and exclusion of other causes.
I 26: Nosocomial infections in neurological intensive care units in India
Department of Neurology, Alexis Hospital, Nagpur, Maharashtra
Introduction: Dedicated Neurological Intensive care units (NICU) came into existence in India since last two decades. There is sparse data on nosocomial infections among these patients. The main objective of the study was to analyze spectrum of nosocomial infections among patients admitted in NICU. Material and methods: Present study is a monocentric, retrospective analysis of all consecutive patients more than 15 years age, admitted in NICU with neurological disorders over a period of 48 month (1st January 2010 to 31st December 2013). Patients admitted with craniocerebral trauma or other neurosurgical indications and acute neurological infections were excluded from the study. Patient admitted in the general wards and other ICUs were excluded from the study. In hospital variables like length of hospital stay (LOS) and outcome and culture reports were collected retrospectively for all patients by review of an electronic database. Mortality data was analyzed and strength of association of mortality and culture positivity was calculated using Chi square test. Results: During the study period of 48 months 1545 patients were enrolled. A total of 487 cultures were sent. Blood culture was positive in 74(24.6%) patients, urine in 104(34.55%) patients, BAL in 19(6.3%) patients, Suction tip in 85(28.24%) patients, central line tip in 77(25.58%) patients and 51(16.94%) patients had other cultures positive. Pseudomonas grew in 130(43.19%) patients, E. Coli in 103(34.22%) patients, Klebsiella in 111(36.88%), Staphylococcus in 69(22.92%), Methicillin Resistant Staph Aurius (MRSA) in 53(17.61%), Acinetobacter in 29(9.63%) and other organisms grew in 33(10.96%) patients. Cultures were positive in 8.4%, 33.33% and 63% in patients with a duration of stay of <7 days, 7-15 days and >15 days respectively. 38 patients expired with positive cultures (p = 0.00055) compared to the culture negative subgroup. Conclusion: Nosocomial infections in NICUs occur in approximately one third of all patients and are associated with significantly increased mortality.
I 27: Imaging findings in cases diagnosed to have dengue infection and undergoing imaging of the brain
Vanjare HA, Mannam P, Mani S
Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu
Aims and Objective: Evaluation of intracranial abnormality in cases diagnosed with dengue infection and undergoing imaging of brain (CT or MRI) for any reason. Materials and Methods: Retrospective analysis of radiology database for all cases with serology proved dengue infection undergoing imaging of the brain (both CT and MRI from 2006 to 2016). Cases were categorised based on age of patient and type of dengue infection. Images were reviewed and categorised based on imaging features. Patient data was assessed for clinical profile. Results: 32 cases were included with mean age of 19 years. 19 were children (18 years of age or less) while 13 were adult. Imaging abnormalities were grossly divided into necrotising encephalitis pattern, posterior reversible encephalitis pattern (PRES) or non-specific pattern which were 7 (22%), 8 (25%) and 6 (19%) respectively. Bleed was present in 9 cases (28%) of which 3 patients had gross haemorrhage (2 with cerebellar haematomas and 1 with gross Intraventricular bleed) while others had microhaemorrhages. There were 9 (28%) death with poorer outcome in adults as compared to children. All the 3 patients with gross haemorrhage did not survive. Conclusion: Acute necrotizing and PRES like pattern of involvement was common. Gross haemorrhage and adult age group was associated with poor outcome. Limitations: Inherent selection bias (only the very sick patients underwent imaging), retrospective data analysis and smaller sample size.
I 28: Neuroimaging in dengue encephalitis
Agrawal AK, Anand KS, Kumar P, Garg J, Mahajan RK
Departments of Neurology & Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER) & Dr RML Hospital, New Delhi
Introduction: Dengue is an arboviral tropical disease caused mainly by bite of Aedes aegypti mosquitoes. Dengue virus is an RNA virus belonging to family flaviviridae. It is classically considered a non-neurotropic virus with rare neurological involvement; however reported complications include encephalopathy, meningoencephalitis, stroke, myelitis and Guillain-Barre syndrome. This is a report of two cases of dengue encephalitis with characteristic neuroimaging findings. Case 1: A 28-years-old unmarried female presented with history of fever, headache and vomiting since 10 days, altered sensorium and generalized seizures since 5 days. On examination she was in altered sensorium and developed corneal edema and bilateral panophthalmitis. On investigation her total leucocyte counts and platelets were reduced. Dengue NS1 antigen by ELISA and IgM antibody were reactive in MAC ELISA. CSF revealed no cells, raised proteins (100 mg %) with normal sugar. CSF stains for Gram stain, AFB smear, TB PCR, HSV PCR and other arboviral PCR were negative. MRI brain with contrast showed bilateral symmetrical large thalamic hyperintensities. Case 2: A 14-years-old male child presented with high grade intermittent fever with bodyache since 10 days. Three days later he developed recurrent generalized seizures followed by altered sensorium. Subsequently he developed respiratory distress for which he was put on mechanical ventilation. On evaluation liver functions were deranged. SGOT, SGPT and PT-INR were elevated (4.5). Platelet counts were 80000/cumm. He developed massive gastrointestinal bleeding and succumbed. MRI brain showed bilateral thalamic and midbrain hyperintensities. Dengue IgM antibody was reactive in MAC ELISA with negative chikungunya, widal and HIV serology. Discussion: The predominant symptoms of dengue encephalitis were headache, seizures and altered sensorium in both cases. MRI is usually normal in patients with dengue encephalitis and prognosis is benign but may show extensive brain lesions with poor prognosis as observed in present cases. Dengue encephalitis should be considered as a differential diagnosis in patients with acute encephalitic syndrome particularly in endemic countries like India.
I 29: Multiple ring enhancing lesions due to atypical fungal infection in an immunocompromised host
Rajadhyax SD, Alexander L, Philip VJ, Patanvadiya A, Parekh M
Department of Neurology, Narayana Health City, Bommasandra, Bangalore, Karnataka
Aim: To audit the clinical presentation, aneurysm characteristics and outcome of patients undergoing stent assisted coiling (SAC) for wide necked intracranial aneurysms at a dedicated neuro-intervention division of a South Indian referral hospital. Method: Consecutive patients undergoing SAC for wide necked aneurysms from 2009 to 2015 were enrolled. Aneurysm characteristics were studied on 3D cerebral angiogram. After deploying the stent across its neck, the aneurysm sac was densely packed with platinum coils. Pre and post procedure antiplatelet agents were administered based on a fixed protocol. Outcome was assessed with modified Rankin Scale (mRS) at discharge and 3 months follow-up. Control cerebral angiogram was performed at 6 month follow-up. Results: A total of 26 patients showed mean age of 49 years, with female predominance (69.23%). Majority of patients had ruptured aneurysms (n=18). Median aneurysm size and neck diameter were 7.5 mm and 4 mm respectively. Internal carotid artery was the most common site for aneurysm (n=18, 69.23%). Stent deployment and complete exclusion of aneurysm from circulation was successful in all the patients. Four cases had minimal stent thrombosis which was treated successfully with intravenous abciximab. Good mRS (0 or 1) at discharge was seen in all except three cases, due to sub-arachnoid haemorrhage related complications. Twenty patients were followed up at three and six months, all having uncomplicated clinical course and angiograms. Conclusion: Our experience with stent assisted coiling in wide necked intracranial aneurysms is promising and justifies this modality as a safe and effective treatment option.
I 30: Immune reconstitution inflammatory syndrome in an immunocompetent patient with cryptococcal meningitis
Shah IS, Jha A, Kaul S, Singhal T, Aggarwal A
Department of Neurology, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
Introduction: Immune Reconstitution Inflammatory syndrome (IRIS) was initially described in patients who are immunocompromised due to AIDS. Since then it has been described in association with other infections including Cryptococcal meningitis. We describe a patient who was immunocompetent and developed Immune Reconstitution Inflammatory syndrome (IRIS) in association with Cryptococcal meningitis. Case Report: We describe a 36 year immunocompetent man suffering from meningitis due to Cryptococcus neoformens var grubii. Liposomal amphotericin and flucytosine were commenced which led to improvements in clinical, radiological as well as serial CSF examination. However after 1 week there was sudden neurological worsening with increased leptomeningeal enhancement on MRI brain. The CSF examination revealed increase in proteins though the CSF total cell count, sugar and cryptococcal antigen titre had improved. The clinico-radiological worsening with the CSF findings suggested C- IRIS. Dexamethasone was commenced and led to clinical and radiological improvement. Conclusion: Although cryptococcal meningitis has been well described in immunocompromised patients, their associations with immunocompetent patients are not well documented. Through this case we would like to emphasise the importance of C-IRIS as a potentially reversible and completely treatable cause in patients of cryptococcal meningitis who are otherwise healthy.
I 31: Neurological involvement in chikungunya: New Delhi 2016 outbreak
Kasundra GM, Prasad A, Handa R, Barman P, Chopra S
Department of Neurology, BLK Superspeciality Hospital, Delhi
Aim: To understand the profile of patients of Chikungunya fever with neurological involvement. Materials and Methods: This was an observational study from 15th August 2016 to 15th November 2016 at a tertiary care hospital in New Delhi, India. All patients with symptoms suggestive of Chikungunya fever were tested for the virus by PCR technique. Patient testing positive were screened for neurological symptoms and records of patients with neurological symptoms were analyzed. Observations: Out of all the Chikungunya positive patients, 62 had neurological symptoms. A bimodal age distribution was seen with affected adults (n=56) aged 62.1±16.9 years and children (n=6) aged 6.2±6.4 years. Males were affected more often than females (39 men versus 17 women and 6 boys versus no girls). Presenting complaints were alteration in sensorium (n=39), seizures (n=8), stroke (n=2), Guillain Barre Syndrome (GBS) (n=7), ADEM (n=2), headache (n=7) and vertigo (n=5). Cranial neuropathy was observed in 8 (two 2nd nerve, one 8th nerve and five 7th nerve) patients. Laboratory findings included hyponatremia (n=41; mean sodium among patients with hyponatremia 129.6±7, range 100-135), sepsis (n=17), renal dysfunction (n=18), multiorgan dysfunction (n=17) and leukocytosis (10734±5495) with neutrophilia in blood (79%±13). Neuroimaging was abnormal in 15 patients and showed encephalitic involvement of temporal (n=8), frontal (n=6), parietal (n=4), occipital (n=3), multiple lobes (n=6), and other regions less often. Cerebrospinal fluid analysis showed raised proteins (adults- 98.8±93.1, children- 49.6±47.5), normal sugar, pleocytosis only in adults (33.1±52.1) with lymphocytic predominance (42.6±33.9). Conclusion: Chikungunya fever is frequently associated with neurological symptoms, especially alteration in sensorium, neutrophilia and hyponatremia in about two-thirds of the patients, sepsis and hepatorenal dysfunction in almost one third of the patients, CSF lymphocytosis with raised proteins and topographically involves temporal and frontal lobes predominantly, mimicing herpes encephalitis. It is also associated with GBS with prominent bulbar involvement.
I 32: Skull base osteomyelitis
Faldu HD, Khadilkar S, Patil S
Department of Neurology, J. J. Hospital Campus, Mumbai, Maharashtra
Background: Skull base osteomyelitis (SBO) is relatively uncommon but life-threatening condition characterized by osteitis of skull base with or without temporal bone. Aim: To evaluate trend in risk factors, clinical presentation, etiology, treatment and outcome of SBO. Type of study: Retrospective study. Period: August 2014 to August 2016. Materials and Methods: 1. Inclusion criteria: Patients presenting with severe headache and ≥1 cranial nerve palsy with radiological finding consistent with osteitis or infection of skull base bone ± temporal bone. 2. Method: Patients were analysed in form of demographic profile, risk factors, source of infection, clinical profile, radiological finding, result of histopathological specimen and microbiological investigation, treatment and outcome. Results: Eight patients fulfilled the inclusion criteria. Mean age at onset was 51.12 years. Among risk factors diabetes (4/8) (50%), microvascular risk factors (4/8)(50%), prior aural exploration (2/8)(25%) were detected. Median time of presentation was 4.06 months. Headache was present in 8/8 (100%), Ear ache in 6/8 (75%) and ear discharge in 3/8 (37.5%), Cranial nerve involvement in form of 6th/7th/12th nerve in 3/8 (37.5%), 8th nerve in 4/8 (50%), 9th, 10th and 11th in 5/8 (62.5%) patients. Imaging showed involvement of petrous apex in 7/8 patients and clivus involvement in 6/8 patients. Tissue examination was available in 6/8 patients. 2/8 has MTB, 2/8 had Pseudomonas aeruginosa owth in culture. One each had chronic inflammation and poorly differentiated squamous cell carcinoma. An injectable antibiotic for 2 week followed by oral was given for 6 weeks. Patients with M. tuberculosis infections were put on antituberculous treatment. Five patients improved completely without any deficits, one had partial improvement, one had carcinoma and one could not be saved. Conclusion: Early and appropriate treatment reveres deficits in majority. Tissue diagnosis is important in planning therapy.
I 33: Acute adenovirus encephalitis in an immunocompetent adult
Mittal A, Vinod S, Wig N
Department of Medicine, AIIMS, New Delhi
Adenoviruses are double stranded-DNA viruses which are most frequently associated with fever and upper respiratory tract infections in children and rarely adults. Due to their propensity to spread by aerosols, epidemics of adenovirus infection are common especially in summer camps and among military recruits. Adenovirus has multiple serotypes each associated with a particular manifestation, epidemiology has been reported to be different in military recruits. Adenoviruses have been implicated in severe manifestations which include pneumonia, hemorrhagic cystitis, epidemic keratoconjunctivitis, meningitis, encephalitis, myocarditis and disseminated disease. These manifestations are reported more commonly in children and immunocompromised patients who include hematopoietic stem cell transplant recipients, solid organ transplant recipients, HIV positive patients and patients on long term steroid therapy. We report a case of adenovirus meningoencephalitis in a previously healthy immunocompetent adult lady with a fulminant course and finally a fatal outcome.
I 34: Utility of modified mental state examination in HIV associated neurocognitive disorder
Kumar S, Tandon R, Himanshu D, Atam V, Sawlani KK, Verma SK
Department of Medicine, King George's Medical University, Lucknow, UP
Introduction: Not all parameters of neurocognition may be affected in HIV (Human Immunodeficiency Virus) patients. Hence, we assessed the diagnostic utility of Modified Mini Mental State Examination (3MS) in HIV Associated Neurocognitive Disorder (HAND). Methods: The 3MS scores of HIV positive patients presenting to Department of Medicine of King George's Medical University between September 2015 to September 2016, were analyzed in context of ART and CD4 counts. Results: Out of 200 patients (65%males, 35% females), maximum were educated between 8th-12th class (89.5%), aged between 25-50 years (81.5%) and significantly higher proportion of males had CD4 count <500 (69.2%) in comparison to females (50%) (p=0.007). Using 3MS, 21% patients were found to be neurocognitively impaired (mean score 76.24±1.51) and 79% HIV patients were not impaired (mean score 87.02±4.15). Mean 3MS score of lower CD4 count patients (82.54±5.58) was lesser as compared to that of higher CD4 count patients (88.54±3.99) (p<0.001). Scores were also lowest with ART duration <48 months (83.10±5.76) and highest with ART duration >72 months (86.11±5.00) (p=0.005). Most decrease from maximum value was seen in similarities (48.3 %), second recall (36.1 %), repetition (33.4 %), copying two pentagons (28.3 %), read and obey (24.0 %), mental reversal (22.7 %) and first recall (21.3%) parameters of 3MS. Conclusions: Using 3MS, HIV patients with higher CD4 count and greater duration of ART had lesser cognitive impairment. The parameters found to be most impaired in HIV patients may be compiled to form a questionnaire to be used for screening for HAND.
I 35: Mysterious cerebral infarction in a returned traveller with iatrogenic immunosuppression - cryptococcus?
Maiti S, Anand SS, Shobhana A
Department of Neurology, Institute of Neurosciences, Kolkata, West Bengal
Introduction: Though rare, Cryptococcal infection may induce vasculitis causing cerebral infarction. Only 7 such cases have been reported. This case reports such case in a non-HIV, iatrogenically immunosuppressed, returned traveller. Case Report: A 72 year male, known hypertensive and ischaemic heart disease and on treatment for Chronic inflammatory Demyelinating polyneuropathy with steroids and Mycophenolate mofetil, came back from 1 month stay in Singapore with acute onset of behavioural change, forgetfulness and fever. Initial work-up showed right basal pneumonitis, ischaemic foci in periventricular and sub-cortical white matter, prostatomegaly with para-aortic and pelvic lymphadenopathy, HIV-seronegativity and a marked peripheral neutrophilic leukocytosis. Patient remained febrile despite treatment with Piperacillin-tazobactam. Urine and sputum culture were negative. Blood culture grew Cryptococcus neoformans, susceptible to Amphotericin B, Flucytosine and Fluconazole. Subsequent cerebrospinal fluid (CSF) showed 75 cells (85% lymphocytes), glucose 66 mg/dl, protein 158 mg/dl, Cryptococcal Antigen (CRAG) positive, India Ink preparation positive and culture positive for Cryptococcus neoformans. Patient was treated with Amphotericin B + Fluconazole and soon became afebrile with CSF cell count of 40 (mostly lymphocytes), glucose 55 mg/dl and protein 88 mg/dl and went home against medical advice. 7 days later he returned with confusion and fever. MRI showed lacunar infarcts and pseudocyst involving thalamus and brainstem with CSF CRAG positive. The patient showed improvement with Amphotericin B + Flucytosine but suddenly succumbed to death due to acute myocardial infarction. Conclusion: Cryptococcal aetiology is a possibility in cerebral infarction in the background of iatrogenic immunosuppresion. Both diagnostic and therapeutic dilemmas arise in the due course.
I 36: Cerebral abscesses as a presentation of nocardiosis in 3 immunocompromised patients
Pujari S, Kulkarni R, Melinkeri S, Purandare B
Department of Neurology, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra
Nocardiosis is an uncommon yet periodically confronted infection in practice, more so in patients with impaired cell-mediated immunity such as lymphoproliferative disorders, transplants, steroid therapy and AIDS. A high degree of suspicion is required for diagnosis, as presentations simulate with other bacterial and fungal infections. Commonest organ to be affected in nocardia is lungs. In half of these, disease is also seen in extrapulmonary tissues. The most common organ involved in disseminated disease is brain. We present three patients who presented to us with neurological symptoms as initial clinical features, and were found to have nocardial brain abscesses. First patient had acute myeloid leukaemia. He had undergone bone marrow transplant, and was on prednisolone, mycophenolate mofetil and tacrolimus. Second patient had systemic lupus erythematosus, nephropathy, was on prednisolone and hydroxychloroquine. Both patients presented with subacute hemiparesis. Third patient had chronic lymphatic leukaemia, and was on prednisolone. He presented with subacute cognitive decline. MRI of all three patients showed features of abscess. All patients had excision biopsy, and modified Ziehl Nielson stain revealed nocardia in fluid/ tissue. They were treated with intravenous Impenem, and showed good response. The purpose of showing this data is to emphasize nocardia as one of the cause of brain abscess, especially in immunocompromised patients. Both clinicians and microbiologists should be on the look-out in a relevant clinical setting.
I 37: Incidence of neurological complications in patients suffering from dengue in two speciality hospitals from Western India
Palasdeokar NR, Rahul K, Shripad P, Mukund V, Sujit J, Dileep M
Department of Neurology, BJ Medical College & Sassoon General Hospitals, Pune, Maharashtra
Introduction: Dengue has become an important endemic disease in India. Neurological complications in dengue are being reported more frequently. This is a retrospective study of neurological complications in patients admitted with a diagnosis of dengue in last 34 months. Materials and methods: Patients admitted in two speciality hospitalswith dengue infection and having neurological symptoms were included in this study. They were clinically examined, underwent laboratory tests, imaging studies whenever indicated, and other relevant investigations. Results: Between Jan 2014 to Oct 2016, a total of 3999 patients were diagnosed with dengue, 2136 in one hospital and 1863 in second hospital. Of these 3999 patients, 70 (1.75%) had neurological manifestations. The commonest neurological manifestation was encephalopathy in a setting of multi-system involvement in 20 patients. True encephalitis with abnormal MRI and/or abnormal CSF was seen in 10. Encephalopathy in absence of imaging abnormality, normal CSF and no major systemic features were seen in 8. Nine patients presented with seizures while another 9 presented with syncope. Acute severe neuropathy with facial weakness was seen in 3. Four patients presented with hypokalemic paresis and 2 presented with myositis. Other uncommon manifestations were: intracerebral haemorrhage (1), stroke (1), PRES (1) and neuropathy (2). Conclusion: In this study with large number of patients of dengue, neurological complications were seen in 1.75% patients. Encephalopathy and encephalitis were the most common manifestations. To our knowledge, this is the largest reported study of neurological complications in dengue.
I 38: Subacute Sclerosing Panencephalitis (SSPE) in a child with Human Immunodeficiency Virus (HIV) Infection: A case report of rare co-infection
Bhimani BB, Trivedi PV, Dave GR
Department of Neurology, Well Care Hospital, Rajkot, Gujarat
A child with HIV infection (on HAART) developed progressive gait difficulty with cognitive decline, later on followed by asymmetrical slow myoclonic jerks. Diagnosis of SSPE was confirmed by Dyken's criteria. After initial neurological deterioration, he still remains stabilized for the past two years. This case report highlights a rare co-infection of HIV and SSPE, with initial diagnostic dilemma with Progressive Multifocal Leucoencephalopathy (PML). Natural history of SSPE with HIV co-infection (with or without HAART) is yet to be determined. This case report concurs with previous observations, that a child with SSPE and HIV co-infection on HAART usually has a lesser fulminant and more indolent course. Role of combination of antiviral drugs, in reducing the rate of progression of disease in Non-HIV SSPE patients can be an area of future research.
I 39: Dengue encephalitis: A Western India experience
Dave G, Kulkarni R, Palasdeokar N, Patel M, Pimpale D
Department of Neurology, Well Care Hospital, Rajkot, Gujarat
Dengue, an arbovirus infection, has been an important viral infection in tropical countries. Neurological involvement is usually in form of encephalopathy secondary to systemic diseases. True encephalitis due to dengue virus has been reported more often now. It is always difficult clinically to differentiate between encephalopathy and encephalitis. We report 38 cases of dengue encephalitis seen by neurologists in Western India over last 3 years. Majority patients were young adults (age range 12-55 years). Males were more common than females. Fifteen patients were deeply unconscious (Glasgow coma scale <5) on admission, 2 presented with status epilepticus, while remaining 21 presented with drowsiness. Seizures occurred in 21 and eye movement abnormalities, ataxia and dysarthria were seen in 4. Shock was present in 12, renal impairment in 8, liver enzymes were raised in 21 and low platelets in 35. Dengue NS1 antigen test was positive in 28 patients, IgM antibody in 21 and IgG antibody in 9. CSF was done in 18 patients and showed raised proteins in 16 and pleocytosis in 8. MRI was done in 34 patients and CT Brain in 4 patients. Bilateral thalamic lesions were most common abnormality seen in 23 patients. These lesions were fairly symmetric and hemorrhagic. Cerebellar lesions were seen in 16 and brain stem lesions, predominantly pontine, in 14. Eight patients had corpus callosal lesion in splenium with diffusion restriction. Cortical lesions of various types were seen in 18 patients. Four patients had hydrocephalus due to third ventricular obstruction due to large thalamic lesions. Seventeen patients died while twenty one showed good recovery. The above-mentioned syndrome is likely to 'infectious' than 'post-infectious' as the presentation was with other systemic features of dengue, their NS1 antigen was positive and majority of the patients had similar clinical and MRI features. Dengue encephalitis seems to follow a predictable MRI pattern with prominent bilateral hemorrhagic thalamic lesions.
I 40: Histopathology as a diagnostic tool in spinal cysticercosis: Report of two cases
Pant I, Chaturvedi S, Singh G, Gupta S, Kumari R
Department of Pathology, Institute of Human Behavior and Allied Sciences, Delhi
Cysticercosis is the most common parasitic central nervous system (CNS) infection worldwide. The vast majority of neurocysticercosis are usually found at meningobasal (30%), parenchymal (20%), intraventricular (17%), intraspinal (1%), or mixed locations (32%). Intraspinal cases are extremely rare; incidence of spinal cysticercosis varies from 0.7% to 5.85%. Spinal cysticercosis commonly affects the subarachnoid space compared to the spinal cord substance. A purely intramedullary location as reported in this paper is quite exceptional. The authors report two cases of spinal cysticercosis, diagnosed only after histopathological examination, one of which was intramedullary in its location. In case 1, a 60yearold male presented with a 3month history of a gradually progressive weakness of both the lower limbs with associated bowel and bladder dysfunction for 20 days. In case 2, a 25yearold female presented with a 5year history of a gradually progressive weakness of both the lower limbs with associated pain and difficulty in walking for 1 month. The provisional clinical diagnoses in both cases did not suggest cysticercosis. Based on radiology, provisional diagnoses of granulomatous/cystic lesions were suggested, however, subsequent histopathological examination in both the cases showed the classical histopathological features of cysticercosis. This report highlights that spinal cysticercosis should be considered in the differential diagnosis of spinal intramedullary/extramedullary lesions as till date it remains a frequently misdiagnosed entity in clinical practice. Cystic lesions of the spine open up the possibility of varied diagnoses. Histopathology can be confirmatory in such cases if proper sample available.
| Poster Session II;|| |
Saturday, 25 March 2017; 17:15-18:15 Hrs
II 1: spectrum of neurological manifestations of acute dengue virus infection: A single centre study from India
Ruikar DD, Mohandas S, Jayalakshmi SS, Varalakshmi EA
Department of Neurology, MIMSR Medical College, Latur, Maharashtra
Objective: To study neurological and neuroradiological manifestations of dengue viral infection. Background: Dengue virus is generally considered as non neurotropic, there is paucity of data available on neurological manifestation of dengue. its global distribution is comparable to that of malaria, and an estimated 2.5 billion people live in areas at risk for endemic zone. Each year thousands of cases of dengue fever and hundreds of cases of dengue haemorrahgic fever occur in almost all regions of India. Methods: Prospective single centre study done at KIMS Hyderabad, During 2008to2013. Acute dengue virus infection defined as positive serology for IgM antibodies. CT/MRI brain and other necessary investigations were done. Patients admitted with acute dengue virus infection studied for neurological and radiological manifestations of acute dengue virus infection and followed for next 6 months. Statistical analysis done with SPSS Ver 17 software. Results: Out of 281 patients with acute dengue fever/DHF who were admitted in our hospital during the study period, 31(11.08%) had neurological manifestations. Age was 14 to 68 years with mean age 36.6 years with M:F ratio 2:1. Mean GSC on admission was 11.8. On MRI Pontine T2 hyperintensity and blooming in thalamus was significantly associated with hospital stay[p<0.005]. GSC at admission has significant correlation with hospital stay, neurodeficits or condition at discharge &outcome measures [p<0.005]. Conclusions: Neurological manifestations of dengue present in wide range as encephalitis at one end and GBS or Myositis at other end. Dengue associated encephalopathy should be considered as differential diagnosis in patients having fever, thrombocytopenia and recent onset neurological deterioration or in patients having acute encephalitis/encephalopathy of unknown cause. MRI is useful aid in diagnosis and GCS on admission is important prognostic factor.
II 2: Acute myositis after scrub typhus-unusal presentation
Shembalkar SP, Timane J, Chafle S, Shembalkar P
Department of Neurology, NKP Salve Institute of Medical Sciences & Research Centre, Nagpur, Maharashtra
Scrub typhus is endemic in certain parts of India. It usually presents with acute febrile illness. Myalgia is reported to be frequent. However, patient presenting with severe proximal muscle weakness is rare. We present a 60 year female patient who presented with severe muscle pain and progressive proximal weakness, two weeks after fever has subsided. On examination, she had a rash around neck. Her neck flexors were severely weak, power at shoulder and hip was MRC grade 2 and distally power was normal. Her total CPK was high (16,600 U/L). Urine myoglobulin was negative. EMG showed myopathic potentials. She was considered to have dermatomyositis and was accordingly evaluated. ANA immunoblot was negative. Left vastus lateralis biopsy was performed and started on IV methyl prednisolone. Meanwhile Scrub Typhus IgM by ELISA came positive. whichwas confirmed with Well Felix test. Oral doxycycline and Inj Ceftriaxone were added. She started improving, muscle pains were relieved and power improved to grade 4 proximally. However, neck flexors were still weak. Muscle biopsy was suggestive of inflammatory myopathy with vasculitis. She was readmitted after 10 days with abdominal pain and vomitings and was diagnosed to have pancreatitis. Oral prednisolone was stopped. Her muscle power is steadily improving. However, she continues to have gastrointestinal complaints. This case highlights the fact that in patients with scrub typhus muscle weakness may develop after fever has subsided and presentation could mimic dermatomyositis. The fever then may be attributed to the inflammatory process. High index of suspicion is needed, especially in endemic areas to diagnose scrub typhus. This has treatment implications as patient may improve with antibiotics only without need for aggressive immunosuppression.
II 3: A rare case of post-spinal surgery invasive aspergillosis
Shobhana A, Anand S, Karmakar M, Maity S
Department of Neurology, Institute of Neurosciences, Kolkata, West Bengal
Fungi of the Aspergillus species are ubiquitous in nature. Although lung is the most common site of disease, invasive aspergillosis affecting other systems is being reported more and more especially in immunocompromised patients. However aspergillosis in post -operative patients has been reported in immunocompetent host. Post- operative aspergillosis after spinal surgery is rare. We describe a case of post- operative invasive aspergillosis post spinal surgery in a young female. 35 year old female suffering from a major depressive disorder had a traumatic multi -level D11- S1 fracture with cord compression following a suicidal attempt which left her paraplegic two years back. She had been operated with pedicle screw fixation and L1-L4 laminectomy. Initially she showed signs of improvement but later developed progressive paraplegia with bowel and bladder incontinence. Her neurological deterioration prompted her to seek admission in this hospital. Neurologiacl investigations were conducted for the first time in the post -operative phase. CT myelogram was ordered.CSF was thick and purulent and contrast could not ascend. CSF revealed 5 cells, 5000mg/dl protein and ADA>10. Possibilityt of post- operative arachnoididitis was high. Etiology was thought to be pyogenic or tubercular. She was on I.V. ceftriaxoneand 5 drug ATD (RHEZS) started. Neurologically she was worsening. Oral prednisolone was started. She was now spiking fever. CSF culture revealed Staph hemolyticus. Her course till june 2016 was punctuated by recurrent urosepsis. However she was readmitted in June 2016 with high fever and a right gluteal abscess. She had developed an epidural abscess also. Reexploration of wound and open biopsy was done this time. Biopsy revealed invasive aspergillosis. Her ATDs were stopped. She was started on parenteral voriconazole followed by oral voriconazole. Six months down the line she is much better, afebrile and now moving in a wheel chair. This was a rare, difficult diagnosis but treatable.
II 4: An interesting case report of Salmonella More Details encephalopathy
Rai V, Rai N, Porwal M, Verma A, Shivde P
Department of Neurology, Choithram Hospital and Research Center, Indore, Madhya Pradesh.
Enteric fever with encephalopathy is very common but can have varying presentation. 18 year old boy, with no previous comorbidities, admitted to Choithram hospital, Indore (M.P.) with: 10 day h/o Fever (H/G with chills), Cough with scanty expectoration & anorexia. 4 day h/o Abdominal pain, Vomiting (2-3 episodes/day, non projectile/bilious/bloody, containing food particles) & Loose Motions (3-4 episodes/day, brownish, non foul smelling, non mucoid) since 1 day, difficulty walking, slurred speech with right focal motor seizures with dyscognition. Subsequently he developed a toxic look & severe encephalopathy. His blood investigations were s/o severe pancytopenia with deranged LFTs. Serologic testing for Dengue, Malaria, Hepatitis Profile and HIV was negative. CXRPAV & urine routine microscopy was normal. CSF pressures, routine microscopy, culture & HSVPCR was also negative. Widal titres for Salmonella typhi ;O” & “H” was 1:160, negative for S. Paratyphi. Ultrasound of abdomen was s/o sub mucosal edema of terminal ileum, IC region & caecum with multiple enlarged lymph nodes (1.5 cm) with echogenicity & fluid in right iliac fossa. Blood cultures were s/o growth of salmonella typhi. MRI of the brain showed hyperintensity of splenium of corpus callosum (“Boomerang sign”) on diffusion-weighted image (DWI) with decreased apparent diffusion coefficient (ADC) values.T2-weighted T2WI & FLAIR image & T1-weighted image (T1WI) did not reveal any abnormal signals in splenium of corpus callosum and other areas of brain. Subsequent MRI brain 10 days post treatment was normal. Electroencephalography showed Generalized Periodic sharp wave complexes at every 1 to 2 seconds over slowed background. After treatment EEG revealed normal activity. This is unique case report of Salmonella Encephalitis associated with Periodic Sharp Wave Complexes on EEG and Boomerang Sign i.e. transient corpus callosal involvement on MRI.
II 5: Comorbidities of epilepsy in low and middle income countries: A systematic review and a meta-analysis
Muhigwa AM, Pierre-Marie P, Gerard D, Aventis S, Marin B
CELPA Hospital Department of Internal Medicine, Bukavu, South-kivu Province in the Democratic Republic of Congo
Introduction: Epilepsy is a major public health problem in low-and middle-income countries (LMICs). Comorbidities also compound the burden of this disease. Objective: To assess through a meta-analysis the type, nature and prevalence of comorbidities of epilepsy in LMICs. Methods: We performed a systematic review of the literature through three databases: PUBMED, SCOPUS, IENT database. Comorbidities were defined as a coexistence of conditions which can precede, aggravate or be directly attributable to epilepsy or its treatment. A meta-analysis of the prevalence of each comorbidity overall and by sub-continent was performed. As heterogeneity was statistically significant for most comorbidities, a random effects model was used. Results: Among 2300 references, we included 109 reports of studies performed in 39 countries. Comorbidities were classified in four groups: the parasitic and infectious diseases (44%), somatic comorbidities (37%), psychosocial comorbidities (11%), and psychiatric comorbidities (8%). In some comorbidities associated to epilepsy have been more studied than the others that's the case NCC for which the results of meta-analysis gives an overall pooled prevalence of 22.79 (95% CI = 17.7 to 29.1), cranial traumatism with an overall pooled prevalence of 9.19% [CI = 5.16 to 15.84], discrimination for education with an overall pooled prevalence of 33.67 [95% CI = 28.21 to 39.6]. Conclusion: Epilepsy is a major public health problem in LMICs. Apart from the disease itself, specific factors associated with epilepsy have a huge impact on the prognosis and quality of life of people with epilepsy while most are preventable and treatable.
II 6: Scropulariopsis brevicaulis invasive sinusitis and meningitis
Purandare BD, Kulkarni RV, Patwardhan S
Department of Neurology, Deenanath Mangeshkar hospital, Pune, Maharashtra
43/M, no comorbidities, owner of a grocery shop at Satara (district place), Presented with low grade fever, persistent runny nose, diplopia since 2 months, Gradual diminution of vision in left eye, Exam- left lateral rectus palsy, ataxia of gait, left eye vision 2/6, no other focal neurodeficit. Investigations: MRI- hyperintense lesion in left posterior ethmoid sinus and left half of sphenoid sinus extending to orbital apex on left side and cavernous sinus, Two attempts of transnasal biopsy from sphenoid sinus done, Sphenoid sinus biopsy- foreign body granulomatous inflammation with necrosis, Gram stain, ZN stain, KOH mount, aerobic culture negative, Increasing ataxia, persistent headache, slurred speech, confusion and disorientation, Repeat brain MRI- developing hydrocephalus, ANA (IF) – negative, Serum GM- 1.41, Review of biopsy from NIMHANS- necrohemorrhagic lesion with no viable tissue, possibly inflammatory in nature, Underwent endoscopic transnasal excision of the lesion. Sphenoid sinus mucosa thickened with pale granulomatous tissue and sinus cavity filled with hemorrhagic mucoid fluid, Excision biopsy- large areas of hemorrhagic and necrotic tissue. Few bits show pseudostratified columnar epithelium with stromal fibrosis and inflammatory infiltrate composed of lymphocytes and neutrophils. Occasional ill-formed granuloma seen. ZN, PAS and GMS- negative, CSF- Protein 147 mg%, sugar 26 mg%, 200 nucleated cells (55L/2P/38 Mono-Macro/5E), no organisms seen on smears, CRAG negative, Was started empirically on ceftriaxone and amphotericin B, CSF fungal culture (after 18 days) grew Scropulariopsis brevicaulis, Excised sphenoid sinus tissue also grew same organism, Triple antifungal therapy with lipid formulation AMB (3mg/kg), voriconazole and flucytosine started, Ventriculoperitoneal shunt placed, Patient showed remarkable clinical improvement, Mould antifungal susceptibility is awaited from referral laboratory
II 7: Fulminant amoebic encephalitis: Report of 2 cases
Sangle SA, Nilesh P, Pramod U, Anju K, Suman P, Dileep K
Department of Neurology, B J Govt Medical College, Pune, Maharashtra.
Introduction: Granulomatous amoebic encephalitis (GAE) caused by free living amoeba is rare but fatal neurological disease usually seen in immuno-compromised patients. We report two patients with fatal amoebic encephalitis; one immuno-compromised due to underlying HIV infection and other was immuno competent. Case 1: 28 year old male, recently diagnosed with HIV infection presented with fever, headache, altered sensorium and seizures. CT brain was normal. CSF showed mild elevation of proteins with 10 lymphocytes. CSF wet mount and iodine stain was studded with acanthamoeba trophozoites which were later grown on non-nutrient agar. Patient succumbed to illness 48 hours after admission. Case 2: 36 year old male was admitted with fever, altered sensorium and seizures. He had chronic ulcer on right arm. On neuro examination he was obtunded and has right hemiparesis with neck stiffness. Contrast MRI brain showed multiple heterogenous lesions in left basal and high frontal, right occipital and left temporal lobe. CSF showed 118 mg/dl proteins, 20 mg/dl sugars and 25 lymphocytes. Patient was treated with antibiotics, anti epileptics and antivirals. Patient succumbed to his illness after one week. Autopsy of multiple section of brain showed large area of necrosis with thrombosed vessels along with trophozoites form of amoeba. PAS and iron hemotoxylin stain was positive for amoeba. Discussion: Encephalitis caused by Acanthamoeba is fatal because of difficulty and delay in diagnosing the diseases. Initial symptoms of GAE are vague and may mimic neurocysticercosis, tuberculoma, or brain tumor. Histo-pathologic analysis is the most common means of detecting amoebae, but a carefully done fresh CSF wet mount can clinch diagnosis in suspected patients. It can rarely occur in immunocompetent patients and high index of suspicion is needed.
II 8: Infection related neurocognitive deficits in North Indian population: A hospital based study
Kushwaha S, Anthony A, Talwar P, Gupta R
Department of Neurology, IHBAS, Delhi
Background: Although cognitive impairment caused by an infection is not very common, there have been reports demonstrating a link between infectious diseases and cognitive impairment mainly from developing countries. A wide range of infectious pathogens including viral, bacterial, protozoa, fungi, and prions can cause neurological damage with manifestation of symptoms such as confusion, delirium, memory loss along with other dementia-related symptoms. As India is highly endemic zone for infections, this study was done to evaluate infective etiology for dementia. Objectives: Here, we aim to identify and evaluate the infective causes of dementia in patients attending the neurology outpatient clinic in IHBAS. Methods: A retrospective hospital based study was carried out involving patients attending the neurology outpatient clinic in IHBAS from 2007-2014. All the patients suspected of chronic infections presenting with symptoms of cognitive decline, atypical presentation of cognitive and behavioral symptoms are evaluated for infective causes of dementia. Detailed clinical history and examinations were followed by routine investigations and Neuroimaging assessments. Special investigation according to etiology such as CSF for cytopathology, microbiological examination and PCR for tuberculosis and HSV were performed. All patients were treated symptomatically. The data was analyzed using descriptive statistics. Results: In our study, a total of 2714 patient's records were screened for over 8 year period, of which cognitive impairment was found to be present in 123 patients due to infective etiologies. The commonest infection was human immunodeficiency virus (HIV) with 52 cases (42.3%) followed by Tuberculous meningitis (TBM) with 25 cases (20.3%). In addition, 24 (19.5) had Herpes simplex viruses (HSV), 11 (8.9%) had Creutzfeldt–Jakob disease (CJD), 8 (6.5%) had Multiple Neurocysticercosis (NCC), and 3 (2.4%) had Neurosyphilis. Conclusion: The findings provide evidence on the infective causes for cognitive impairment in north Indian population. HIV was found to be the most common cause for neurocognitive deficits. This study highlights the need for awareness related to infection related dementia in clinical settings and propose for wider screening to uncover other possible infectious causes. Early identification and diagnosis will help in better management for possible reversibility.
II 9: Disseminated nocardiosis in a patient of myasthenia gravis: A case report
Kar M, Reddy MY, Chaudhary NV, Jaiswal SK, Parida S, Murthy JMK
Department of Neurology, Care Hospital, Hyderabad, Telangana
Introduction: Nocardiosis is an uncommon bacterial infection with awide range of clinical manifestations. It is more common inimmunocompromised individuals. Pulmonary Nocardiosis is the mostcommon form. Haematogenous spread can cause disseminated diseaseinvolving nervous system, skin, bone, retina, heart, joints and kidneys. Wepresent a case of myasthenia gravis with disseminated Nocardiosis. Case Details: A 69-yr- old lady known case of diabetes and hypertensionwas diagnosed to have thymomatous myasthenia gravis 6 months ago. Thedisease was stable on pyridostigmine, prednisolone and azathioprine. Shedeveloped recurrent boils, right sciatic pain since one month. Boils appeared first over right arm followed by left forearm which ruptured spontaneouslyand drained purulent discharge. Sciatic pain resolved with analgesics andmuscle relaxants. Fifteen days later, she fell down at home and presentedwith inability to move the left lower limb at hip. Examination showed noneurological deficits. MRI Pelvis showed osteomyelitis of left superior pubicramus with pathological fracture, right ileopsoas abscess and hyperintesities inleft pectineus, obturator externus and obturator internus muscles on T2W andSTIR sequences suggestive of myositis. Microbiological analysis of ileopsoasabscess showed nocardia on modified acid fast stain and aerobic culture. Shewas treated with IV ceftriaxone and oral trimethoprim and sulfamethoxazole. Conclusion: Nocardiosis is a rare bacterial infection. It should always besuspected in an immunocompromised patient with multiple organinvolvement.
II 10: Bickerstaff brain stem encephalitis and miller fischer overlap syndrome as a complication of dengue fever
Halprashanth DS, Vijayashankar P, Praveen Chander N, Ponniah V
Department of Neurology, Global Health City, Chennai, Tamil Nadu
Introduction: Dengue is an important global public health problem. It's an arboviral infection transmitted by the Aedes genus of mosquito. Most infected individuals present with asymptomatic infection, but few may present with clinical signs like classic dengue fever or hemorrhagic fever. Rarely could it produce neurological manifestations like encephalopathy and Gullian barre syndrome. We report a young woman presented with dengue fever subsequently developed Bickerstaff brain stem encephalitis and Miller Fischer overlap syndrome (BBE/MFS). To our knowledge BBE/MFS as a complication of Dengue is not reported in the literature. Case report: A 40 years old woman presented with complaints of fever and headache since four days. Her Serum dengue IgM and NS1 were positive. She was treated conservatively. Subsequently she developed status epilepticus and admitted in our hospital. She was intubated and treated with antiepileptic's. Her routine investigations showed leucopenia, thrombocytopenia and high hematocrit. She was diagnosed as meningoencephalitis and treated emperically with antiviral, antibiotics and steroids. Later, she developed asymmetric dilatation of pupil with bradycardia. Her MRI Brain with contrast showed non-specific hyperintensities in bilateral lateral temporal lobe. EEG showed generalized slow waves. Gradually she developed opthalmoplegia, quadriplegia and areflexia. Nerve conduction study showed acute demyelinating motor and sensory polyneuropathy and CSF analysis showed albumino-cytological dissociation. Anti GQ1b antibodies was negative. CSF encephalitis panel were negative. Serum auto-immune panel, Lyme's disease, West Nile fever, urine porphobilinogen were negative. She was diagnosed as BBE/MFS overlap syndrome and started on IV immunoglobulins for 5 days. However, she deteriorated and resembling brain death for the next one week, later she gradually recovered. Conclusion: Our case highlights a rare complication of Dengue. Timely recognition and intervention after establishing the exact cause is the key for good clinical outcome.
II 11: Acqisition of mucormycosis on voriconazole therapy in a case of invasive aspergillosis with newly diagnosed diabetes and Kochs: A case report
Kumar A, Gupta N, Vinod S, Singh G, Biswas A, Wig N
Department of Neurology, AIIMS, New Delhi
Introduction: Sino orbital cerebral aspergillosis is an uncommon entity described mainly from Indian subcontinent, middle east and parts of Africa. Although voriconazole is the drug of choice for invasive aspergillosis, its use has been linked to breakthrough mucormycosis infections in specific scenario.Case report: A 55 year old gentleman presented with right sided headache along with redness and watering of right eye for two months and sudden loss of vision in the right eye for one month. On examination, there was partial ptosis and absence of light perception in right eye. Direct ophthalmoscopy showed optic atrophy. Lab investigation suggested an HBA1c of 6.9, right upper lobe consolidation on Chest X ray (Bronchio-alveolar lavage gene Xpert-positive) and extensive sinusitis with extension into orbit and brain on MRI. With a provisional diagnosis of invasive fungal rhinosinusitis, amphotericin B was started. Biopsy from right maxillary sinus showed septate hyphae and serum galactomannan was positive. With a probable diagnosis of invasive aspergillosis, the patient was shifted to voriconazole. After a period of initial improvement, he developed fever, swelling in the right eye and headache. An emergency debridement showed aseptate hyphae suggestive of invasive mucormycosis. Pan Fungal PCR was positive for both the samples but primers specific for Mucormycetes was positive only in the second sample suggestive of acquisition of mucormycosis during the voriconazole therapy. He was restarted on amphotericin B. Repeat imaging after 25 days showed partial resolution. The patient was discharged on oral posaconazole and antitubercular drugs. Conclusion: This is to highlight the in-hospital acquisition of mucormycosis in a newly diagnosed case of diabetes, pulmonary kochs, and invasive aspergillosis; probably secondry to voriconazole as a risk factor for the same which so far is mostly known for transplant and malignant cases.
II 12: Profile of rapidly progressive dementia in a tertiary care institute in Eastern India
Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, West Bengal
Introduction: Rapidly progressive dementias (RPDs) are neurological conditions that develop subacutely over weeks to months, or rarely acutely over days. It is critical to evaluate the RPD patient without delay, usually in a hospital setting, as they may have a treatable condition. Current observational study aims to determine the various causes of the various rapidly progressive dementia cases in a tertiary care neurology institute in India. Material and methods: A cross sectional study was undertaken to collect the cases of rapidly progressive dementia which was defined as cognitive deterioration in one or more domain resulting in impairment of activities of daily living within a span of 1 year. The study was conducted from 1st December 2015 till 1st December 2016. Patients admitted in indoor of Bangur Institute Of Neurosciences, Kolkata were taken for the study. Standard definition were used to classify various diseases. Results: A total of 27 cases were obtained during the stipulated time period. Out of which 8 were found to be prion illness (probable creutzfeld Jakob disease), 2 were HIV related dementia, 4 were alzeihmers disease, 4 were autoimmune encephalitis, 2 were Japanese B encephalitis, 1 patient was Hepatitis B positive, 1 patient was found to have tubercular lymphadenopathy, 1 patient was found to have diffuse large B cell lymphoma and another 4 cases cause remained undetermined. Conclusion: The current study though small tends to throw a light upon the profile of rapidly progressive dementias in our country which if done taking a large population might help to elucidate the causes in a tropical country like ours and help in better and earlier management.
II 13: Immunological and proteomics based studies in identification of biomarkers in Subacute Sclerosing Panencephalitis (SSPE)
Pathak A, Singh A, Joshi D
Department of Neurology, IMS, BHU, Vranasi, Uttar Pradesh
Background: Subacute sclerosing panencephalitis (SSPE) is a neurodegenerative disease of children and young adults due to persistent measles virus (MV) infection. Factors related to host and virus appear involved in its pathogenesis Although, estimation of inflammatory cytokines have been reported in serum and cerebrospinal fluid of infected individuals, but their level are also variable and not specific to disease outcome. Currently, there big gap in prognostic and diagnostic biomarkers for the disease identification. Methods and Results: The level of cytokines IL-6 and IL-10 along with proteomics studies were carried out in 20 SSPE patients and aged matched controls. The cytokine estimation and proteomics studies were performed in isolated cerebrospinal fluid (CSF) of patients and respective controls. The result of the study demonstrate that the level of IL-6 is significantly up regulated and IL-10 is down regulated in all SSPE subject as compared with respective controls. Further, the proteomics study demonstrated up regulation of three proteins, in the CSF of SSPE subjects as compared with control. Matrix assisted laser desorption ionization and Time of flight (MALDI/TOF-MS/MS) based characterization of these proteins found to be of unknown function in available protein data base. Conclusion: The current study signifies the role of cytokines imbalance mainly related to altered cellular immunity of host towards infection and identification of three proteins in SSPE subjects will help to establish potential biomarker for disease identification.
II 14: Neurological manifestations of dengue infection - from Eastern India
Ghorai P, Chatterjee A
Department of Neurology, BIN Kolkata Neurology, Kolkata, West Bengal
Dengue, an acute viral disease transmitted by Aedes mosquitoes, is highly endemic in many tropical and subtropical areas of the world. Neurological complications of dengue infection have been observed more frequently in the recent past and some studies highlighted varied neurological complications arising in the course of dengue illness. Eastern India specially West Bengal – dengue is very much prevalent. Very few studies are there from eastern India. It is a cross-sectional observational study, done in a tertiary care centre in Kolkata, department of neurology and medicine, from November 2015 to till date and it is an ongoing study. Serologically proved dengue cases with neurological manifestations are included. Patients with neurological manifestations which cannot be explained otherwise and dengue IgM antibody positive, are also included. Other causes of neurological manifestations are excluded. 30 cases are included till now. Detail history and clinical examination are done. Routine investigations, HIV serology, CNS imaging, Nerve conduction study are done according to clinical indications. CSF study is done when required. Data are collected in a pretested proforma and analyzed. Male patients outnumbered female patients. Following clinical manifestations are found in this study: headache, insomnia, encephalitis, meningoencephalitis, myelopathy, myositis, ischaemic stroke, haemorrhagic stroke, acute inflammatory demyelinating polyradiculoneuropathy, mononeuropathy, cranial neuropathy, ADEM. Sample size is small, but it is an ongoing study.
II 15: Varied neurological manifestations of scrub typhus in teritiary care centre
Thomas R, Rajesh A
Department of Neurology,
Travancore Medical College Hospital, Kollam, Kerala
Introduction: Scrub typhus (synonyms: chigger-borne rickettsiosis, tsutsugamushi disease, rural typhus) is an acute febrile rural zoonosis endemic in the Asia-Pacific region. About 1 million cases have been estimated to occur each year and 1 billion people may be exposed. The disease is transmitted by the bites of larval-stage of trombiculid mites (commonly called “chiggers”), which are known as both reservoirs and vectors of the disease. They bite humans on any part of the body and feed for 2 to 10 days. Neurological manifestations are dreaded and treatable if diagnosed early with history, bite marks, immunological test. Case reports: Scrub typhus with varied neurological manifestations are encountered in our hospital and treated. Meningoencephalitis, Acute disseminated encephalomyelitis, Isolated 6th nerve palsy, Brain Stem Encephalitis. Patients presented with above clinical manifestations, supported with MRI and CSF studies. ELISA test, Weil felix test for OX-K were positive in these patients and other causes were ruled out. Patients responded well to standard treatment of Doxycycline within 7 days without any neurological deficits. Conclusion: The mortality of scrub typhus remains high because of multiple factors, including late presentation, delayed diagnosis or misdiagnosis, inappropriate presumptive treatment. We report these cases in this international conference in order to highlight the neurological manifestations of scrub typhus in India and to highlight the effectiveness of early treatment awaiting serological test to prevent neurological deficits and death.
II 16: Garcin syndrome - A rare presentation of HIV opportunistic infection
Sharief SM, Butchiraju G, Gopi S, Kumar TS, Kumar UA
Department of Neurology, King Gorge Hospital, Visakhapatnam, Andhra Pradesh
History: 40 year married female who is retroviral positive since3 years with CD 4 count of 154 cells /cu mm at diagnosis presented with 2 ½ months history of insidious onset and gradually progressive headache with reeling sensation of surroundings, and swaying to right side on walking with decreased hearing, tinnitus in the right ear and hearing better in calm environment followed by decreased perception of smell and 2 month history of decreased vision in the right eye and with double vision on looking to right, since 1 ½ month there was difficulty in closure of right eyelid and deviation of angle of mouth to left slurring of speech over 1 ½ month, followed since 1 month by difficult in chewing food, decreased perception of all modalities of sensation over the right cheek and all three divisions of trigeminal nerve, followed by nasal twang, nasal regurgitation and choking episodes and difficulty maneuvering food bolus inside mouth since 15 days. There was low grade fever on and off since 2 months. One episode of vomiting with increased headache 10 days prior to admission. Other history insignificant. On examination: cranial nerve examination has shown right Garcin syndrome with left partial 3rd nerve palsy. Cerebellar signs noted and vestibular signs significant over cerebellar signs and Motot, Sensory and Autonomic examination were normal. Investigations: CD4 count 159 cells /cumm CT brain shown hypodense lesion in rt cerebellar peduncle, CT Skull base normal, MRI Brain with contrast shown ring enhancing intraaxial lesion inert cerebellar peduncle and pons, midbrain with edema, Serum antibodies for Toxoplasma IgG Positive VEP shown prolonged Rt. P100 latencies and BERA –Rt. SNHL and Blink reflex – Rt. Abnormal. Conclusion: This was a Retroviral positive case with Rare presentation as Right Garcin syndrome secondary to opportunistic CNS Toxoplasmosis.
II 17: A case of partial seizures secondary to dengue encephalitis
Nandasiri S, Gunaratne PS, Pathirana G, Kavietha E, Vithana W
Department of Neurology, National Hospital, Colombo, Sri Lanka
Background: Sri Lanka is a country where Dengue infection is endemic. Neurological manifestations of Dengue have been increasingly reported over the past few years. It could present as an encephalitis, encephalopathy, neuromuscular dysfunction or with neuro ophthalmological involvement. We report a patient who presented with partial seizures secondary to dengue infection. Case Presentation: A 25 year old previously healthy lady presented with a one day history of right sided headache and frequent, stereotypic jerky movements of the left side of the body suggestive of partial seizures leading to secondary generalization with loss of consciousness. There was no history of preceding febrile illness or head trauma. Her neurological examination was normal without evidence of lateralizing signs. Her EEG revealed focal ictal discharges in the right temporal lobe and the MRI showed diffuse alteration of signal intensity in right frontotemporal region suggestive of an infective process. Her CSF was normal with negative PCR for HSV, CMV and Tuberculosis. She was negative for retroviral testing and for the paraneoplastic screen with antineuronal antibodies and thyroid peroxidase antibodies. Her serum dengue Ig M was positive with negative Ig G. Discussion: Partial seizures in patients with dengue encephalitis have been rarely reported in patients with acute febrile infection in Indian Subcontinent. This is the first case of partial seizures with dengue to be reported in Sri Lanka. We highlight the fact that dengue encephalitis can mimic HSV encephalitis. Dengue should be considered as a differential diagnosis in patients coming with seizures even the absence of febrile episodes, especially in countries where dengue is endemic.
II 18: A rare MRI finding: An “Eye of Tiger” sign in a patient with subacute sclerosing panencephalitis
Kawale SS, D Joshi, A Pathak
Department of Neurology, BHU, Amravati, Maharashtra
Objective: To know the radiological profile of SSPE patients and analysis of “eye of tiger” sign in non PKAN patients. Case- A 16 year old, right handed, fully immunised boy presented with 9 months history of episodes of transient jerks involving legs followed by trunk leading to falls and inability to play or run, further associated with progressive difficulty in paying attention in school, declining performance in studies, irritability, poor attention and self care later on leading to bed bound state with delirium, bowel/bladder incontinence, persistent slow type axial myoclonic jerks and 1-2 episodes of generalised tonic clonic seizures. There was no preceding history of fever, diarrhoea, any psychiatric manifestations, past history of measles or drug or toxin exposure. Family history was negative. Patients EEG showed slow background with sharp and slow wave, periodic complexes of 0.5 to 1 Hz, occurring every 4-7 seconds. MRI scan revealed T2 globus pallidal hypo intensity with central hyper intensity s/o “eye of tiger sign” without any other features. CSF showed high titres of IgG anti-measles antibody and the ratio of CSF IgG anti-measles antibody / Serum IgG anti-measles antibody was > 4, suggesting SSPE. Discussion- Cortical and subcortical asymmetrical hyper intensities, thalamus, basal ganglia and corpus callousum affection has been previously described in the literature as MRI findings in SSPE. We are reporting “eye of tiger” sign in SSPE for the first time. “Eye of tiger “ sign is usually ascribed to PKAN due to iron accumulation in globus pallidus. However, there are many reports of PKAN negative “eye of tiger” sign, mostly in elderly, in progressive supra nuclear palsy, multiple system atrophy and cortical basal ganglionic degeneration. This sign is yet not reported in PKAN negative young patients and especially any tropical diseases.
II 19: Cerebrovascular injury following scorpion sting: A case series and a review of relevant literature
Mishra AK, Kuriakose CK, George AA, Arvind VH, Prabhakar AT, Ramya I
Department of General Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu
Aim: To study the clinical profile, brain imaging, mechanisms of injury and outcomes of cerebrovascular injury following Scorpion sting, in a tertiary care centre in South India. Methodology: Fifty five patients with Scorpion sting related complications; over 11 years were retrospectively enrolled. Three met the inclusion criteria of having neurological symptoms with appropriate imaging of the brain. Patterns of CNS involvement, clinical parameters and outcomes of patients were analyzed. A review of literature including 35 other cases was done. Result: Three [5%] of the 55 patients with scorpion sting had evidence of cerebrovascular injury on imaging. All patients were males, with a mean age of 40.6 years. Local pain, profuse sweating, palpitation and hypertension indicating severe toxemia were present in all. While 2 patients had infarcts, 1 had a haemorrhage. All were acute and unilateral. Both the infarcts involved posterior cerebellar artery territory [cerebellum], and the bleed was capsuloganglionic in nature. The mean time to onset of symptoms following the sting was 1.6 days. The mean duration of stay was 5 days. All 3 patients had arterial hypertension and one had myocarditis with non-sustained atrial tachycardia. Supportive care and prazosin was administered to all. All patients were discharged in stable condition and had a median follow up of 1 year. Among the 38 patients reported, 33 were adults. The mean age of the adult patients were 34 years. Among the 33 adult patients, 21 [64%] were male, and 19 [58%] had Ischaemic stroke. Mortality was seen in 9 [30%] of patients. Patients with hemorrhagic strokes had a two times higher risk of mortality. Conclusion: Acute Cerebrovascular accident is a rare neurological complication following scorpion sting. Infarcts are commoner than bleeds. With prompt recognition, initiation of alpha blocker and supportive care mortality can be reduced.
II 20: Assessment of severity due to neurotoxic effects in patients exposed to poisons
Antuley JGA, Raut A, Pawar A
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth University, Pune, Maharashtra
Background: Neurotoxic effects due to poisoning include cholinergic syndrome, the intermediate syndrome, poisoning induced polyneuropathy and neuropsychiatric disorders. More than 15% fatality is observed due to cholinergic syndrome in poisoning cases each year. Objective: The present study aims to highlight the severity and fatality due to neurotoxic effects of poisoning agents. Method: A cross sectional study was conducted from January 2013 to December 2015 in government and private teaching hospitals. Results: Of 261 poisoning cases, central nervous system (CNS) manifestations such as giddiness (32.9%), drowsiness (29.5%), disturbance of consciousness (11.9%) and headache (7.3%) were the main presenting symptoms. Psychiatric manifestations which include depression, irritability and anxiety were also prevalent. Household (32.2%) and agricultural (25.3%) agents were responsible for maximum neurotoxic effects. Mortality rate of 4.6% was observed with organophosphates leading the cause of mortality. Poison Severity Scale (PSS) was used to assess the severity due to CNS manifestations which revealed that unconsciousness, seizures, convulsions and respiratory depression lead to fatality. Conclusion: The study highlights the importance of rapid diagnosis, initiation of early and effective treatment which may result in fewer complications and also decrease the mortality rates. It also highlights the importance of psychiatric counseling to combat the neuropsychiatric disorders post poison exposures.
II 21: Safety and effectiveness of newer vs. conventional anti epileptic drugs
Gore SS, Raut A, Dave P, Kher NR, Mandlekar HA.
Clinical Pharmacy Department, Bharati Hospital And Research Centre, Pune, Maharashtra
Objectives: Safety and effectiveness of newer vs. conventional anti epileptic drugs. Method: A prospective observational study was conducted in 1000 bedded teaching hospital. A total of 102 adult patients of either gender, prescribed with Anti Epileptic Drugs (AED's) were enrolled. Clinical review was performed to study the clinical characteristics of seizure and review the Utilization of AED's. Following the initiation of treatment on admission, effectiveness was evaluated in terms of seizure control. Safety was interpreted by assessing its side effects occurred which was analyzed with the help of Naranjo's Adverse Drug Reaction Probability Scale and Hartwig's Severity Assessment Scale. Result: The study observed male predominance in utilization of AED's. Symptomatic seizures were perceived by 79% patients, male population being prominent. Generalized seizures were observed in 61% while Focal seizures in 9%. Monotherapy was broadly utilized i.e. 75% and 25% was more than one drug therapy. Irrespective of treatment pattern, Levetiracetam, a newer AED was largely utilized than Phenytoin, Carbamazepine and Sodium Valproate. Effectiveness of Levetiracetam was significant as compared to conventional AED's (p value < 0.05). 67% percent of adverse effects were seen with Levetiracetam and 32% with conventional AED's. Adverse effects with Levetiracetam were more of mild severity while, with conventional AED's were more of moderate severity along with a case of Phenytoin toxicity. Levetiracetam was determined safer as compared to conventional AED's. (p value < 0.05). Conclusion: Levetiracetam, newer AED was found to be of choice and was frequently prescribed as monotherapy as well as adjuvant irrespective of seizure type. Levetiracetam was also found to have better effectiveness and safety profile as compared to conventional AED's.
II 22: Hypokalemic paralysis: Single centre experience from a tropical country
Acharya MK, Banerjee S, Chatterjee A, Ganguly G, Das SKR
Department of Neurology, IPGMER & SSKM Hospital, Kolkata, West Bengal
Objective: To report the clinical, biochemical, electrophysiological parameters and etiological profile in acute flaccid paralysis (AFP) patients admitted with hypokalemia in a tertiary care teaching hospital. Methods: Patients admitted with hypokalaemic paralysis were evaluated clinically & electrophysiologically for weakness and biochemically to look for the etiology of hyppkalemia. Patients with GB syndrome, myasthenia & myositis were excluded. Patients received IV/oral potassium supplementation and their underlying causes were treated, if found. Results: Consecutive 53 patients (24 females, 29 males) age range (18-51) years were included. Secondary causes of hypokalaemia included thyrotoxicosis in 6, and Gitelman in 5, Barter in 2, Sjogren in 3, RTA in 5 & primary hyperaldosteronism in 1 patients. Hypokalemic periodic paralysis was found in 11(20.8%) and 15(28.3%) cases had no identifiable etiology. Isolated paraparesis were present in 5(9.5%) patients whereas quadriparesis in 48(90.5%) patients with predominant proximal involvement. Truncal & neck muscle involvement present in 46(86.7%) & 29(54.7%) cases. DTR were reduced in 22(41.5%), normal in 28(52.8%) and brisk in 3 patients. CPK were elevated in 21(39.6%) cases. Uwave & prolong PR were resent in 13(24.5%) & 6(11.2%) respectively. Mean serum potassium was significantly lower in the secondary group (mean2.14) compared to pimary group (mean2.76). Severe hypokalaemia (<2 mmol/l) were present in 20(37.7%) cases, 9 cases had acidosis, and 12 cases had alkalosis. Reduced CMAP were present in 25(47.1%) cases. Though sensory symptoms were present in 6(11.3%) cases, sensory abnormality either clinical or electrophysiological were present in none of the cases. Myopathic pattern is present in 16(75%) cases out of 24 patients in whom EMG is performed. One patient developed hypokalemia induced polyuria which improved with potassium correction. Conclusion: 49.1%of patients had a secondary cause which should be suspected if patient had severe hypokalemia or abnormal serum pH, for further evaluation and treatment. Reduced/absent DTR with/without reduced CMAP is a frequent finding in hypokalemic paralysis, so serum potassium must be evaluated in any case of is flexic AFP. Sensory symptoms without electrophysiological abnormality may be present in hypokalemic paralysis patients.
II 23: Expanding spectrum of contactin associated protein 2(caspr2) autoimmunity-syndrome of parkinsonism and ataxia with encephelitis
Shah SP, Kannoth S, Nambiar V, Gopinath S, Anandakuttan A, Mathai A
Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala
Importance: Contactin associated protein 2(CASPR2) antibodies are originally associated with Morvan's syndrome, limbic encephelitis and peripheral nerve hyper excitability. The spectrum of CASPR2 autoimmunity is expanding. Objective: Our objective was to study retrospectively the clinical spectrum of CASPR2 antibody positive patients in our hospital. Design: Retrospective observational study. Setting: Tertiary care teaching hospital. Participants: Patients treated in Amrita Institute of Medical Sciences from May 2013 to April 2016, who was tested positive for CASPR2 antibodies were included. Methods: Cases were identified retrospectively from review of neuroimmunology laboratory register. Subsequently electronic medical records were reviewed. Details of clinical history, examination, MRI brain, CSF study, and other laboratory evaluations were extracted from medical records. Results: A total of 1584 samples were tested in the neuroimmunology laboratory during the study period for voltage gated potassium channel complex antibodies (VGKC) - leucine rich glioma inactivated protein 1 (LGI1) and CASPR2 antibodies. Thirty four were positive for LGI1, 13 were positive for CASPR 2 and seven were for both (total 54 -3.4% positivity). Of these 54 cases, 11 were treated in our hospital. Seven were positive for LGI1, three for CASPR 2 and one for both. The patient who had both CASPR2 and LGI1 antibody positive had Morvan's syndrome. One patient with CASPR2 had neuromyotonia. The other patient was admitted with status epilepticus with a syndrome of parkinsonism and ataxia. The third patient had encephalopathy and myoclonus with a syndrome of parkinsonism and ataxia. Two of them underwent Siddha treatment for other ailments prior to the onset of the disease for other ailments. Conclusion and relevance: Our short series shows the expanding spectrum of CASPR 2 autoimmunity. Syndrome of parkinsonism and ataxia is an important manifestation of CASPR2 autoimmunity.CASPR2 positivity helps us to offer a definitive treatment in parkinson ataxia syndrome.
II 24: Profile of CNS demyelination in a tertiary care hospital in Eastern India
Dewangan R, Mukherjee A
Department of Neurology, Calcutta Medical Research Institute, Howrah, West Bengal
Introduction: Idiopathic Inflammatory Demyelinating Diseases of the central nervous system (IIDDs) include a broad spectrum of disorders characterised by inflammation & selective destruction of the myelin. The common IIDDs of the CNS include Multiple Sclerosis (MS), Acute Disseminated Encephalomyelitis (ADEM), disorders of Neuromyelitis optica spectrum (NMO & NMOSD) and related disorders. Objective: To Study the clinical spectrum of demyelinating diseases of the central nervous system & to subgroup them into MS, ADEM, and NMO, CIS & CRION based on the standard Diagnostic criteria. Design: Prospective, cross sectional study. Methods: This is an ongoing study in the Department of Neurology, Calcutta Medical Research Institute, Kolkata since March 2016. All patients underwent detailed history, neurological examination, biochemical, serological (AQP4) & radiological investigations along with CSF study in selected groups. Results: A Total of 23 patients have been studied till date. Among which 12 patients were of MS, 6 ADEM & 5 NMOSD. Mean onset age of MS patients was 27.5 years with female preponderance. Most patients of MS were from 2nd to 4th decade with 2 patients were < 18 years of age. RRMS was the most common type of MS seen in 8 patients, SPMS seen in 2 patients & 2 patients were of possible MS. Afferent visual pathway manifestations (optic neuritis) as initial presentation of MS observed in 4 patients. Diplopia, nystagmus & other ocular motility disorders found in 3 patients. INO was noted in 2 patients. Weakness of limbs & sensory symptoms were other common initial manifestations of MS observed in 8 patients. In NMOSD group mean onset age was 24.2 years with one patient presented at the age of 7 years. Acute long segment myelitis (LETM) was the most common initial manifestation evaluated in 5 patients followed by optic neuritis in 3 out of 5 patients. ADEM patients mean onset age was 46.83 years with male preponderance. Fever & altered sensorium were the most common presentations. Conclusions: MS found to be the most common demyelinating disease of CNS followed by ADEM & NMOSD. Final results will be analysed and presented.
II 25: Phenytoin toxicity: Case report
Kher NR, Raut A, Dave P, Gore SS. Clinical Pharmacy
Department, Bharati Hospital and Research Centre, Pune, Maharashtra
Background: Phenytoin is a conventional Anti-Epileptic Drug and one of the most commonly prescribed for all types of seizures. Adverse reaction often occurs due to its narrow therapeutic index. Long term utilization may develop toxicity which can be fatal and therefore requires monitoring. Case Report: A 28 year old female patient was admitted with known case of seizure disorder since 5 years and was on tablet Phenytoin 100 mg thrice daily. She presented with complaints of gingival swelling, urinary incontinency, nystagmus, bradycardia and hypotension. Based on her clinical manifestations, therapeutic drug monitoring was performed and phenytoin concentration was found to be in a toxic range i.e. more than 40 mcg/ml. Phenytoin was withheld and alternatively tablet Levetiracetam and tablet Clobazam were started which subsequently improved the sign and symptoms of patient and brought down the level of Phenytoin concentration level. Conclusion: The case report and review highlights the adverse drug reaction of Phenytoin and the need of regular monitoring in patients on long term therapy.
II 26: Glasgow coma scale as a predictor of severity and mortality in organophosphorus poisoning
Mukhopadhyay A, Singh BK, Jha SC, Yadav KK
Department of General Medicine, Darbhanga Medical College and Hospital, Darbhanga, Bihar
Introduction: Organophosphorus (OP) compounds, first synthesized in 1873 by V. Hoffman, have been employed as pesticide, additive & chemical warfare agents. OP poisoning may result from occupational, accidental or intentional exposure with a higher mortality in developing tropical countries due to easy availability. Objective: To assess utility of GCS (Glasgow coma scale) in predicting severity &clinical outcome in OP poisoning. Methods: An observational study was conducted in Darbhanga Medical College, Bihar from October 2014 to September 2015 in 150 patients presenting with history &clinical feature of OP poisoning. Clinical, demographic, laboratory data were recorded. Intravenous pralidoxime at highest recommended dosage and atropine as per requirement were administered as soon as possible for treatment. GCS at the time of admission was recorded. Requirement of atropine, need of mechanical ventilation and mortality were also recorded. Observation: 96%cases were suicidal.76% were male.54% patients were in age group 25-40 years.84% improved after treatment with 16% mortality. Significant association was seen between GCS and outcome of poisoning (p<0.001). Patients with GCS <10 had 36% mortality, whereas patients with GCS>10 had only 10% mortality. Requirement of mechanical ventilation and total dosage of atropine required were also higher in patients with lower GCS score.20% patient needed mechanical ventilation,70% of them had GCS<10 and only 30% had GCS >10. Increased age was associated with higher mortality. Conclusion: This study highlights the importance of clinical indices in predicting severity which in turn can be very useful during triage. GCS being less time consuming can be used in peripheral centers to identify high risk patients for urgent referral. Identification of severity at an early stage followed by prompt treatment can prevent the late complication and death.
II 27: Rare tropical neuroinfection presenting as acute ataxia
Patanvadiya AH, Philip VJ, Huded V, Rajadhyax S
Department of Neurology, NH Institute of Neuroscience, Bangalore, Karnataka
Purpose: To audit the clinical, etiological and prognostic variables in patients with alpha coma at a tertiary care hospital in South India. Method: Between the years 2013 to 2016, we identified seven patients with alpha coma and analyzed their clinical, EEG, etiological and prognostic factors. Outcome at discharge was documented in the form of modified Rankin Scale (mRS), with mRS more than 3 being poor outcome. Results: The etiology of alpha coma was post cardiac arrest hypoxic encephalopathy (3, 42.85%), metabolic encephalopathy (2, 28.5%) and drug intoxication (2, 28.5%). Clinically, Glasgow Coma Scale (GCS) was 8 or less (deep coma) in 6 cases (86%) and more than 8 (light coma) in 1 case (14%). Brain-stem reflexes were present in 5 out of 7 cases (71.5%). EEG in all cases showed diffuse alpha pattern, non-reactive to noxious stimuli. Five patients (71.5%) had poor outcome, which included all 3 cases of hypoxic encephalopathy and 1 case each of metabolic encephalopathy and drug intoxication. Conclusions: Majority of the cases with alpha coma had poor outcome (5/7, 71.5%). Neither the clinical variables nor EEG reactivity influenced the clinical outcome. Similar to prior studies, underlying etiology of alpha coma probably determined the severity of clinical outcome. Hypoxic encephalopathy was the most common etiology and was associated with poor outcome.
II 28: “Churg Strauss Syndrome” A rare disease with atypical presentation
Kumawat B, Kumar K, Sharma C, Vyas A, Shah M, Saini P
Department of Neurology, SMS Medical College, Jaipur, Rajastha
Background: Vitamin B12 deficiency, by virtue of causing hyperhomocysteinemia, may be implicated as an acquired risk factor of Ischemic stroke, which is also easily modifiable. There is scarcity of data from India regarding prevalence of B12 deficiency in Ischemic stroke (IS) patients. Objectives: To explore the relationship between B12 and folate deficiency, hyperhomocysteinemia and IS. Design: Case control study. Materials and methods: Eighty cases of IS where compared with equal number of age and sex matched controls. Homocystiene, B12 and folate levels were analyzed as continuous data (Student's T – test) as well as categorical data (Chi-square test). Odds ratio for occurrence of IS were calculated for each variable. Correlation of homocysteine with B12 and folate was studied using Pearson's coefficient. Results: Mean Homocysteine was higher in cases compared to controls (20.49 +_ 12.64 versus 13.09 +_ 6.96 umol/L, P<0.001, while B12 (282.46 +_ 161.52 versus 480 +_ 248.92 pg/ml, P<0.001) and folate (10.49 +_ 6.86 versus 17.00 +_ 5.52 ng/ml, P<0.001) were lower. Both hyperhomocysteinemia (Odds ratio 4.82, 95% CI; 2.28-10.19, P + 0.0003) and Vitamin B12 deficiency (Odds ratio 4.48, 95% CI; 1.99-10.07, P + 0.0003) emerged as significant risk factors for occurrence of Ischemic stroke. Negative correlation of homocysteine with B12 (r-0.457, P < 0.0001) and folate (r -0.337, P=0.0001) was observed. Conclusion: Hyperhomocysteinemia appears to be an important risk factor for IS in Indian population. B12 deficiency is a major acquired cause for the same while folate deficiency is relatively rare.
II 29: Immunoglobulin in postinfective opsoclonus and opsoclonus myoclonus syndrome
Rai N, Rai V, Verma A, Porwal M, Shivde P
Department of Neurology, Choithram Hospital and Research Center, Indore, Madhya Pradesh
Acute onset post infective opsoclonus and opsoclonus myoclonus syndrome is rare and shows good response to iv immunoglobulin therapy irrespective of the age of patient. 26 year old female with two days history of fever, encephalopathy and generalised seizures presented with acute onset opsoclonus myoclonus. Cell counts were raised, eeg showed generalised epileptiform discharges but csf, mri, usg and serum markers were non-contributory. Patient was put on iv immunoglobulin therapy on the third day of illness. Opsoclonus myoclonus responded on day five of treatment and disappeared completely on 10th day of illness. 16 months old male child presented with acute onset opsoclonus without myoclonus on third day of fever, altered sensorium and seizures. Japanese B encephalitis was confirmed after MRI and CSF examination. EEG showed generalised slowing. Iv immunoglobulin was started on second day of opsoclonus. Opsoclonus responded by 90% after five days of iv immunoglobulin therapy. Post infective opsoclonus and opsoclonus myoclonus is rare but disabling. Prompt treatment must be started with iv immunoglobulin in patients with suspected post infective opsoclonus and opsoclonus myoclonus irrespective of age of involvement.
II 30: Clinical spectrum of seizures in infancy excluding neonatal seizures
Department of Neurology, Osmania Medical College and General Hospital, Hyderabad, Telangana
Aim: To study about clinical spectrum of seizures in infancy excluding neonatal seizures – prospective study. Inclusion criteria: Infants presented with seizures. Exclusion criteria: Neonates and Children more than 1 yr of age are excluded. Materials and Methods: Source of data: Patients presenting with Seizures to Osmania general hospital and Referred from Niloufer Hospital–Hyderabad. Method of collection of data: A prospective study will be carried out in OGH Hyderabad (December 2014- January 2017). Approximately 50 patients will be included in the study and consent will be taken from them. Following information to be noted in semi structured proforma like presenting age, sex, symptoms relevant history, clinical examination findings. Basic and relevant investigations to be done. The data to be tabulated and analyzed.
II 31: Moyamoya disease: A case presentation
Ramarajan M, Justin, Muthukumar, Ramu, Malaiarasu, Thirumalairajan
Department of Neurology, Government Medical College, Rajaji Hospital, Madurai, Tamil Nadu
Introduction: Moyamoya disease is a chronic, progressive occlusive disease of the circle of willis which leads to the development of characteristic collateral vessels seen on imaging, especially cerebral angiography. By definition, the pathognomonic arteriographic findings are bilateral in moyamoya disease, although the severity can differ between the sides. Case Vignette: A 30 year old female presented to our hospital by July 2014 with acute onset of LOC with weakness of right upper limb and lower limb. On detailed history evaluation, she presented with similar episode by 2008 for which she got treated outside and she improved. At present, clinical examination revealed unconscious, DEM +, PERRLA, right UMN facial lag+, right hemiplegia +, plantar extensor right. Results of metabolic parameters were normal. Coagulation profile was normal. CXR, ECG, ECHO were normal. CT brain revealed left thalamic bleed with intraventricular bleed, subarachnoid bleed with mild obstructive hydrocephalus. Patient was treated with antiedema measures, antiepileptics, antibiotics and physiotherapy. Patient improved symptomatically and discharged after a period of 2 weeks. Conclusion: Moya moya disease is probably an inherited vascular disease first described in Japan and now reported from all over the world. Most common presentations are- Ischemic stroke 50–75%, Transient ischemic attack (including drop attacks) 50–75% and Hemorrhage (in adults) 10–40%. Our patient presented with hemorrhagic stroke. Characteristic radiographic findings confirm the diagnosis, and recognition of the disease early in its course, with prompt institution of therapy, is critical in order to achieve the best outcome in patients. Revascularization surgery appears to be effective in preventing stroke in patients with moyamoya.
II 32: Acute organotin neurotoxicity: A case series of six patients from Central India
Department of Neurology, Jabalpur Hospital and Research Centre, Jabalpur, Madhyapradesh
Introduction: Organic tin or organotin compounds are widely used as polyvinyl chloride (PVC) heat stabilizers, wood preservative and agricultural pesticides. Trimethyltin, triethyltin, dimethyltin and diethyltin are frequently used organotin stabilizers. Sparse reports of organic tin related neurotoxicity manifesting as acute limbic-cerebellar syndrome have been published previously. Methods: We describe six factory workers (all males, age range 19-50 years) who had accidental inhalational exposure to the fumes of trimethyltin organotin compound. Clinical manifestations, brain MRI findings and metabolic derangements were observed. Results: About 48-72 hours later, exposed subjects exhibited diverse neurological manifestations like muscle pain (6), ataxia (5), seizures (1) delirium (2), spatial disorientation (3), perseveration (2), inappropriate affect (1), and memory defects (6). Brain MRI was abnormal in 5 patients and showed hyperintense signals in the T2-weighted and FLAIR sequences with predominant affection of corpus callosum and medial temporal lobe. Urine and serum tin assays was done in subject with severe metabolic and neurotoxic manifestations on the third day after exposure showed 64 parts per billion (ppb) of tin (normal, <3.3 ppb). Metabolic derangements like refractory metabolic acidosis (1), hypokalemia (4), hyperammonemia (2) and acute kidney injury (1) were found. One patient died due to severe metabolic acidosis and cardiac arrhythmia. Five patients improved significantly after chelation therapy and correction of metabolic derangements. Repeat MRI brain after 2 weeks did not reveal significant changes in comparison to previous MRI. On subsequent follow-up visits at 1, 3 and six months, all five patients showed improvement on detailed formal neurocognitive testing. Conclusion: We observed that trimethyltin toxicity can lead to various neurological manifestations attributed to selective involvement of medial temporal lobe, cerebellum and corpus callosum. Risk and harmful effects of organo-metallic compounds as well as adequate precautions at work place need to be strictly instructed to the workers for prevention from such events.
II 33: Neuroprotective effect of Folic acid in Caenorhabditis Elegans
Department of Microbial Technology and Nematology, CSIR-Central Institute of Medicinal and Aromatic Plants, Lucknow, UP
Several vitamins possess antioxidative property which helps in stress modulation by scavenging ROS and free radicals. Now days, there has been a major advance in the use of vitamins for the prevention of age-related disorder. Folic acid (FA) is an essential nutrient that the human body needs but cannot be synthesized its own. Fortified foods and plant food sources such as green leafy vegetables, beans, fruits, and juices are good sources of FA to meet the daily requirements of the body. The progression in age is accompanied by neurological disease like Alzheimer's disease (AD) which is associated with aberrant protein folding or aggregation. In the present study, we investigated the role of FA in anti- neurodegeneration efficacy using C. elegans model system. Our results demonstrated that the worms treated with 25µM of FA showed reduced level of oxidative stress. We noticed that FA (25µM) reduced the apoptotic cells in worm's body. Further, FA (25µM) treatment significantly suppressed α- synuclein level in C. elegans (NL5901) transgenic strain. Moreover, FA also delays amyloid beta induced paralysis and attenuates ROS level in transgenic C. elegans model of AD. The alteration in lipid levels was found to be normalized significantly in wild type worms upon FA treatment. Altogether, the present investigation supports the exploitation of vitamin supplements such as FA for developing natural therapeutic interventions for treating aging and age-related neurodegenerative disorders.
II 34: Identification and evaluation of mild cognitive impairment in elderly population using neuro-psychological assessments and diffusion tensor imaging in North India
Singh V, Kumar A, Verma S, Pushkar RR, Pathak A, Mishra VN
Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP
Background: Studies provide ample evidence that pathophysiological changes associated with Alzheimer's disease begin 10-25 year before clinical dementia onset and are possible detectable in mild cognitive impairment stage (MCI) stage. Currently, available pharmacological therapies, slow cognitive decline only for about a year. Although new interventions are under investigation, they are likely to be more successful by preventing rather than reversing neurodegeneration. Study design: The present study aim to find the early biomarker in elderly population aged above 60 year at nearby area of eastern Uttar Pradesh and Bihar, having complaint of cognition. The studies used Mini Mental State Examination (MMSE) cognitive function test and Montreal Cognitive Function test (MOCA) on the elderly population with age above 60 years, further, the individuals screened for cognitive decline, were subjected to diffusion tensor imaging (DTI) imaging tests in frontal lobe, temporal lobe, parietal lobe, occipital lobe corpus callosum, forcep minor regions of brain. Result and Conclusion: The result of the current study depicts that 25/50 elderly individual's performance on MMSE and MOCA was significantly less as compared to healthy aged elderly individual. Further, DTI imaging parameters such as Fractional Anisotropy (FA) and Apparent diffusion coefficient(ADC) values in right and left regions of frontal lobe, temporal lobe, parietal lobe, occipital lobe corpus callosum, forcep minor respectively shows significant decline in white matter integrity as compared to case controls subjects. The current study for the first time in North India has significantly established the changes in white matter integrity in brain and psychological function based tests in the screening of the subjects with early onset of Alzheimer's disease.
II 35: A case of neuromyelitis optica with cerebral venous sinus thrombosis and ulcerative colitis
Kesireddy S, Aditya MGV, Raju GB, Gopi S, Kumar TS, Kumari UA
Department of Neurology, Adhra Medical College, Visakhapatnam, Andhra Pradesh
A 22 year old woman presented with acute onset and rapidly progressive bilateral painful loss of vision, right eye more than left eye of 5 years duration and 3 year history of sub acute onset and rapidly progressive weakness of both lower limbs, left more than right along with bladder and bowel incontinence with remissions and relapses in between and pain abdomen, hematochezia and anaemia. No history suggestive of cranial nerve involvement other than second optic nerve/ sensory/ cerebellar/ cognitive involvement. Physical examination revealed pallor, optic atrophy, right more than left, asymmetric spastic paraparesis[left more than right] both proximal and distal and loss of vibration and joint position till anteriosuperior iliac spines. Her Hb was 6 gm%, Anti ds DNA was positive. MRI Brain and spine with contrast showed venous infarct in the left frontal region, bilateral periventricular white matter hyperintensities, superior saggital sinus thrombosis and long segment C4-D9 cord atrophy. CT Venogram showed superior sagittal sinus thrombosis, bilateral transverse sinus and right sigmoid sinus thrombosis. Serum antibodies against aquaporin 4 were positive. Colonoscopy showed pancolitis and multiple pseudopolyps consistent with Ulcerative colitis. A diagnosis of NMOSD was made [modified Wingerchuck criteria]. NMOSD in association with other autoimmune conditions like Ulcerative colitis and SLE should be considered in patients with frequent relapses and other systemic features of autoimmunity. Awareness of this presentation is important as early initiation of immunosuppressive therapy will decrease the disease burden.
II 36: A clinicoradiological profile of skull base osteomyelitis - A short case series
Reddy VK, Reddy MY, Parida S, Chaudhary NV, Jaiswal SK, Kumar BS, Murthy JMK
Department of Neurology, Institute of Neurological Sciences, CARE hospital, Banjara Hills, Hyderabad
Background: Skull base osteomyelitis (SBO) is an uncommon condition with significant morbidity and mortality. We describe a short case series here. Material and Methods: Retrospective analysis of case records of patients with SBO admitted between April 2014 and October 2016. Diagnosis was based on radiology and organism isolation. Results: During the study period five male patients (mean age 62 years; range 58-66 years) were admitted with SBO with symptom duration of 1-4 months. Of the 5 patients, 4 had diabetes, 2 had chronic kidney disease. Source of infection was ear (otitis and mastoiditis) in 4 and paranasal sinuses (sinusitis) in 1. The clinical syndromes were: polyneuritis cranialis in all, cerebellar ataxia and spastic hemiparesis in one patient each. Cranial neuropathies were unilateral in 4 patients and bilateral in 1 patient. Most common nerves involved were V, VII, VIII, IX, X in all the 5 patients and VI and XII in 2 patients. Contrast MRI brain and skull base showed inflammation in pterygoid fossa, meninges in all, subdural empyema in 1 and extensive skull-based osteomyelitis. All patients had abnormal CSF: lymphocytic pleocytosis and elevated protein. Etiology was bacterial in all 4 originating from ear (Pseudomonas in 3; Streptococcus in 1) and fungal in one originating from paranasal sinuses (Aspergillus). All patients underwent extensive debridement of the source. Patients due to bacterial cause were treated with appropriate antibiotics for 6 weeks/ Patient with aspergillus etiology was treated with voriconazole for 6 months. All had favourable outcome. Conclusion: SBO is a potentially treatable disease and should be considered in diabetic patients with polyneuritis cranialis and adjacent ear or paranasal infections. Otogenic SBO type is most likely due to bacterial etiology and sinonasal due to fungus in tropical countries.
II 37: Acute stroke with plasma vivax malaria
Dr. Nirmal Surya, MD,DNB, FIAN
Bombay Hospital Institute of Medical Sciences, Mumbai
Case Report: Cerebral Malaria due to P. Vivax is rare but has been reported from Indonesia, India & Papua New Guinea and recently a case of multiple infarct with P. Vivax is reported from Korea. We present a 45 year male from Mumbai, who is non-hypertensive, non-diabetic presented with giddiness, left facial numbness, slurring of speech imbalance with intermittent fever with for past 2 months. His MRI show acute infarct in left hemi pons, he was treated with anti-malarial treatment & made complete recovery 0n 3rd day of the treatment. Conclusion: We present a case young male without any risk factor with fever, Dysarthria, giddiness, imbalance & facial weakness with P. Vivax positive on smear & made complete recovery with anti-malaria treatment.
II 38: Case series of brainstem encephalitis - A diagnostic enigma
Kothari K, Chakor R, Nadaf S
Department of Neurology, Topiwala National Medical College, Nair Hospital, Mumbai, Maharashtra
II 39: Not always tuberculosis! Unusual case of meningitis with ring enhancing lesions
Patil S, Khadilkar S, Jagiasi K, Soni G, Bijwe SR
Department of Neurology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra
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