We undertook a study 25 patients, all clinically suspected to have vitamin B12 deficiency; they were investigated hematologically, biochemically, & by gastric biopsy and MRI. Most of the patients were more than 40 years of age, were either vegetarian or non-vegetarian; 21 patients were belonging to the middle-income group. The total number of males in the study was 22 and there were three females. The clinical features of vitamin B12 deficiency are described. Clinical evidence of pyramidal tract involvement was found in six patients (24%). MRI confirmed cord involvement in 12 of the 17 patients (70.5%): follow up MRI of two patients showed marked reductions in signals after one year of treatment. These patients showed improvement after receiving injectable vitamin b12. Nerve conduction studies (N.C.V) showed evidence of neuropathy in fifteen of eighteen (83%) patients. Gastric biopsy was abnormal in all except one in the 20 patients in whom it was conducted. Anti intrinsic factor blocking antibodies (AIFBA) were elevated in 11/24 (45.8%) and anti parietal cell antibodies (APCAB) were elevated in 19/24 patients (79%). The possible etiological factors responsible for vitamin B12 deficiency are age and pernicious anemia. As concluded in this study, diet was not found to be a contributory factor in the causation of cobalamin deficiency. We conclude that pernicious anemia is probably an important etiological factor as a cause of vitamin B12 deficiency in Indians. The male predominance is intriguing.

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Acute symptomatic seizures are those caused or provoked by an acute medical or neurological illness,' Acute seizures are common in the acute phase of most of the infections of central nervous system (CNS). Acute symptomatic seizures show clearly differentiated characteristics with regard to true epileptic seizures: 1) a clearly identified causal association, 2) generally tend not to recur, 3) usually long-term antiepileptic drug (AED) treatment is not necessary.

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Infections of central nervous system are still a major problem. Despite the introduction of newer antimicrobial agents, mortality and long-term sequelace associated with these infections is unacceptably high. Based on the evidence that proinflammtory cytokines have a role in pathophysiology of bacterial and tuberculous meningitis, corticosteroids with a potent anti-inflammatory and immunomodulating effect have been tested and found to be of use in experimental and clinical studies, Review of the available literature suggests steroid administration just prior to antimicrobial therapy is effective in decreasing audiologic and neurologic sequelae in childern with H. influenzae nenigitis. Steroid use for bacterial meningitis in adults is found to be beneficial in case of S. pneumoniae. The value of adjunctive steroid therapy for other bacterial causes of meningitis remains unproven. Corticocorticoids are found to be of no benefit in viral meningitis, Role of steroids in HIV positive patients needs to be studied.

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The diagnosis of Duchenne Muscular Dystrophy (DMD) and Becker Muscular Dystrophy (BMD) is mainly based on clinical profile, serum CPK values, muscle biopsy and immunostaining for dystrophin. Most recent and accurate method for diagnosing DMD/BMD is by detection of mutations in the DMD gene. This was done in 100 unrelated patients using 19 exons including the promoter region in two sets of multiplex polymerase chain reaction (PCR). These primers amplify most of the exons in the deletion prone 'hotspot' regions allowing determination of deletion end point. Intragenic deletions were detected in 74 patients indicating that the use of PCR-based assays will allow deletion detection help in prenatal diagnosis for most of the DMD/BMD patients. The frequency of deletions observed in the present study was 74%.

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Disorders of sodium and water are common complications of acute infections of central nervous system. (CNS) and are associated with poor outcome. Hyponatremia is the most common electrolyte and water-related disorder among these patients. Brain oedema associated with the primary pathology of the infection can worsen with hyponatremia. A systematic evaluation and management of sodium and water dysregulation in acute CNS infections may contribute to improved outcome.

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Sixteen cases of Herpes simplex Encephalitis (HSE) from Eastern India seen over a period of five years (1996-2001) are reported. Selection criteria included clinical features, characteristic MRI changes and positive immunological test. CT scans, EEG and CSF findings supported the diagnosis. Altered sensorium and seizure were the two commonest presenting features. Other presentations included behaviour abnormality, personality change, speech disturbance and hemiparesis. The onset of neurological symptoms was preceded by a prodrome of fever and headache in 80% patients. CT scan was abnormal in50% cases. Typical MRI changes, key point for diagnosis consisted of T2 weighted hyper intensities involving the temporal and frontal lobes. EEG showed focal periodic discharges over temporal lobes in 6 cases and non-specific slowing in5. Commonest CSF abnormalities noted in our series were moderate pleocytosis and raised protein. All reported cases showed presence of antibody against herpes simplex virus (HSV) in CSF. Presence of RBC in CSF and absence of hypoglychorrea were important diagnostic indicators. The response to treatment with acyclovir was satisfactory. All our patients survived. Six out of 16 our patients had moderate to severe neurological deficits at the time of discharge.

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Fever is a very common problem in neurological intensive care units (NICU) and in about a half the patients fever is associated with and infections. There is overwhelming evidence from both experimental and clinical studies to suggest that elevated temperature has deleterious effects on the acutely injured brain and is associated with poor outcome. There are no data on the effect of elevated temperature on the injured brain in patients with infections of central nervous system. Elevated temperature irrespective of the etiology should be treated aggressively. Antipyretic drugs lower body temperature in pyrogen-induced fever, which implies intact thermoregulation, but may be ineffective in brain-injured patients with impaired thermoregulatory mechanisms. It appears that cooling devices both external and endovascular, are promising in the treatment of fever in NICU.

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Increased intracranial pressure (ICP) is a pathological state common to a variety of infections of central nervous system (CNS) and is associated with higher morbidity and mortality. The pathology associated with increased ICP in CNS infections is diverse and often multiple, multi-approach aggressive treatment strategies are essential for better outcomes.

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Mechanisms of brain injury in infections of central nervous system (CNS) are complex. While the primary injury may be due to meningeal and/or parenchymal invasion by the pathogen and release of toxins, a variety of secondary insults occur, which may influence the outcome as much as the primary insult. This concept is well recognized in brain trauma(1,2) where early recognition of secondary injuries and their appropriate treatment has been shown to improve outcome. Hypoxia, ischemia and metabolic disturbances are important secondary insults recognized in brain trauma, These are known to cause permanent neurological damage and worsening of outcome if undetected and untreated. In CNS infections, with their complex pathophysiologies, there is ample scope for such secondary insults. Monitoring in patients with CNS infections is to detect these secondary insults, allowing for a more informed approach to treatment.

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