Hyperkinetic and Hypokinetic Movement Disorders in SSPE: A Systematic Review of Case Reports and Case Series

Background

Subacute Sclerosing Panencephalitis (SSPE) typically presents with periodic myoclonus; however, a spectrum of movement disorders including dystonia, chorea, tremor, and parkinsonism have also been described. This review aims to evaluate the array of movement disorders in SSPE, correlating them with neuroimaging findings, disease stages, and patient outcomes.

Methods

A comprehensive review of published case reports and case series was conducted on patients with SSPE exhibiting movement disorders other than periodic myoclonus. PRISMA guidelines were followed, and the protocol was registered with PROSPERO (2023 CRD42023434650). A comprehensive search of multiple databases yielded 37 reports detailing 39 patients. Dyken's criteria were used for SSPE diagnosis, and the International Movement Disorders Society definitions were applied to categorize movement disorders.

Results

The majority of patients were male, with an average age of 13.8 years. Approximately, 80% lacked a reliable vaccination history, and 39% had prior measles infections. Dystonia was the most common movement disorder (49%), followed by parkinsonism and choreoathetosis. Rapid disease progression was noted in 64% of cases, with a disease duration of ≤6 months in 72%. Neuroimaging showed T2/FLAIR MR hyperintensities, primarily periventricular, with 26% affecting the basal ganglia/thalamus. Brain biopsies revealed inflammatory and neurodegenerative changes. Over half of the patients (56%) reached an akinetic mute state or died.

Conclusion

SSPE is associated with diverse movement disorders, predominantly hyperkinetic. The prevalence of dystonia suggests basal ganglia dysfunction.

Treatment Outcome in Patients with Disseminated Cysticercosis: A Systematic Review of Case Reports and Case Series

Disseminated cysticercosis is defined by multiple brain lesions and involvement of other body sites. Cysticidal treatment in disseminated cysticercosis is considered life-threatening. We conducted a systematic review of all published cases and case series to assess the safety and efficacy of cysticidal treatment. We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO CRD42022331895) to assess the safety and efficacy of cysticidal treatment. Using the search term "disseminated neurocysticercosis OR disseminated cysticercosis," databases like PubMed, Scopus, Embase, and Google Scholar were searched. Outcomes included death and secondary measures like clinical improvement and lesion reduction. We calculated the predictors of primary outcome (death) using the binary logistic regression analysis. We reviewed 222 published cases from 101 publications. Approximately 87% cases were reported from India. Of 222 cases, 134 (60%) received cysticidal treatment. Follow-up information was available from 180 patients, 11 of them died, and 169 showed clinical improvement. The death rate was 4% (5 out of 114) in patients treated with cysticidal drugs plus corticosteroids, in comparison with 13% (5 out of 38) in patients who were treated with corticosteroids alone. All patients using only praziquantel faced fatality. Death predictors identified were altered sensorium and lack of treatment with albendazole. We noted that the risk of death after cysticidal treatment is not as we expected, and a multicentric randomized controlled trial is needed to resolve this issue.

Neuroimaging Abnormalities in Patients with Subacute Sclerosing Panencephalitis : Prospective Follow-up Study

OBJECTIVE

This study aimed to assess the neuroimaging abnormalities and their progression in patients with Subacute sclerosing panencephalitis (SSPE) and identify clinical predictors of these imaging findings.

METHODS

This prospective observational study evaluated clinical and neuroimaging features in patients with SSPE. Patients were categorized using Dyken's criteria, Jabbour's staging system, and the definition of fulminant SSPE. They underwent comprehensive clinical assessments, cerebrospinal fluid examination, Electroencephalogram (EEG), and Magnetic Resonance Imaging (MRI) scans. Treatment involved intrathecal interferon‑α and antiepileptic medications. Functional disability was assessed using the modified Barthel index. Follow-ups were performed at 6 months, including reassessment of Modified Barthel Index (MBI) and Jabbour's staging and EEG and MRI scans.

RESULTS

The mean age was 13.9 ± 6.7 years, with males comprising 81.5% (44/54) of the cohort. Fulminant SSPE was noted in 33% (18/54) of cases. Disease duration before presentation varied significantly between fulminant and non-fulminant forms (p = 0.001). Neuroimaging abnormalities were more prevalent in JS III stage patients, with diffuse cerebral atrophy being a significant finding (p = 0.011). Basal ganglia involvement correlated with movement disorders. The 6‑month follow-up showed increased cerebral atrophy (p = 0.004). Increasing disease duration was an independent predictor of cerebral atrophy. An Intercomplex interval (ICI) of more than 10 minutes correlated with normal neuroimaging, 10 patients died within the study period, 8 of whom had fulminant SSPE.

CONCLUSION

Parieto-occipital White matter hyperintensity (WMH) is the most prevalent and sensitive neuroimaging finding for the diagnosis of SSPE. Despite interferon treatment, cerebral atrophy progressed in both aggressive and fulminant SSPE. Increasing disease duration is an independent predictor of cerebral atrophy.

The spectrum of central nervous system manifestations in leprosy: a systematic review of published case reports and case series

BACKGROUND

This systematic review aimed to investigate central nervous system (CNS) involvement in leprosy by analysing multiple cohort studies, individual cases and case series.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. PubMed, Scopus and Embase databases were searched up to 8 July 2023, using a predefined search strategy. Inclusion criteria included patients diagnosed with leprosy with evidence of CNS involvement. The quality of the included cases was evaluated using the Joanna Briggs Institute checklist.

RESULTS

A total of 34 records were identified, including 18 cohort studies and 16 reports describing 27 isolated cases. Autopsies revealed macroscopic changes in the spinal cord, neurofibrillary tangles and senile plaques. Mycobacterium leprae was detected in neurons of the medulla oblongata and spinal cord using PCR and phenolic glycolipid 1 staining. Cerebrospinal fluid (CSF) analysis showed inflammatory changes, increased gamma globulins and detection of Mycobacterium leprae antigens and antibodies. In 21 patients (78%), spinal cord/brachial plexus abnormities were detected. In the majority, MRI revealed T2/fluid-attenuated inversion recovery (FLAIR) hyperintensity in the cervical cord. In patients with brainstem involvement, T2/FLAIR hyperintensity was noted in the cerebellar peduncles, facial nerve nuclei and/or other cranial nerve nuclei. Brain parenchymal involvement was noted in three patients.

CONCLUSIONS

This systematic review provides evidence of CNS involvement in leprosy, based on autopsy findings, neuroimaging, CSF analysis and neurophysiological studies.

Humoral and cellular immune response in patients of liver cirrhosis and immunocompetent recipient of ChAdOx1nCoV-19 Vaccine (Covishield)

Despite the effectiveness of COVID-19 vaccination in reducing the severity of the disease, the demand for booster is increasing in vulnerable populations like elderly and immunocompromised individuals especially with each new wave of COVID-19 in different countries. There is limited data on the sustained immunity against COVID-19 in patients with liver cirrhosis. The study was aimed to compare the T cell and humoral immune response after 1 year of ChAdOx1nCoV-19 Vaccine in patients with liver cirrhosis and healthy health care workers (HCW). This was a prospective observational study including 36 HCW, 19 liver cirrhosis patients and 10 unvaccinated individuals. Anti-SARS-CoV-2S antibody, neutralizing antibody and memory T cell subsets were evaluated by ELISA and flow cytometry, respectively, in all three groups after 1 year of initial vaccination. Compared to HCW and unvaccinated individuals, liver cirrhosis patients had significantly depleted T cells, although CD4:CD8 + T cell ratio was normal. Both cirrhotic patients and HCW developed memory T cell subset [effector memory RA (P = 0.141, P < 0.001), effector memory (P < 0.001, P < 0.001), central memory (P < 0.001, P < 0.01), stem cell memory (P = 0.009, P = 0.08) and naïve (P < 0.001, P = 0.02)] compared to unvaccinated unexposed individuals of CD4 + T and CD8 + T, respectively. However, among HCW and cirrhotic group no difference was noted on central memory and stem cell memory cells on T cells. Patients with liver cirrhosis developed comparable memory T cells after vaccination which can evoke sustainable immune response on reinfection. Therefore, additional vaccine doses may not be necessary for cirrhosis patients.

Occurrence and determinants of seizures and their impact on tuberculous meningitis: a prospective evaluation

OBJECTIVE

To assess the incidence of seizures and the factors contributing to poor outcomes in patients with tuberculous meningitis (TBM).

METHODS

In this prospective observational study, 129 patients with TBM were enrolled at the Department of Neurology, King George's Medical University, Uttar Pradesh, India, from April 2021 to April 2023. Detailed clinical history, neurological examinations, baseline laboratory tests, contrast-enhanced Magnetic resonance imaging (MRI) and electroencephalography (EEG) were obtained for all patients. Patients received anti-tuberculous therapy and, if necessary, anti-epileptic treatment. Patients were followed for 6 months, with outcomes evaluated using the Modified Rankin Scale (MRS).

RESULTS

Of the 129 patients, 48 (37.2%) reported seizures. Advanced TBM stage (p = 0.040, OR = 2.50 95% CI:1.02-6.07), cortical involvement (p = .0.013, OR = 2.58 95% CI:1.20-5.51) and spike-wave discharges in the EEG (p = 0.001) were significantly associated with seizure occurrence. After multivariate analysis, only cortical involvement (p = 0.031, OR = 2.34, 95% CI:1.08-5.08) emerged as independent predictor of for seizures. Focal to bilateral seizures (p = 0.008, OR = 9.41, 95% CI: 1.76-74.04), status epilepticus (p = 0.002, OR = 8.00, 95% CI: 1.86-34.32), and rifampicin resistance (p = 0.022, OR = 9.25, 95% CI: 1.43-59.50) were significantly associated with poor outcomes at the 6-month mark.

CONCLUSION

Seizures were significantly associated with advanced stage of the disease, cortical involvement on neuro-imaging and epileptiform pattern on EEG. Additionally, focal to bilateral seizures and status epilepticus adversely affected the outcome.

Phenomenology, quality of life, and predictors of reversibility in patients with drug-induced movement disorders: a prospective study

BACKGROUND

Drug-induced movement disorders (DIMDs) form an important subgroup of secondary movement disorders, which despite conferring a significant iatrogenic burden, tend to be under-recognized and inappropriately managed.

OBJECTIVE

We aimed to look into phenomenology, predictors of reversibility, and its impact on the quality of life of DIMD patients.

METHODS

We conducted the study in the Department of Neurology at a tertiary-care centre in India. The institutional ethics-committee approved the study. We assessed 55-consecutive DIMD patients at presentation to our movement disorder clinic. Subsequently, they followed up to evaluate improvement in severity-scales (UPDRS, UDRS, BARS, AIMS) and quality of life (EuroQol-5D-5L). Wilcoxan-signed-rank test compared the scales at presentation and follow-up. Binary-logistic-regrerssion revealed the independent predictors of reversibility.

RESULTS

Fourteen patients (25.45%) had acute-subacute DIMD and 41 (74.55%) had tardive DIMD. Tardive-DIMD occurred more commonly in the elderly (age 50.73±16.92 years, p<0.001). Drug-induced-Parkinsonism (DIP) was the most common MD, followed by tardivedyskinesia. Risperidone and levosulpiride were the commonest culprit drugs. Patients in both the groups showed a statistically significant response to drug-dose reduction /withdrawal based on follow-up assessment on clinical-rating-scales and quality of life scores (EQ-5D-5L). DIMD was reversible in 71.42% of acute-subacute DIMD and 24.40% of patients with chronic DIMD (p=0.001). Binary-logistic-regression analysis showed acute-subacute DIMDs and DIP as independent predictors of reversibility.

CONCLUSION

DIP is the commonest and often reversible drug-induced movement disorder. Levosulpiride is notorious for causing DIMD in the elderly, requiring strict pharmacovigilance.

Reasons for re-hospitalization in patients with tuberculous meningitis, and its impact on outcome: a prospective observational study

BACKGROUND

Patients with tuberculous meningitis may worsen despite being treated adequately with anti-tuberculosis drugs. This worsening may lead to re-hospitalization. The exact frequency and causes of re-hospitalization have not been studied previously. We aimed to study the causes of clinical worsening leading to re-hospitalization and its impact on prognosis.

METHODS

This was a prospective observational study. Newly diagnosed patients with tuberculous meningitis (N = 150) were enrolled. Baseline clinical evaluation, neuroimaging, and cerebrospinal fluid examination were performed. Anti-tuberculosis drug regimen and corticosteroids were given as per WHO guidelines. Patients were followed for 6 months. Re-hospitalized patients were worked up and clinical evaluation, neuroimaging, and cerebrospinal fluid examination were performed again. Outcome assessment was done at the end of 6 months, and a modified Barthel index of ≤ 12 was considered a poor outcome.

RESULTS

Twenty-three (15.3%) out of 150 patients needed re-hospitalization. The median time between discharge after the first hospitalization and re-hospitalization was 60 days. The common reasons for re-hospitalization were paradoxical neurological deterioration seen in 19 (82.6%) out of 23 patients, followed by drug toxicities (N = 2) and systemic involvement (N = 2). Paradoxically developed spinal arachnoiditis and opto-chiasmatic arachnoiditis were amongst the predominant reasons for re-hospitalization. At six months, re-hospitalization was an independent predictor of poor outcome (OR = 7.39, 95% CI 2.26-24.19).

CONCLUSION

Approximately 15% of tuberculous meningitis patients needed re-hospitalization. Paradoxically developed spinal arachnoiditis and opto-chiasmatic arachnoiditis were predominant reasons for re-hospitalization. Re-hospitalization adversely affected the outcome.

Satellite Epidemic of Covid-19 Associated Mucormycosis in India: A Multi-Site Observational Study

BACKGROUND

Sudden upsurge in cases of COVID-19 Associated Mucormycosis (CAM) following the second wave of the COVID-19 pandemic was recorded in India. This study describes the clinical characteristics, management and outcomes of CAM cases, and factors associated with mortality.

METHODS

Microbiologically confirmed CAM cases were enrolled from April 2021 to September 2021 from ten diverse geographical locations in India. Data were collected using a structured questionnaire and entered into a web portal designed specifically for this investigation. Bivariate analyses and logistic regression were conducted using R version 4.0.2.

RESULTS

A total of 336 CAM patients were enrolled; the majority were male (n = 232, 69.1%), literate (n = 261, 77.7%), and employed (n = 224, 66.7%). The commonest presenting symptoms in our cohort of patients were oro-facial and ophthalmological in nature. The median (Interquartile Range; IQR) interval between COVID diagnosis and admission due to mucormycosis was 31 (18, 47) days, whereas the median duration of symptoms of CAM before hospitalization was 10 (5, 20) days. All CAM cases received antifungal treatment, and debridement (either surgical or endoscopic or both) was carried out in the majority of them (326, 97.02%). Twenty-three (6.9%) of the enrolled CAM cases expired. The odds of death in CAM patients increased with an increase in HbA1c level (aOR: 1.34, 95%CI: 1.05, 1.72) following adjustment for age, gender, education and employment status.

CONCLUSION

A longer vigil of around 4-6 weeks post-COVID-19 diagnosis is suggested for earlier diagnosis of CAM. Better glycemic control may avert mortality in admitted CAM cases.

Case Report: An Unusual Case of Subacute Sclerosing Panencephalitis with Distinctive Clinical and Neuroimaging Features

Subacute sclerosing panencephalitis (SSPE) is a relentlessly progressive brain disorder with invariable mortality. Subacute sclerosing panencephalitis is common in measles-endemic areas. We report an unusual SSPE patient with distinctive clinical and neuroimaging features. A 9-year-old boy came with a 5-month history of spontaneously dropping objects from both hands. Subsequently, he developed mental decline, a loss of interest in his surroundings, decreased verbal output, and inappropriate crying and laughing along with generalized periodic myoclonus. On examination, the child was akinetic mute. The child demonstrated intermittent generalized axial dystonic storm with flexion of upper limbs, an extension of lower limbs, and opisthotonos. Dystonic posturing was more dominant on the right side. Electroencephalography revealed periodic discharges. Cerebrospinal fluid antimeasles IgG antibody titer was markedly elevated. Magnetic resonance imaging revealed marked diffuse cerebral atrophy, and periventricular T2/fluid-attenuated inversion recovery hyperintensity. T2/fluid-attenuated inversion recovery images also revealed multiple cystic lesions present in the region of periventricular white matter. The patient was given a monthly injection of intrathecal interferon-α. The patient is currently continuing in the akinetic-mute stage. In conclusion, in this report, we described an unusual case of acute fulminant SSPE in which neuroimaging demonstrated unusual multiple small discrete cystic lesions in the cortical white matter. The pathological nature of these cystic lesions currently is not clear and needs to be explored.

Bilateral Vision Loss and Visual Hallucinations in Subacute Sclerosing Panencephalitis: A Case Report

We report an interesting case of visual loss and visual hallucinations in a 37-year-old man. He presented with decreased vision in both eyes and visual hallucinations for the last one and a half months. He also had multiple focal to bilateral tonic-clonic seizures. On examination, there was no perception of light rays in both eyes. Fundus examination revealed disc oedema with peripapillary small haemorrhages in both eyes. Initially, the discs were hyperaemic, which turned pale in the subsequent examination at 1 month. Magnetic resonance imaging (MRI) of the brain revealed T2 hyperintensities in periventricular white matter and right fronto-parietal-occipital gray matter. His electroencephalogram showed intermittent slowing. His cerebrospinal fluid (CSF) examination showed five cells (all lymphocytes), protein 50 mg/dl, sugar 76 mg/dl (corresponding blood sugar 90 mg/dl). His CSF specimen was positive for anti-measles IgG antibodies. In conclusion, acute vision loss can rarely be the presenting symptom and, therefore, SSPE should also be considered in differential diagnoses of acute vision loss in measles-endemic regions.

Value of whole-body MRI for the assessment of response to albendazole in disseminated neurocysticercosis: a prospective follow-up study

BACKGROUND

Disseminated neurocysticercosis is defined as simultaneous involvement of the brain (≥3 cysts) and at least one additional body site/organ. We aimed to identify disseminated cystic lesions in other body parts and investigate the effect of albendazole.

METHODS

We enrolled patients with multiple (≥3) neurocysticercosis brain lesions. Whole-body MRI (short tau inversion recovery coronal sequences) was performed to assess the number of lesions in the brain and other body parts at baseline and 3 months after albendazole therapy.

RESULTS

We screened 35 patients with multiple brain neurocysticercosis. In 13 patients, whole-body MRI demonstrated disseminated neurocysticercosis lesions. Ten patients were treated with albendazole. We excluded three patients. Brain MRI showed a mean lesion count of 163.6±193.8. Whole-body MRI (excluding the brain) showed a mean lesion count of 629.9±486.1. After albendazole therapy, the lesion load of the brain reduced significantly (163.6±193.8 to 99±178.3; p=0.008). Similarly, whole-body MRI showed a significant reduction in extracerebral neurocysticercosis lesion load (629.9±486.1 to 183.4±301.9; p=0.005). Three patients had complete resolution, five patients showed ≥50% reduction and two patients had <50% reduction in extracerebral lesion load.

CONCLUSION

Whole-body MRI should routinely be performed in multiple neurocysticercosis lesions of the brain. Albendazole treatment leads to a remarkable reduction in neurocysticercosis lesions throughout the body.

Spectrum of Serious Neurological and Psychiatric Adverse Events in Indian COVID-19 Vaccine Recipients: A Systematic Review of Case Reports and Case Series

Indian data regarding serious neurological and psychiatric adverse events, following coronavirus disease 2019 (COVID-19) vaccination, are lacking. We, therefore, systematically evaluated cases of post-vaccinal serious neurological and psychiatric adverse reactions published from India. A systematic review of cases published from India, which were archived in PubMed, Scopus, and Google Scholar databases, was performed; pre-print databases along with ahead-of-print contents were searched in addition. Retrieved articles, as on June 27, 2022, were evaluated following PRISMA guidelines. EndNote 20 web tool was used to make a PRISMA flow chart. Individual patients' data were compiled in a tabular form. The protocol of the systematic review was registered with PROSPERO (CRD42022324183). A total of 64 records describing 136 instances of serious neurological and psychiatric adverse events were identified. More than 50% (36/64) reports were from the following four states, namely, Kerala, Uttar Pradesh, New Delhi, and West Bengal. The mean age of persons developing these complications was 44.89 ± 15.77 years. In the majority, adverse events occurred within 2 weeks of administration of the first dose of COVISHIELD vaccine. Immune-mediated central nervous system (CNS) disorders were identified in 54 instances. Guillain-Barre syndrome and other immune-mediated peripheral neuropathies were reported in 21 cases. Post-vaccinal herpes zoster was recorded in 31 vaccine recipients. Psychiatric adverse events were recorded in six patients. In Indian recipients of COVID-19 vaccine, a variety of serious neurological complications were reported. The overall risk appears minuscule. Immune-mediated central and peripheral neuronal demyelinations were the most frequently reported post-vaccinal adverse events. A large number of cases of herpes zoster have also been reported. Immune-mediated disorders responded well to immunotherapy.

Impact of comorbid psychogenic non-epileptic seizures on migraine: An observational study

Objectives

There is a bidirectional and complex interplay between psychiatric comorbidities and migraine. Migraine has been observed in 50-60% of patients with psychogenic non-epileptic seizures (PNES). Studies describe migraine as a medical comorbidity in PNES. However, there are limited studies on impact of PNES on migraine. We aim to see the impact of PNES on migraine.

Materials and Methods

This cross-sectional and observational study was conducted at a tertiary-care center from June 2017 to May 2019. Fifty-two patients with migraine with PNES and 48 patients with migraine without PNES were included on the study. Migraine and PNES were diagnosed based on International Classification of Headache Disorders-3 (ICHD-3) and International League Against Epilepsy (ILAE) criteria, respectively. Headache intensity was assessed using visual analog scale. Comorbid depression, anxiety, and somatoform-symptom-disease were assessed using the Generalized Anxiety Disorder-7 Scale, Patient Health Questionnaire-9, and DSM-5 criteria, respectively.

Results

Females were common in both groups and the difference was statistically insignificant. Headache frequency was significantly more in patients with migraine with PNES (P < 0.05). However, headache intensity was similar in both groups. Patients with headaches and PNES identified triggers less commonly except for stress. Depression and somatoform symptom disorder were significantly more common in patients with migraine with PNES. Abnormal neurocircuitry involving frontal, limbic, and thalamic regions due to comorbid PNES may cause central sensitization, resulting in frequent migraine headaches which is further augmented by coexisting depression and somatoform-symptom-disease.

Conclusion

Migraine with PNES patients suffers more frequent headaches than patients with migraine without PNES. They differ in various headache triggers, with mental stress being the predominant trigger.

A Novel Case of Primary Conus Medullaris Epithelioid Glioblastoma with Gliosarcomatous Differentiation

Intramedullary location is seldom seen in spinal cord neoplasms. Ependymomas and astrocytomas comprise the vast majority of these intramedullary lesions. Primary spinal origin is rarely seen in gliosarcomas. No epithelioid glioblastomas have been reported in the spine. We describe the case of an 18-year-old male who presented with symptoms suggestive of a spinal mass lesion. Magnetic resonance imaging revealed a homogeneous intradural-intramedullary lesion involving the conus medullaris. Biopsy of the lesion showed a unique morphology comprising gliosarcoma and epithelioid glioblastoma differentiation, supported by relevant immunohistochemistry. The prognosis of such an entity is expected to be poor. However, the presence of mutant BRAF V600E, as seen in the current case, and the availability of targeted therapy against it are expected to improve the prognosis.

Does Calcified Neurocysticercosis Affect Migraine Characteristics and Treatment Responsiveness? A Case-Control Study

Recently, inflammation and free-radical release has been described in the surrounding brain parenchyma of seemingly inert calcified lesions of neurocysticercosis. These free radicals can induce migraine by stimulating calcitonin gene-related peptide release. This stipulated mechanism led us to hypothesize that calcified neurocysticercosis may increase migraine severity. This case-control study included patients (migraine with calcified neurocysticercosis) and control subjects (migraine without calcified neurocysticercosis) in a 1:1 ratio. Headache frequency, visual analog scale (VAS) score, and Migraine Disability Assessment (MIDAS) score were assessed at baseline and at the end of 3 months. To compare treatment responsiveness between patients and control subjects, we treated both groups identically so that difference in treatment would not confound the results. Each group comprised 78 patients. Baseline headache frequency (11.3 ± 3.3 versus 7.9 ± 3.4), VAS score (7.5 ± 1.1 versus 6.0 ± 1.2), and MIDAS score (15 ± 7.6 versus 9.6 ± 4.5) were significantly greater in patients than control subjects. Interestingly, the change from baseline to the end of 3 months in headache frequency (6.0 ± 1.7 versus 2.8 ± 1.4), VAS score (2.6 ± 0.02 versus 1.4 ± 0.01), and MIDAS score (8.3 ± 5.0 versus 3.6 ± 2.0) were significantly greater in patients than control subjects. Our study emphasizes that calcified lesions of neurocysticercosis are not inert, and cause an increase in the frequency and severity of migraine attacks. Interestingly, these patients also showed a better response to treatment with amitriptyline, possibly resulting from its anti-inflammatory action. Further studies are warranted to explore possible inflammatory mechanisms in calcified neurocysticercosis, which influences migraine physiology.

T-cell dysfunction as a potential contributing factor in post-COVID-19 mucormycosis

BACKGROUND

The second wave of COVID-19 in India was followed by large number of mucormycosis cases. Indiscriminate use of immunosuppressive drugs, underlying diseases such as diabetes, cancers, or autoimmune diseases was thought to be the cause. However, the mortality was not as high as that seen in non-COVID mucormycosis.

OBJECTIVE

To study the detailed characteristics of T-cells for evaluating the underlying differences in the T-cell immune dysfunction in post-COVID and non-COVID mucor patients.

MATERIAL AND METHOD

The study included histopathologically confirmed cases of mucor (13 post-COVID, 13 non-COVID) and 15 healthy individuals (HI). Expression of T-cell activation (CD44, HLADR, CD69, CD38) and exhaustion (CTLA, PD-1, LAG-3 and TIM-3) markers was evaluated by flow cytometry.

RESULTS

All cases showed significant depletion of T-cells compared to HI. Both post-COVID and non-COVID groups showed increased activation and exhaustion as compared to HI. Non-COVID mucor group showed significant activation of CD4+ T cells for HLADR and CD38 (p = .025, p = .054) and marked T-cell exhaustion in form of expression of LAG-3 on both CD4+ T and CD8+ T cells in comparison with post-COVID patients (p = .011, p = .036). Additionally, co-expression of PD-1 & LAG-3 and LAG-3 & TIM-3 on CD8+ T cells was statistically significant in non-COVID mucor patients (p = .016, p = .027).

CONCLUSION

Immunosuppression in non-COVID mucor showed pronounced exhaustion of T-cells in comparison to post-COVID mucor cases implicating T-cell immune dysfunction is much more severe in non-COVID mucor which are in a state of continuous activation followed by extreme exhaustion leading to poorer outcome.

Determinants of stroke in patients with rhino cerebral mucormycosis seen during the second wave of COVID-19 pandemic: A prospective cohort study

BACKGROUND

Rhino cerebral mucormycosis is an uncommon opportunistic infection of the nasal sinuses and brain, and a group of saprophytic fungi causes it. During the second wave of COVID-19, India witnessed an unprecedented number of patients with rhino cerebral mucormycosis. Invasion of the cavernous sinus and occlusion of the internal carotid artery in many cases resulted in a stroke. The study aimed to assess the clinical and neuroimaging predictors of stroke in patients with rhino cerebral mucormycosis. We also evaluated the predictors of death in these patients at 90 days.

METHODS

A prospective study was performed at a tertiary care centre in India between July 2021 and September 2021. We enrolled consecutive microbiologically confirmed patients of rhino cerebral mucormycosis. All patients underwent neuroimaging of the brain. Treatment comprised of anti-fungal drugs and endoscopic nasal/sinus debridement. We followed the patients for 90 days and assessed the predictors of stroke and mortality RESULTS: Forty-four patients with rhino cerebral mucormycosis were enrolled. At inclusion, in 24 patients, the RT-PCR test for SARS-COV-2 was negative. Diabetes mellitus was the most frequent (72.7 %) underlying risk factor; in most, diabetes mellitus was recently discovered. At inclusion or subsequent follow-up, stroke was seen in 11 (25 %) patients. Only seven patients had hemiparesis. Imaging revealed internal carotid artery occlusion in 17 (38.6 %) patients. Hypertension, corticosteroid use, and cavernous sinus thrombosis were independent predictors of stroke. Nine (20.5 %) died during follow-up, and stroke was an independent predictor of death.

CONCLUSION

Stroke indicated poor prognosis among rhino cerebral mucormycosis patients encountered during the second wave of the COVID-19 epidemic.

Central nervous system, spinal root ganglion and brachial plexus involvement in leprosy: A prospective study

Background

Leprosy is primarily a disease of peripheral nerves. Some isolated case reports and case series have communicated imaging changes in the central nervous system (CNS) and brachial plexus in patients with leprosy.

Objectives

To study the neuroimaging abnormalities in patients with lepra bacilli-positive neuropathy in the context of CNS, spinal root ganglion, and brachial plexus.

Design

Prospective observational study

Methods

We screened newly-diagnosed patients with multibacillary leprosy presenting with neuropathy. Patients with bacilli-positive sural nerve biopsies were included in the study and subjected to magnetic resonance imaging (MRI) of the brain and spinal cord.

Results

A total of 54 patients with bacteriologically confirmed multibacillary leprosy were screened; Mycobacterium leprae was demonstrated in the sural nerve biopsies of 29 patients. Five patients (5/29; 17.24%) had MRI abnormalities in CNS, spinal root ganglion, and/or brachial plexus. Three patients had MRI changes suggestive of either myelitis or ganglionitis. One patient had T2/FLAIR hyperintensity in the middle cerebellar peduncle while 1 had T2/FLAIR hyperintensity in the brachial plexus.

Conclusion

CNS, spinal root ganglion, and brachial plexus are involved in patients with leprous neuropathy. Immunological reaction against M leprae antigen might be a plausible pathogenetic mechanism for brachial plexus and CNS imaging abnormalities.

Tuberculous myelitis: a prospective follow-up study

Background

Prospective studies regarding tuberculous myelitis are lacking. We aimed to prospectively evaluate patients with tuberculous myelitis to identify the features that distinguish tuberculous myelitis from other myelitis.

Methods

This was a prospective study. Patients presenting with paraparesis/quadriparesis, and MRI showing myelitis were included. All patients were subjected to clinical, neuroimaging, and laboratory evaluation. Diagnosis of definite tuberculous myelitis was made if GeneXpert test in CSF was positive. Probable tuberculous myelitis was diagnosed if there was evidence of tuberculosis elsewhere in the body. Patients were treated with methylprednisolone and antituberculosis treatment. Patients were followed for 6 months. We compared the clinical, laboratory, and neuroimaging parameters and response to treatment of tuberculous myelitis with other myelitis. P values were adjusted using the Benjamini-Hochberg (BH) procedure to control false discovery rate.

Results

We enrolled 52 patients. Eighteen (34.6%) patients had tuberculous myelitis. Headache (P = 0.018) was significantly more common in tuberculous myelitis. The CSF protein (P < 0.001), and CSF cell count (P < 0.001) were significantly higher in tuberculous myelitis. On neuroimaging, a LETM was common in tuberculous myelitis. Spinal meningeal enhancement (14; 77.8%), extra-axial collection, and CSF loculation (6; 33.4%), arachnoiditis (3;16.7%), and concomitant spinal tuberculoma (2;11.1%) were other common imaging features of tuberculous myelitis. Tuberculous myelitis patients showed a better response (P = 0.025) to treatment.

Conclusion

Tuberculous myelitis was seen in approximately 35% of all myelitis cases, in a high tuberculosis endemic zone. Headache, markedly elevated CSF protein and spinal meningeal enhancement were distinguishing features. Tuberculous myelitis patients responded well to corticosteroids.

COVID-19 cases and their outcome among patients with uncommon co-existing illnesses: A lesson from Northern India

Introduction

Newer coexisting conditions should be identified in order to modify newer risk factors. Aim was to identify patients with non-classical or less common coexisting conditions in patients infected of COVID 19.

Method

Single centred study from June 2020 to May 2021 at a tertiary centre in North India. A preformed questionnaire was used to record clinical and laboratory parameters and to identify cases which are in addition to CDC list and Indian data.

Results

0.67% (46) cases out of 6832 patients were identified to have non-classical coexisting illness. It was divided into 2 groups-infections A (60.1%) and non-infections B (39.9%). Group A included-tuberculosis- pulmonary (14.3%) & extra pulmonary (32.9%), bacterial (25.0%) viral infections [dengue, hepatitis B & C] (14.3%), HIV disease (10.7%) and malaria (3.6%). Group B included- organ transplant (27.8%), autoimmune [myasthenia gravis, polymyositis, psoriasis] (22.6%), haematologic [Haemophilia, ITP, Aplastic anaemia, APML, CML] (27.8%), uncommon malignancies [disseminated sacral chordoma and GTN] (11.1%) and snakebite (11.1%). Serum Procalcitonin was not helpful for diagnosis of bacterial infection in COVID-19 disease. Group A had significantly longer duration of illness, hepatitis and elevated CRP. The mortality in group A & B were 32.1% and 43.8% respectively. Death in non-severe COVID cases was in tetanus and snakebite. 30.7% death among tuberculosis patients. More than 70% of deaths were attributable to COVID 19 in both the groups.

Conclusion

In Indian settings, comorbidities like tuberculosis and bacterial infections can precipitate severe COVID 19 unlike other parts of the world where tuberculosis is relatively uncommon.

Osteo-Cutaneous Trophic Changes in Complex Regional Pain Syndrome and their Reversal with Steroids

BACKGROUND

Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by autonomic and inflammatory features. There is paucity of data regarding sustained benefits of any treatment modality. We aimed to document the effect of steroids in CRPS on long-term basis.

MATERIALS AND METHODS

We came across five patients of CRPS in Out Patient clinics of super-speciality Institutes in North India. All five cases fulfilled the Budapest criteria for the diagnosis of CRPS. All of them received prednisolone and were prospectively followed up for 2 years. Treatment outcome was carefully recorded in all affected modalities.

RESULTS

All five cases were found to have excruciating neuropathic pain in defined regions along with cutaneous manifestations. Osseous changes in the form of surface erosion of underlying bones in four cases and marked marrow edema leading to considerable increase in bone thickness in one case were noted. All these features improved considerably following steroid therapy. Bone marrow edema and bone resorption showed improvement on serial imaging.

CONCLUSION

Apart from pain relief, steroids therapy is capable of reversing the osteo-cutaneous autonomic changes of CRPS type I.

Utility of itraconazole and terbinafine in mucormycosis: a proof-of-concept analysis

An epidemic of mucormycosis followed the second wave of COVID 19 in the state of Uttar Pradesh, India in May 2021. This epidemic, however, had additional challenges to offer in the form of acute shortage of all forms of amphotericin B, posaconazole and isavuconazole. It was, therefore, planned to assess the trends in minimum inhibitory concentration (MIC) of antifungal agents, viz itraconazole and terbinafine, and provide a template for personalized therapy to see whether the results could be translated clinically. This is an observational, single-center study. Samples comprising nasal swab, nasal and paranasal sinus tissue, brain tissue, brain abscess and orbital content, derived from 322 patients from northern India with mucormycosis, of whom 215 were male and 107 were female, were used for analysis. Cultures were identified both by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and conventional methods of identification. Antifungal susceptibility was done for amphotericin B, posaconazole, isavuconazole, itraconazole and terbinafine as per Clinical Laboratory Standard Institute M38-A2. The outcome was identification of the species of mucormycosis and susceptibility to itraconazole and terbinafine besides other primary antifungal agents. Patients or the public were not involved in the design, or conduct, or reporting or in the dissemination plans of our research. Of 322 patients, 203 were culture-positive, of whom 173 were positive by both MALDI-TOF and conventional methods of identification. Final antifungal susceptibility testing was available for 150 patients. The most common Mucorales found to cause this epidemic was Rhizopus oryzae, followed by R. microsporus Amphotericin B, posaconazole and isavuconazole had low MIC values in 98.8% of all Mucorales identified. The MIC of itraconazole was species-dependent. 97.7% of R oryzae had MIC ≤2 µg/mL. However, only 36.5% of R microsporus had MIC ≤2 µg/mL. For terbinafine, 85.2% of R. microsporus had MIC ≤2 µg/mL. We conclude that identification at the species level is required as antifungal susceptibilities seem to be species-dependent. Assessment of the efficacy of itraconazole and terbinafine warrants further studies with clinical assessment and therapeutic drug monitoring as they seem to be potential candidates especially when the primary agents are not available.

Acute hemorrhagic leukoencephalitis after administration of the first dose of ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELD™) vaccine

Background

Many central and peripheral nervous system complications, following COVID-19 vaccination, have been described. We report an unusual case of central demyelinating disorder, following the administration of the ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELD™) vaccine.

Case-report

The 28-year female developed sudden onset headache followed by weakness of the left upper and lower limbs, and gait ataxia. Neurological symptoms developed two weeks after administration of the first dose of the ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELD™) vaccine. Magnetic resonance imaging brain revealed T2/FLAIR hyperintense lesions involving bilateral subcortical white matter, splenium of the corpus callosum, and both cerebellar hemispheres. Few lesions showed blooming on gradient echo sequence suggestive of a hemorrhagic component. Post-contrast T1 images showed mild enhancement of demyelinating lesions. The patient was treated intravenously with methylprednisolone. After 12 weeks of follow-up, there was a substantial improvement in her symptoms. She became independent in all her activities of daily living.

Conclusion

In conclusion, this is an unusual case of acute hemorrhagic leukoencephalitis following ChAdOx1 nCoV-19 SARS-CoV-2 (COVISHIELD™) vaccination.

Prevalence of primary immunodeficiency syndromes in tuberculous meningitis: A case-control study

BACKGROUND

Only a proportion of patients with tuberculosis develop tuberculous meningitis. We hypothesize that inherent abnormalities in the host's innate or adaptive immune system may affect the outcome in tuberculous meningitis. In this study, we evaluated the proportion of underlying primary immunodeficiency in patients with tuberculous meningitis and its impact on the outcome.

METHODS

Newly-diagnosed cases with tuberculous meningitis and healthy controls were included. Patients with HIV disease were excluded. Blood specimen were subjected to immunological assessment to detect primary immunodeficiency syndrome/s. We estimated serum levels of IgG, IgA, IgM, IgE and IgD along with complement C3, C4, and C5 assay. Absolute lymphocyte count was obtained from an automated three-part cell counter. Flow cytometry was used to enumerate the following lymphocyte subsets: T Cell (CD3, CD4, CD8), B cell (CD19/CD20), and Natural killer cells (CD16 and CD56). Cases were followed for 6 months. Modified Barthel Index was used as a measure of disability.

RESULTS

We included 55 cases with tuberculous meningitis and 30 healthy controls. We notedthat among immune parameters, absolute lymphocyte count and CD4 T-cell count in the tuberculous meningitis group was lower; higher serum IgG levels were noted in the poor outcome group. On multivariate regression analysis, none of the immunological, clinical or radiological features were found to predict a poor outcome.

CONCLUSION

Host's immune factors contribute to the pathogenesis of tuberculous meningitis. Absolute lymphocyte count and CD4+ T-cell count were lower in tuberculous meningitis cases. Higher serum IgG levels may be associated with a poor outcome. A study with a larger sample size is needed to confirm our findings.

Concurrent central nervous system involvement in immunocompetent adults with pulmonary miliary TB: a prospective analysis

BACKGROUND

Wallgren's tuberculosis (TB) timetable demonstrated co-occurrence of miliary TB and tuberculous meningitis in children. To verify the same in immunocompetent adults, we prospectively evaluated the prevalence and spectrum of central nervous system (CNS) involvement in patients with pulmonary miliary TB.

MATERIALS AND METHODS

This was a tertiary care, University hospital-based, prospective evaluation performed from December 2018 to June 2020. Newly diagnosed patients with pulmonary miliary TB were subjected to a detailed clinical, laboratory and MRI-based evaluation. All patients received treatment as per WHO guidelines.

RESULTS

Out of 342 patients with pulmonary TB, 53 patients met the eligibility criteria. The median age at presentation was 32 y and approximately two-thirds of patients were female. Clinically, only two-fifths of patients had features of CNS involvement. Cerebrospinal fluid (CSF) and imaging abnormalities were noted in 46 patients each. Twelve (23.5%) patients were diagnosed with definite-category tuberculous meningitis. Presence of an infarct significantly correlated with neurological features. Mantoux positivity correlated significantly with the presence of choroid tubercles, CSF changes and brain tuberculomas.

CONCLUSION

This is the first study to endorse Wallgren's observations in immunocompetent adults. A high index of suspicion, even in asymptomatic patients, may uncover tuberculous lesions involving the CNS and guide optimal monitoring of patients.

18FDG-Positron Emission Tomography in patients with Tuberculous Meningitis: A Prospective Evaluation

Lower yield of available diagnostic tests for tuberculous meningitis (TBM) frequently causes delay in diagnosis. Recently, 18F-fluorodeoxyglucose positron emission tomography (FDG PET) has been used in infectious disorders such as pulmonary tuberculosis; however, it is rarely used in TBM. This study was aimed to ascertain the role of FDG PET in the diagnosis and determination of the extent of disease and prognosis in patients with TBM. After excluding unsuitable patients, 25 patients were subjected to whole-body PET-computed tomography (CT) image acquisition along with separate brain protocol with an integrated PET-CT device. FDG PET was found to be abnormal in 92% patients. Extracranial FDG uptake was observed in 80% patients. Most common extracranial site of involvement was lymph nodes (60%), followed by lung (56%), vertebral body (8%), genitourinary organs (8%), and spleen (4%). FDG PET observed extracranial involvement had 80% sensitivity and 20% specificity in detecting definite TBM cases. In conclusion, FDG PET may be a useful test in TBM evaluation.

The Multiple Cranial Nerve Palsies: A Prospective Observational Study

Background

Neurological presentation with isolated multiple cranial nerve palsies is common and its diverse causes include infectious, neoplastic, and inflammatory pathologies. The aetiological spectrum may depend upon geographical regions. We undertook this study to explore clinical spectrum and aetiological profile of multiple cranial nerve palsies.

Methods

This hospital-based prospective observational study was conducted from August 2015 to August 2017. All the consecutive patients of multiple cranial palsies presenting to the neurology department were included in the studies. Primary objectives were to define anatomical syndromes/cranial nerve combinations and to establish aetiology. Secondary objectives were to study associated factors. The multiple cranial nerve palsy was defined as involvement of two or more non-homologous nerves. Patients of neuromuscular junction disorders, anterior horn cell disorders, myopathies, brain stem syndromes were excluded. All patients underwent structured protocol of clinical evaluation, investigations and few specialized investigations in accordance with clinical suspicion to establish the diagnosis.

Results

Fifty-four patients with a mean age of 39.9 ± 14.2 years were included. Commonest cranial nerve involved was the abducens (75.9%) among all nerve combinations. The cavernous sinus syndrome (37%), orbital apex syndrome (22.2%) and jugular foramen syndrome (11.1%) were the most frequent anatomical patterns. Infections (40.7%) were the commonest aetiology followed by neoplastic and idiopathic in four patients.

Conclusion

Cavernous sinus syndrome was the commonest anatomical syndrome of multiple cranial nerve palsies and infections were the commonest cause in this study.

Hemophagocytic histiocytosis in severe SARS-CoV-2 infection: A bone marrow study

Introduction

The clinical and laboratory features of severe COVID‐19 infection overlap with those of hemophagocytic lymphohistiocytosis (HLH), a hyperinflammatory disorder often associated with several viral infections. The clinical syndrome of HLH encompasses fever, organomegaly, cytopenias, hyperferritinemia, hypertriglyceridemia, raised transaminases, hypofibrinogenemia, absent natural killer (NK) cell activity, increased soluble CD25 and hemophagocytic lymphohistiocytosis in bone marrow, spleen, and lymph nodes.

Methods

We analyzed clinicopathological and laboratory features of thirteen patients with severe COVID‐19 infection suspected to have HLH and found to have hemophagocytic histiocytosis on bone marrow examination (BME).

Results

Five of thirteen (38.46%) patients fulfilled five of eight HLH 2004 criteria and/or had a H‐score ≥169. Three (23.08%) satisfied four of eight and remainder five (38.46%) satisfied three of eight HLH 2004 criteria. Fever, raised serum ferritin (13/13, 100%), transaminases (9/13, 69.23%), triglycerides (4/13, 30.76%), cytopenias (5/13, 38.46%), hypofibrinogenemia (2/13, 15.38%), and organomegaly (1/13, 7.69%) were observed in our patients. BME showed hemophagocytic histiocytosis without lymphocytosis in all. Contrary to HLH, lymphocytopenia (11/13, 84.61%), leukocytosis (7/13, 53.84%), neutrophilia (7/13, 53.84%), and hyperfibrinogenemia (7/13, 53.84%) were observed. Serum CRP, LDH, and plasma D‐dimer were elevated in all, while serum albumin was decreased in 12 of 13 (92.3%) patients. Five patients recovered with high‐dose pulsed corticosteroid therapy.

Conclusion

The immune response associated with severe COVID‐19 infection is similar to HLH with few differences. HLH should be suspected in severe COVID‐19 infection although all patients may not fulfill required HLH diagnostic criteria. BME should be done in suspected cases so that appropriate therapy may be initiated early.

Cyclooxygenase 2 and vascular endothelial growth factor-potential targets to manage lepra reactions: A case-control study

Reactions in leprosy have an immune mediated pathogenesis. While type 1 reactions are delayed hypersensitivity phenomenon, type 2 reactions are immune complex mediated. Key molecules which mediate the immune insult in lepra reactions require evaluation in order to tailor their therapy and prevent disability. The objective of the study was to evaluate expressions of Cyclooxygenase 2 and Vascular Endothelial Growth Factor in skin biopsies from leprosy patients and correlate their expression with presence of either type 1 or type 2 lepra reactions. This was a case control study. Cyclooxygenase 2 and Vascular Endothelial Growth Factor expression in dermal macrophages and vascular endothelium was assessed immunohistochemically. Biopsies from patients with Non-reactive leprosy and healthy controls were used for comparison. SPSS software was used for statistical analysis. A total of 147 skin biopsies were evaluated, including 18 with Type 1 reaction, 39 Type 2 reaction, 81 non-reactive leprosy and 9 healthy controls. Both Cyclooxygenase 2 and Vascular Endothelial Growth Factor expression were significantly higher in type 1 followed by type 2 reaction as compared to controls. These results may guide us regarding use of Cyclooxygenase 2 and Vascular Endothelial Growth Factor inhibitor drugs which may be a major step in treating reactive leprosy patients and preventing nerve damage and disability.

Diagnosing Muscular Dystrophies: Comparison of Techniques and Their Cost Effectiveness: A Multi-institutional Study

Background  The diagnosis of muscular dystrophies involves clinical discretion substantiated by dystrophic changes on muscle biopsy. The different subtypes of muscular dystrophy can be diagnosed using techniques to identify the loss of protein or molecular alterations.

Materials and Methods  Clinically suspicious cases confirmed to have muscular dystrophy on muscle biopsy seen at two tertiary care centers in North India were enrolled for the study. Immunohistochemistry (IHC) for dystrophin, merosin, sarcoglycan, emerin, and dysferlin proteins was performed. The spectrum of muscular dystrophies diagnosed was analyzed. Cost of diagnosing the cases using IHC was estimated and compared with that of standard molecular tests available for the diagnosis of muscular dystrophies.

Statistics  Descriptive statistics were used for data analysis. Mean and standard deviations were used for continuous variables, whereas categorical variables were analyzed using frequency percentage.

Results  A total of 47 cases of muscular dystrophies were studied. This included nine cases of Duchenne, three cases of Becker’s dystrophy, and one dystrophinopathy carrier. One case of α, seven cases of β, and two cases of δ sarcoglycanopathy, along with two cases of facioscapulohumeral dystrophy and a single case of dysferlinopathy were detected. Genetic studies were required for a subset of 16 cases. The cost of using muscle biopsy and IHC was substantially lower than that of molecular methods for the identification of muscular dystrophy subtypes.

Conclusion  We detailed an algorithmic approach for diagnosing muscular dystrophies using muscle biopsy. The prevalence of biopsy proven muscular dystrophies from two tertiary care centers in North India is compared with that from other centers. Genetic studies are currently of limited availability in India and are more expensive as compared with biopsy and IHC. Using these methodologies sequentially with a “biopsy first approach” may be the prudent approach for low-income countries.

Movement Disorders in Children: An Observational Study in a Tertiary Care Center in North India

Movement disorders (MDs) are disorders of pathological movements that cannot be fully initiated, modulated, or interrupted voluntarily. Spectrum and etiology of MDs are likely to vary with geographical location, but there are few studies on pediatric MDs from India, and severity of the disease is not well documented. Response to treatment of MDs is often unpredictable. Objective of the study was to describe the relative prevalence, types, severity, etiology, and response to treatment of pediatric MDs as seen at a public teaching hospital in northern India. Over a period of 1 year, consecutive children with MDs seen in outpatient department (OPD) or wards were enrolled, after excluding cerebral palsy and musculoskeletal disorders. Detailed history, examination, treatment, and outcome were recorded. Severity was rated according to Battini's scale at initial contact and each follow-up. Neuroimaging and relevant investigations were done for etiology. Serial 2-minute video recordings were obtained. Out of 93 patients enrolled, the most common MDs were dystonia (24.7%), tremors (22.4%), ataxia (19.6%), and chorea (12.9%). Tics, hemiballismus, and myoclonus were also seen and 4% could not be classified. Mixed MDs were seen in 9.7%. Etiologies of MDs were infectious (acute encephalitis syndrome, tuberculous meningitis, subacute sclerosing panencephalitis, and rheumatic chorea) or nutritional (infantile tremor syndrome) in 46%. Genetic neurodegenerations accounted for a significant proportion (15.1%). Improvement occurred in majority (63.4%) of patients. Etiology of MDs was largely specific to this part of the world, related to infectious and nutrition causes. In the absence of complex genetic investigations, many cases were left with unknown etiology.

Extra-central nervous system tuberculosis in HIV-uninfected patients of tuberculous meningitis: A prospective evaluation

OBJECTIVE

Disseminated tuberculosis is characterized with involvement of two or more non-contiguous sites. In this work we evaluated patients of tuberculous meningitis for possible extra-central nervous system tuberculosis.

METHOD

This prospective observational study was performed at a tertiary care institute in Northern India. We included consecutive HIV-uninfected cases of TBM. Patients were evaluated for extra-central nervous system (CNS) tuberculosis. We focussed on peripheral lymph nodes, chest, abdomen, and spinal involvement. All patients were subjected to MRI brain and spine. Patients were also subjected to CT thorax and abdomen. Enlarged lymph nodes, if present, were biopsied. Ascitic and pleural fluid were subjected to biochemical, cellular analysis as well as cartridge-based nucleic acid amplification test (CBNAAT) for detection of Mycobacterium tuberculosis and rifampicin resistance.

RESULTS

We enrolled 110 patients of TBM. After cerebrospinal fluid examination alone, 14 (12.7%) patients had microbiologically-confirmed TBM. After planned work-up for extra CNS tuberculosis, 5 additional cases were microbiologically confirmed. Similarly, before work-up for extra CNS tuberculosis, 29 (26.4%) patients were categorized as probable TBM. The number of probable cases increased to 72 (65.5%) (P<0.001) with identification of tuberculosis elsewhere. Lung (83.6%) was the most involved site. Abdominal tuberculosis was noted in 29 (26.4%) patients. On imaging spine, 17 (15.5%) patients demonstrated presence of spinal tuberculous. Lymph adenopathy recorded in 2 cases. Lymph node biopsy revealed tuberculous granuloma in both the cases. All 7 patients, who died, had disseminated tuberculosis.

CONCLUSION

Extra CNS tuberculous involvement is common in TBM. Search for extra CNS tuberculous enables upgrading diagnostic accuracy.

Quantitative assessment of lesion load and efficacy of 3 cycles of albendazole in disseminated cysticercosis: a prospective evaluation

BACKGROUND

The management of disseminated cysticercosis is unclear and largely considered hazardous. The role of albendazole remains controversial in such patients.

METHODS

A tertiary care, University hospital-based prospective intervention study was conducted from December 2015 to December 2017. Patients with disseminated cysticercosis, defined as the presence of multiple viable neurocysticerci (≥ 3) in the brain along with involvement of an additional extra site, were included in the study. Patients with cysticercal encephalitis were excluded. A detailed evaluation, including ophthalmoscopy, ocular B scans, ultrasound abdomen, and X-rays were done. Albendazole was administered at a dose of 15 mg/kg/day in 3 cycles of 28 days each. All patients were also given adjuvant corticosteroids and anti-epileptic drugs. Clinical and radiological follow up was carried out at a difference of 3 months between each treatment cycle. For radiological quantification, lesions were counted at 10 pre-specified levels. Statistical analysis was done to estimate the difference in seizure frequency and lesion load.

RESULTS

Twenty-nine patients (21 with > 20 lesions; 8 with ≤ 20 lesions) were given albendazole as per the protocol. There was a significant reduction in the occurrence of seizures (P < 0.001) and headache (P < 0.001). A significant reduction in lesion load from baseline to third follow-up was seen in the estimations done at different levels (P < 0.001). No patient developed serious side-effect warranting cessation of therapy.

CONCLUSION

Cyclical use of albendazole appears efficacious in treating disseminated cysticercosis. The method of quantification described may be used in future studies for objective assessment.

TRIAL REGISTRATION

ISRCTN11630542; 28th September 2019; Retrospectively registered.

Early Mortality among Immunocompetent Patients of Tuberculous Meningitis: A Prospective Study

Most deaths in tuberculous meningitis occur in the early part of the illness. We assessed the determinants of early deaths, occurring within 2 months of intensive therapy. We prospectively included consecutive newly diagnosed adults with HIV-negative tuberculous meningitis. Patients were given WHO-recommended antituberculosis treatment and were followed up for 9 months. We enrolled 152 patients. A total of 26 deaths were recorded during 2 months. The logistic regression analysis revealed that papilledema (P = 0.029, odds ratio (OR) = 4.8 [1.2-19.8]), increasing age (P = 0.001, OR = 1.07 [1.03-1.1]), stage-III disease (Glasgow coma scale score ≤ 10; P = 0.01, OR = 4.2 [1.4-12.3]), and hydrocephalus (P = 0.003, OR = 8.4 [2.1-33.6]) were independently associated with death. In addition, cerebral infarcts (P = 0.012, OR = 5.6 [1.5-21.3]), paraparesis (P = 0.004, OR = 8.8 [2.02-38.1]), and age (P = 0.005, OR = 1.05 [1.02-1.09]) were associated with poor functional outcome. In conclusion, disease severity predicts early deaths in tuberculous meningitis.

Platelet dysfunction and coagulation assessment in patients of tuberculous meningitis

INTRODUCTION

Tuberculous meningitis (TBM) is the most severe form of tuberculosis. As reported in various studies, stroke is common among patients with TBM, with a prevalence of 17-54%. The present study assessed platelet dysfunction and coagulation abnormality in patients with TBM.

METHODS

This was a prospective observational study that included 123 consecutive patients with TBM. In addition to clinical and radiological parameters, the complete platelet function and coagulation function were studied. The patients were followed up to 6 months.

RESULTS

A significant correlation between platelet abnormality and stroke in patients with TBM was reported in this study. Results of the univariate analysis revealed that haematological parameters such as mean platelet volume (MPV) (p < 0.001), platelet distribution width (PDW)(p < 0.001), platelet-large cell ratio (P-LCR) (p < 0.001), and platelet aggregometry (PAg) (p < 0.001) were significantly associated with infarct. However, other haematological parameters such as bleeding time (p = 0.712), clotting time (p = 0.362), activated partial thromboplastin time (p = 0.094), INR (p = 0.420), protein C (p = 0.988), and protein S (p = 0.579) were not significantly associated with infarct. During follow-up at 3 and 6 months, parameters such as MPV (p < 0.001), PDW (p < 0.001), and P-LCR (p < 0.001) were significantly associated with infarct.

CONCLUSION

The present study concluded that platelet abnormalities in patients with TBM contribute to infarct and are associated with poor clinical outcomes. This study suggested the role of antiplatelet agents in preventing stroke in patients with TBM.

Cardiovascular complications and its relationship with functional outcomes in Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is a monophasic disease characterized by acute polyradiculoneuropathy.

AIM

This study investigated cardiovascular complications in patients with GBS and their relationship with outcomes.

DESIGN AND METHODS

We included 96 patients, who were diagnosed with GBS according to Brighton case definitions. All enrolled patients were evaluated according to a predetermined algorithm, which included nerve conduction studies, cerebrospinal fluid analysis, electrocardiography, 2D echo, cardiac markers and autonomic function testing.

RESULTS

We enrolled a total of 96 patients. The mean age of patients was 35.75 ± 17.66 years. Furthermore, 54.2% of patients developed cardiovascular complications, of which changes in electrocardiography (ECG) findings (50%), hypertension (28.12%), labile hypertension (12.5), tachycardia (26.04), bradycardia (13.54%) and a fluctuating heart rate (HR) (11.46) were common. Other cardiovascular complications seen in GBS patients were increased pro-BNP (26.04%), raised troponin T levels (3.12%), acute coronary syndrome (2.08%), heart failure (2.08%) and abnormal 2D echo findings (8.33%). The results of the univariate analysis revealed that a history of preceding infection, a Medical Research Council sum score, neck muscle weakness, facial nerve involvement, bulbar involvement, respiratory failure, cardiovascular complications, autonomic dysfunction, acute motor sensory axonal neuropathy subtype and baseline Hughes score were significantly (P < 0.005) associated with poor outcomes. However, none of these factors were found to be independently associated with poor outcomes in the multivariate analysis.

CONCLUSION

A considerable number of patients with GBS developed cardiovascular complications and it needs attention.

Study of interleukin-6 and interleukin-8 levels in patients with neurological manifestations of dengue

Context:

Pro-inflammatory markers play a key role in the pathogenesis of various Flavivirus infection.

Aim:

In this study, we evaluated the role of these markers in neurological manifestations of dengue.

Settings and Designs:

Consecutive dengue cases with different neurological manifestations who presented between August 2012 and July 2014 were studied in hospital-based case–control study.

Materials and Methods:

Interleukin (IL-6) and IL-8 level were measured in serum and cerebrospinal fluid (CSF) of dengue cases with different neurological manifestations and also in age- and sex-matched controls. Level was analyzed with various parameters and outcomes.

Statistical Analysis:

Statistical analysis was done using SPSS version 16.0 by applying appropriate statistical methods. P < 0.05 considered statistically significant.

Results:

Out of the 40 enrolled cases of dengue with neurological manifestations, 29 had central nervous system and 11 had peripheral nervous system (CNS/PNS) manifestations. In CNS group, both IL-6 and IL-8 (CSF and serum) were significantly elevated (P < 0.001), whereas CSF IL-6 (P = 0.008), serum IL-6 (P = 0.001), and serum IL-8 (P = 0.005) were significantly elevated in PNS group. CSF IL-6, serum IL-6, and IL-8 were significantly elevated in poor outcome patients in CNS group (P < 0.05). CSF IL-6 and IL-8 were significantly elevated in CSF dengue positive cases as compared to CSF negative patients (P < 0.05). Cytokine level was not significantly correlated with neuroimaging abnormality in CNS group. Nine patients died and the remainder recovered.

Conclusion:

Elevated level of IL-6 and IL-8 is associated with different neurological manifestations and poor outcome, but whether they are contributing to neuropathogenesis or simply a correlate of severe disease remains to be determined.

Case Report: Subacute Sclerosing Panencephalitis Presenting as Acute Encephalitis

Subacute sclerosing panencephalitis (SSPE) is still a common disease in India which is characterized by a progressive mental decline, myoclonus, periodic encephalographic abnormalities, and raised anti-measles antibody titter in the cerebrospinal fluid. Acute fulminant SSPE is characterized by a rapid course of disease culminating in death, within 6 months. We report of a 10-year-old boy, who came with a 14-day history of continuous involuntary jerky movements of the left half of the body, including the head. There was a highly increased anti-measles IgG antibody titer, both in the cerebrospinal fluid and serum. We conclude that acute rapidly progressive SSPE can present as acute encephalitis syndrome.