Kumudini Sharma

Is reversible posterior leukoencephalopathy with severe hypertension completely reversible in all patients

Leukoencephalopathy with severe hypertension is a recently described entity in nephrology, with only a few case reports to date in children. We prospectively studied 18 children with severe hypertension to evaluate the clinical features, severity, reversibility, and prognosis. All were subjected to clinical and biochemical tests, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Headache was reported in 16 children, 13 had confusion and drowsiness, 12 had nausea and vomiting, and 9 had visual disturbances, seizure, and dyspnea. Only 2 had focal neurological deficit (1 with right facial palsy and another with right lateral rectus palsy). Of these 18 children, 14 patients had hypertensive retinopathy and 4 had normal fundus. MRI revealed leukoencephalopathic changes in 16 of 18 patients. These changes were bilateral occipito-parietal in 9 patients, diffuse white/gray matter lesion in 2, brain stem hyperintensity in 2, and hemorrhagic lesion in 3. On MRA, 11 of 18 patients had attenuation of cerebral arteries of different degree. On follow-up, MRI findings resolved in all except 3 patients and all patients had normal MRA, except for 1 with persistent minimal attenuation and another with spasm in all vessels. We conclude that leukoencephalopathy with severe hypertension is reversible both clinically and radiologically in the majority of children after the control of hypertension. However, a few patients may have residual damage and may need psychometric analysis and follow-up for neurodevelopmental sequelae.

Peduncular hallucinosis: an unusual sequel to surgical intervention in the suprasellar region

Peduncular hallucinations are formed visual images often associated with sleep disturbance, and are caused by lesions in the midbrain, pons and diencephalon. In the present study, we report two patients who developed peduncular hallucinations following surgery in the suprasellar region. In one of these, the peduncular hallucinations were a sequel to endoscopic third ventriculostomy, while in the other, they were due to diencephalon and mid-brain compression by a postoperative clot following excision of a hypothalamic astrocytoma.

Selective involvement of basal ganglia and occipital cortex in a patient with acute endosulfan poisoning

We report a teenage girl with acute endosulfan poisoning who developed psychosis, generalized tonic-clonic seizures, myoclonic jerks, cortical blindness and limb rigidity. Serial magnetic resonance imaging (MRI) showed bilateral reversible lesions localized to caudate nucleus, putamen and occipital cortex; internal capsule and thalamus were spared. This selective involvement may have a bearing on mechanisms underlying endosulfan toxicity.

Irreversible blindness due to multiple tuberculomas in the suprasellar cistern.

A 14-year-old girl developed fever, severe headache, vomiting, and no light perception in both eyes over a 3-day period without a previous complaint of visual or other neurologic difficulties. Neuro-ophthalmologic examination was normal apart from meningismus and blindness. Brain imaging showed ventriculomegaly and multiple enhancing nodules around the optic chiasm. Lumbar puncture showed an elevated opening pressure with lymphocytic pleocytosis. Polymerase chain reaction and enzyme-linked immunoabsorbent antibody tests on the cerebrospinal fluid were positive for Mycobacterium tuberculosis. There was no evidence of tuberculosis elsewhere in the body. Standard antituberculous treatment, including corticosteroids, did not reverse the blindness.

Metastatic tumor of orbit presenting as pulsatile proptosis

Pulsatile proptosis is caused by vascular lesion of orbit or by herniation of brain through bony defect in orbit. Pulsatile proptosis secondary to a metastatic tumor of orbit is very uncommon. We report a 69-year-old male who presented with pulsatile proptosis owing to metastasis of an asymptomatic renal cell carcinoma.

Migraine-like visual hallucinations in occipital lesions of cysticercosis.

Four Indian patients with occipital lesions of cysticercosis presented with visual hallucinations. Neuro-ophthalmic and systemic examinations were normal in all cases except for one patient who had a partial homonymous hemianopia. Electroencephalography was normal in all cases. Neuroimaging revealed ring-enhancing lesions in the occipital lobe typical of neurocysticercosis. In endemic regions like India, neurocysticercosis should be suspected in patients presenting with visual hallucinations, even when there are no other clinical findings.

Isolated abscess of extraocular muscle in two young boys: clinical and imaging features.

PURPOSE: To report two cases of a cystic isolated extraocular muscle abscess in a young boy. METHOD: Case report. RESULTS: Two cases of young boys with a cystic isolated extraocular muscle abscess are described. Each presented as an inflammatory lesion in the orbit that had been stable for approximately three weeks. Neurodiagnostic imaging of the two cases revealed a cystic lesion in close proximity to an extraocular muscle. An ultrasound-guided aspiration of each lesion revealed material that, when cultured, grew Staphylococcus aureus . Both patients recovered with appropriate antibiotic therapy. No other systemic illness could be identified in either case. CONCLUSION: These cases illustrate that an isolated abscess involving an extraocular muscle may present like an inflammatory cyst even without any evidence of systemic illness. When evaluating and managing such lesions, the authors recommend the use of ultrasound-guided aspiration to avoid complications arising from delay in diagnosis and inappropriate treatment.

Scan-Negative Neurocysticercosis

An 11-year-old child was diagnosed as having benign intracranial hypertension on basis of clinical examination and normal CT scan. Magnetic resonance imaging demonstrated multiple lesions in both cerebral hemispheres, some of which showed nodular scolex characteristic of cysticerci.

Acute bilateral ophthalmoplegia secondary to metastatic prostatic carcinoma. Demonstration on magnetic resonance imaging.

We report an unusual case of acute bilateral ophthalmoplegia secondary to bilateral cavernous sinus metastasis from prostatic adenocarcinoma. The lesion was demonstrated with magnetic resonance imaging.

Choroidal metastasis as the presenting feature in a case of testicular choriocarcinoma

A twenty-six year old male with decreased vision in right eye was diagnosed with non-rhegmatogenous retinal detachment. Further evaluation revealed a yet undiagnosed left testicular mass found to be choriocarcinoma on histopathology. Chemotherapy resulted in complete remission; however, there was no improvement in vision. There is a substantial risk of visual loss in the presence of ocular metastatic lesions. Early detection and treatment is highly effective in terms of tumor control and a more favorable survival and visual outcome. The onus of the ocular diagnosis lies on the ophthalmologist. The presence of a testicular origin tumor must be considered in a young male with intraocular metastasis.