Serum Vitamin-D Levels And Severity Of Clinical Depression In Patients Of A Psychiatric Clinic in Pakistan

Vitamin D deficiency is often correlated with nervous system disorders like major depression, Parkinson’s disease and dementia. While much of the clinical literature suggests its association with clinical depression, very few studies have looked into the relationship between vitamin D levels and clinical depression severity. Objectives: To find out the association between vitamin D levels in patients suffering from different severities of clinical depression with the confounding socio-cultural factors of a third-world country i.e., Pakistan. Methods: The cross-sectional study was conducted in Lady Reading Hospital, Peshawar for five months with convenience sampling. Results: Overall, the study had 132 (36.57%) males and 229 (63.43%) females, and 236 diagnosed cases of Clinical Depression. In terms of Vitamin D levels, 242 (67.04%) had deficient, while 77 (21.33%) and 42 (11.63%) had insufficient and normal vitamin D levels, respectively. There was a statistically significant difference in the serum Vitamin D levels between at least two groups (F (3,232) = [38.64], p < 0.05). Conclusions: Vitamin D levels showed a dose-dependent, inverse relation with the severity of clinical depression in the Pakistani population

Mitochondrial neurogastrointestinal encephalomyopathy in a Pakistani female: a case report

Background

Mitochondrial neurogastrointestinal encephalopathy is a rare multisystem autosomal recessive disease caused by mutations in the TYMP gene, that encodes for thymidine phosphorylase. Mitochondrial neurogastrointestinal encephalopathy is a progressive degenerative disease characterized by a distinctive tetrad of gastrointestinal dysmotility, peripheral neuropathy, ophthalmoplegia with ptosis, and asymptomatic leukoencephalopathy. It provides a diagnostic dilemma to physicians in regions like Pakistan because of a lack of genetic study availability and associated financial constraints of the population. However, with careful examination and a few basic investigations, mitochondrial neurogastrointestinal encephalopathy can be diagnosed by ruling out most of the close differentials.

Case presentation

We report the case of a 23-year-old Asian female whose chief complaints were epigastric pain, bilious emesis, weight loss for 3 months, and bilateral lower limb weakness for 20 days. All clinical signs and symptoms along with relevant investigations including nerve conduction studies, electromyography, and magnetic resonance imaging of the brain were highly suggestive of mitochondrial neurogastrointestinal encephalopathy syndrome. Because of financial constraints, genetic studies could not be performed. The patient was managed with a multidisciplinary approach involving gastroenterology, physiotherapy, and nutrition departments. Currently, therapeutic options for the disease include allogeneic hematopoietic stem cell transplant and carrier erythrocyte entrapped thymidine phosphorylase; however, these could not be provided to the patient owing to certain limitations.

Conclusions

As misdiagnosis and delayed diagnosis are quite common in this disease, the prime objective of this case report is to increase the basic understanding of this disease, especially its signs and symptoms, and address the limitations regarding the diagnostic investigations and management of patients with mitochondrial neurogastrointestinal encephalopathy.

Crossed Cerebellar Diaschisis in a Child with Status Epilepticus

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Crossed Cerebellar Diaschisis In A Child With Status Epilepticus: An Unusual Presentation

Crossed Cerebellar Diaschisis (CCD) describes a depression of oxidative metabolism and blood flow in the cerebellum secondary to a supratentorial lesion in the contralateral cerebral hemisphere. The pathophysiology is not clear but appears to be caused by abnormal neuronal connection of the primary to the remote site. The diagnosis is usually done using positron emission tomography (PET) and singlephoton emission CT (SPECT) scans. Almost all the reported cases of CCD are caused by acute ischemic stroke in adults. Hence, CCD secondary to status epilepticus, extremely rare and there is limited literature available on it. This is important because it's findings can easily be confused with acute ischemic stroke and similar concurrent diseases. Correct diagnosis can also help localize the cause of the seizures and significantly influence surgical decisions. We present a case of CCD in a child with status epilepticus using MRI of the brain with DWI.

Post-COVID Opsoclonus Myoclonus Syndrome: A Case Report From Pakistan

Background: Coronavirus disease-2019 (COVID-19), caused by the severe acute respiratory distress syndrome–coronavirus-2 (SARS-CoV-2), is primarily a respiratory infection but has been recently associated with a variety of neurological symptoms. We present herewith a COVID-19 case manifesting as opsoclonus-myoclonus syndrome (OMS), a rare neurological disorder.

Case Presentation: A 63-year-old male diagnosed with COVID-19 infection developed behavioral changes, confusion, and insomnia followed by reduced mobility and abnormal eye movements within 48 h of recovery from respiratory symptoms associated with COVID-19. On examination, he had rapid, chaotic, involuntary saccadic, multidirectional eye movements (opsoclonus), and limb myoclonus together with truncal ataxia. CSF analysis, MRI of the brain, and screening for anti-neuronal and encephalitis related antibodies were negative. Extensive testing revealed no underlying malignancy. The patient was successfully treated with intravenous immunoglobulin (IVIG) with complete resolution of symptoms within 4 weeks of treatment.

Conclusion: COVID-19 infection can be associated with the manifestation of opsoclonus myoclonus syndrome, a rare neurological disorder that can be treated with IVIG if not responsive to corticosteroids.

Sequential Optic Neuritis: A Neuromyelitis Optica Spectrum Disorder

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune relapsing demyelinating disorder which often leads to severe disability typically targeting spinal cord, optic nerves, and brainstem. Around 75% of NMOSD patients have serum immunoglobulin-G (IgG) autoantibodies to the aquaporin-4 channel (AQP4-IgG). AQP4-IgG antibodies have a central role in new diagnostic criteria of NMOSD. These antibodies have a critical role in long-term management after the first attack. The prevalence of this disorder is lower than multiple sclerosis in European countries. However, NMO makes a substantial proportion of the demyelinating diseases of the central nervous system in countries like Pakistan, where it can be mistaken for multiple sclerosis. Accurate diagnosis is essential as some of the drugs for multiple sclerosis can potentially worsen NMOSD. We present a case of sequential optic neuritis with positive aquaporin 4 antibodies. We have discussed the history, examination findings, diagnostic workups, and treatment of the patient.

Dyke-Davidoff-Masson Syndrome: An Unusual Cause of Status Epilepticus and Refractory Seizures

Dyke-Davidoff-Masson Syndrome (DDMS) is a rare neurological condition characterised by drug-resistance seizures, hemiparesis, mental retardation, facial asymmetry, and intellectual disabilities. On brain imaging, the disease is characterised by cerebral hemiatrophy with ipsilateral calvarial thickening and hyperpneumotisation of paranasal sinuses or mastoid air cells. Although more common in men and on the left side of the brain, the disease can affect both genders and cerebral hemispheres. It mainly presents in childhood. The adult presentation is unusual but has been reported in medical literature. Most of the patients need more than one antiepileptic agent for optimal control of seizures. Hemispherectomy is reserved for patients who have drug-resistant and disabling seizures. The good prognostic factors are disease onset before age of two and better seizure control. We report two cases of DDMS occurring in teenage boys who presented with status epilepticus. The clinical histories, radiological findings, and treatment of both patients are discussed below.

Barr humbug: acute cerebellar ataxia due to Epstein-Barr virus

Epstein-Barr virus (EBV) infection is associated with neurological sequellae, but rarely there is acute cerebellar ataxia (ACA) in an adult. We present a novel case of a 26-year-old man, who presented with ACA. He had normal MRI and CSF analysis. Serum testing confirmed active EBV. A course of oral prednisolone 1 mg/kg for 4 weeks, with a subsequent taper was started. He made a full recovery within 3 weeks of presentation.