K Saifudheen

First case of scrub typhus with meningoencephalitis from Kerala: An emerging infectious threat.

Scrub typhus is a rickettsial disease caused by Orientia tsutsugamushi, one of the most common infectious diseases in the Asia-Pacific region. It has been reported from northern, eastern, and southern India, and its presence has been documented in at least 11 Indian states. However, scrub typhus meningoencephalitis has not been well documented in Kerala. We report two cases of scrub typhus meningoencephalitis from northern Kerala. The diagnosis was made based on the clinical pictures, presence of eschar, and a positive Weil–Felix test with a titer of > 1:320. The first patient succumbed to illness due to respiratory failure and the second patient improved well.

Plasmapheresis in neurological disorders: Experience from a tertiary care hospital in South India

Background: Therapeutic plasma exchange (PE) or plasmapheresis is the treatment of choice in many neurological disorders. Even though it is safe in experienced hands, there is a major concern about its safety among physicians. Objectives: To analyze our experience with 230 patients who underwent PE for various neurological disorders. Materials and Methods: Retrospective review of PE procedures done during a period of 48 months, from July 2007 to June 2011 in a tertiary care teaching hospital in South India. Indications, clinical results and technical factors are discussed. Results: The main indication for PE was GBS (203 patients; 88.3%). Age of patients ranged from 14-65 (mean = 42.3 years). The most common complications were paraesthesias and/or cramps (36.1%) and hypotension (32.2%). Four pregnant patients who underwent PE had good recovery with one intrauterine death. There was no mortality. Conclusion: The analysis of 240 cases of PE done in our department shows that the procedure is safe, with only minimal procedure related complications and no mortality.

Idiopathic intracranial hypertension presenting as CSF rhinorrhea

presented with spontaneous intermittent CSF rhinorrhea of 6 months duration. There was history of episodic pulsatile tinnitus for the last 1 year. There was no history of headache, vomiting, visual symptom, or head injury. Neurologic examination was normal. An ophthalmologic assessment revealed normal fundus, visual acuity, and visual field (by perimetry). Magnetic resonance imaging (MRI) of brain demonstrated a leak in the cribriform plate into the anterior ethmoid cells [Figure 1]. In addition, distension of the perioptic subarachnoid space [Figure 1], elongation and vertical tortuosity of the optic nerve [Figures 2 and 3] and complete empty sella [Figure 4] were also found. MR venogram was normal. Based on these finding, a radiological diagnosis of idiopathic intracranial hypertension (IIH) was made. A lumbar puncture done 1 month later, after the resolution of CSF rhinorrhea, revealed opening

Accuracy of the ice test in the diagnosis of myasthenic ptosis

BACKGROUND Diagnosis of myasthenia gravis is difficult, especially when the disease is restricted to ocular muscles. It is a well-known observation that myasthenic ptosis improves with cold and based on this, the ice pack test has been used as a tool in its differential diagnosis. The aim of the study is to investigate the diagnostic value of ice pack test as a preliminary test in the differential diagnosis of myasthenia and to find out the percentage of positivity and negativity of the ice pack test. MATERIALS AND METHODS The study included patients seeking treatment for ptosis in a tertiary care center in Kerala. All patients were subjected to the ice pack test. Evaluation of patients was made by recording the marginal reflex distance (MRD). MRD was recorded before and after the application of ice pack, and an improvement of more than 2 mm was considered positive. Patients were divided into two groups: (1) those who had ptosis and features suggestive of myasthenia; and, (2) those who had ptosis but no features of myasthenia. Patients of both groups were subjected to relevant investigations and the diagnosis of myasthenia was established. RESULTS Ice cold test was positive in 48 (96%) patients and negative in two patients of the myasthenia group. In the control group, 6 (12%) patients had a false positive ice cold test and in the remaining 44 patients (88%), ice cold test was negative. CONCLUSION Ice pack test has a high specificity and sensitivity in the differential diagnosis of myasthenic ptosis.

Cerebral venous thrombosis presenting as multiple lower cranial nerve palsies.

Cerebral venous thrombosis (CVT) is a well-recognized entity, but its clinical presentation is varied and often mimics many neurological disorders, making it a diagnostic challenge. Cerebral venous thrombosis has a wide spectrum of signs and symptoms, which may evolve suddenly or over weeks. It mimics many neurological conditions such as meningitis, encephalopathy, idiopathic intracranial hypertension, and stroke. Cerebral venous thrombosis presenting as multiple lower cranial nerve palsies, are rarely reported. We describe a pregnant lady who presented with sensorineural deafness of the right ear and paralysis of the 9th, 10th, and 12th cranial nerves on the right side. She was diagnosed to have thrombosis of the right transverse sinus and sigmoid sinus with extension to the jugular vein and confluence of sinuses. She improved with anticoagulant treatment.

Inflammatory pseudotumor of the head presenting with hemiparesis and aphasia.

Inflammatory pseudotumor most commonly occurs in the orbit and produces orbital pseudotumor, but extension into brain parenchyma is uncommon. We report a case of inflammatory pseudotumor involving sphenoid sinus, cavernous sinus, superior orbital fissure, orbital muscle, and intracranial extension into left temporal lobe producing right hemiparesis and wernickes aphasia. The patient improved clinically and radiologically with steroid administration. This paper provides an insight into the spectrum of involvement of inflammatory pseudotumor and the importance of early diagnosis of the benign condition.

Posterior cortical atrophy: A rare visual variant of Alzheimer's disease

evaluating entrapment neuropathies, our patient demonstrates the additional value of ultrasonography in eliciting underlying etiology and site of nerve compression in tarsal tunnel syndrome. Nerve conduction studies are limited in localizing the site of tibial nerve compression which can be within the tarsal tunnel or distal to it.[4] Ultrasound provides direct evidence of nerve compression by demonstrating focal nerve enlargement and change in nerve echogenicity. In our patient, ultrasound localized the tibial nerve pathology at the tarsal tunnel due to a synovial cyst attached to flexor hallucis tendon. Our patient serves as an example how conventional nerve conduction testing can be complimented by adding ultrasound evaluation, providing comprehensive information for better treatment planning. A. K. Therimadasamy, R. C. Seet1, Y. H. Kagda2, E. P. Wilder-Smith1 Neurology Diagnostic Laboratory, 1Division of Neurology and 2Department of Orthopaedic Surgery, National University Hospital, Singapore E-mail: mdcwse@nus.edu.sg