Parul Dubey

The global mental health assessment tool-validation in hindi: A validity and feasibility study

Background: A computer-assisted interview, the Global Mental Health Assessment Tool-validation (GMHAT/PC) has been developed to assist general practitioners and other health professionals to make a quick, convenient, yet reasonably comprehensive standardized mental health assessment. GMHAT/PC has been translated into various languages including Hindi. This is the first study conducted in India, using the Hindi version GMHAT/PC of the series of studies assessing its validity in different cultures. Aim: The study aims to assess the feasibility of using a computer assisted diagnostic interview by health professionals and to examine the level of agreement between the Hindi version GMHAT/PC diagnosis and psychiatrists’ ICD-10 based clinical diagnosis. Design: Cross-sectional validation study. Setting: Psychiatric clinic of a General Hospital and an out patient (Neurology) clinic in the Teaching General Hospital in Jaipur, India. Materials and Methods: All consecutive patients attending the psychiatric out patient clinic were interviewed using GMHAT/PC and psychiatrists made a diagnosis applying ICD-10 criteria for a period of six weeks. A small sample of subjects was interviewed in a similar way in a Neurology clinic for four weeks. Results: The mean duration of interview was under 17 minutes. Most patients were pleased that they were asked about every aspect of their mental health. The agreement between psychologists’ GMHAT/PC interview diagnoses and psychiatrists’ clinical diagnoses was excellent (Kappa 0.96, sensitivity 1.00, and specificity 0.94). Conclusion: GMHAT/PC Hindi version detected mental disorders accurately and it was feasible to use GMHAT/PC in Indian settings.

Ophthalmoplegic migraine with trigeminal nerve involvement

We report a 25-year-old man with a history of uncontrolled migrainous headaches who developed third nerve palsy and sensory loss over V1 distribution of trigeminal nerve, during an attack of severe migraine. Gadolinium-enhanced MRI of the brain and cavernous sinus was normal and did not disclose nerve enhancement. CT angiogram was also normal. The patient recovered uneventfully in 2 weeks on oral steroids. The commonest cranial nerve implicated in ophthalmoplegic migraine is the occulomotor nerve. Involvement of the fifth nerve has never been reported.

Combination of Steven-Johnson syndrome and neuroleptic malignant syndrome following carbamazepine therapy: a rare occurrence

Stevens–Johnson syndrome (SJS) is a severe, episodic, acute mucocutaneous reaction that is most often elicited by drugs and occasionally by infections. The drugs commonly implicated as the cause of SJS are anticonvulsants, sulfonamides, non-steroidal anti-inflammatory drugs and antibiotics. Carbamazepine (CBZ) has been commonly implicated in SJS. Neuroleptic malignant syndrome (NMS) is a rare, life-threatening but potentially treatable condition. Among the neuroleptics, haloperidol (parenteral) is implicated as a most common drug for NMS. Though rare, association of NMS with CBZ and association of NMS with toxic epidermal necrolysis (TEN) in a single patient after administration of neuroleptics has been reported in the literature before. However, a combination of NMS and SJS in a single patient after administration of CBZ has not been reported so far. We present a patient with seizure who developed SJS and NMS following administration of CBZ.

Reversible neurological syndromes with atypical pneumonia.

Simultaneous or sequential involvement of lungs is frequently encountered with neurological syndromes like meningoencephalitis, cerebellitis, aseptic meningitis, transverse myelitis, or multiple cranial nerve palsies. However, pulmonary involvement is frequently overlooked when all the attention of physician is diverted to neurological disorder. Prompt and early recognition of such potentially treatable association is required to improve diagnostic and therapeutic outcome. We report six patients presenting with various neurological manifestations like meningitis, meningoencephalitis, and myelits associated with atypical pneumonia. With proper clinical correlation and relevant investigations, all of them were diagnosed in time and had remarkable recovery with appropriate treatment.

Subarachnoid hemorrhage with transient ischemic attack: Another masquerader in cerebral venous thrombosis

Cerebral venous thrombosis has a wide spectrum of clinical manifestations that may mimic many other neurological disorders and lead to frequent misdiagnoses or delay in diagnosis. The most frequent symptoms and signs are headache, seizures, focal deficits, and papilledema. A number of rare atypical manifestations have been described. Cerebral venous thrombosis may present with an isolated intracranial hypertension type picture, thunderclap headache, attacks of migraine with aura, isolated psychiatric disturbances, pulsatile tinnitus, isolated or multiple cranial nerve involvement, and occasionally as subarachnoid hemorrhage (SAH) or transient ischemic attack. Our patient presented with thunderclap headache and transient ischemic attack like episode with obvious SAH on CT scan. Acute SAH suggests the presence of a vascular lesion, such as ruptured aneurysm, and CVT is not generally considered in the diagnostic workup of SAH. The case emphasizes the importance of cerebral venous study in nonaneurysmal cases of SAH. It is important to have a high index of suspicion in such atypical cases to avoid delay in diagnosis.

A rare case of alcoholic pellagra encephalopathy with startle myoclonus and marked response to niacin therapy: time for a new dictum?

We report a case of 56-year-old man, chronic alcoholic, presented to us with progressive weakness in all the four limbs with stiffness and gait disturbance since 1-year associated with cognitive impairment. On examination he had mild confusion, spastic quadriparesis with brisk reflexes, extensor plantars and cerebellar features. During the hospital stay myoclonus was noticed in the patient, which was startle in nature. He did not have dermatitis, ascites or any stigmata of liver failure. MRI of brain revealed bilateral subdural effusion, left focal subarachnoid haemorrhage at perisylvian area and diffuse cortical atrophy. He was treated with supportive measures including thiamine with which his condition worsened. His serum niacin was low. With a possibility of alcoholic pellagra encephalopathy (APE) the patient was treated with niacin. His clinical condition improved drastically over next 1 week and startle myoclonus disappeared, favouring the diagnosis of APE though multiple confounding factors were present.

Single Dose Does Matter! An Interesting Case of Parkinsons Hyperpyrexia Syndrome

Parkinsonism- hyperpyrexia syndrome (PHS) is a neurological emergency that mimics neuroleptic malignant syndrome and sepsis. Abrupt cessation of anti parkinsons drugs, usually levodopa is responsible for this syndrome. Relative dopamine deficiency is proposed mechanism for PHS and replacement of dopaminergic drugs is the mainstay of treatment. We report a case who presented with manifestations of PHS after missing a single dose of levodopa.

Prevalence, Demographic Profile, and Psychological Aspects of Epilepsy in North-Western India: A Community-Based Observational Study

Aims: This study was undertaken to determine the prevalence of active epilepsy, assess the sociodemographic profile, and psychological aspects of epilepsy in the Jaipur district of Rajasthan, India. Methods: We conducted a community-based, cross-sectional observational study covering both rural (n = 165,660) and urban (n = 179,142) populations of Jaipur district using a house-to-house survey. An adapted, pre-designed World Health Organization screening questionnaire was used to identify the cases. Those confirmed by neurologists as true seizures were included in the study. Cases were classified as per the International League against Epilepsy recommendation. Global Mental Health Assessment Tool electronic questionnaire was used to analyze psychological aspects of cases. The caregivers of the patients participated in the knowledge, attitude, and practice (KAP) survey. Results: A total of 380 patients (258 men, 122 women) were identified with active epilepsy. The estimated prevalence of active epilepsy was 1.1/1,000 population and 71% of cases belonged to low socioeconomic classes. Primary treatment gap was documented in 18.8% of cases in our study, 38% of cases were non-compliant to treatment with poorer compliance in those on pol-therapy, 76% had some psychiatric disorder, anxiety and depression being the commonest, and positive family history of epilepsy was found in 4.7%. KAP survey revealed that only 15% of the respondents believed that epilepsy is non-curable, 74% denied its infectious nature, 26% believed that epilepsy occurs due to past sins, and 81% said that they would not marry persons with epilepsy. Conclusion: A relatively low prevalence (1.1/1,000) of active epilepsy and a smaller primary treatment gap (18.8%) was found in our study population. Almost three-fourth of cases had an associated psychological problem, Though caregivers were aware of the nature of disease, majority would not prefer to marry a person suffering from epilepsy.

Newer forms of unclassified headaches.

Subsequent to reading Guerrero et al article entitled “Epicrania Fugax: Ten New Cases and Therapeutic Results”, we were struck by the similarities encountered in some of our own patients, who complain of sudden, sharp shooting episodic pains on the vertex, lasting from a few seconds to a maximum of 30 seconds, with intense discomfort, occurring multiple times, mostly during daytime, and disappearing spontaneously, leaving the patient scared. We have come across 16 such patients in the headache clinic of our tertiary care hospital in the last 5 years. Such pains do not have any precipitating factors and occur spontaneously, without any associated symptoms or any post headache features. Often such headaches are seen in pediatric and adolescent populations, more so in school aged boys. Neurological examination is completely normal. Brain imaging (CT scan or magnetic resonance imaging [MRI]) of such patients does not show any abnormalities. Most of these patients did not respond to traditional analgesics and often visited psychiatrists as these were considered escape phenomena. In view of the episodic attack like features, the possibility of them being ictal was considered and electroencephalographic examination invariably showed epileptiform discharges in the form of spike and sharp waves. These children have shown dramatic response to carbamazepine, which was generally continued for a period of 4-6 weeks. Recovery is generally complete. Recurrence occurs in about 10-20% cases. Rare reports of an entity called cephalgic seizures have appeared in published literature since the 1980s. The case descriptions include paroxysmal headache as a manifestation of cerebral seizure. The electroencephalographic changes and the response to anticonvulsants were considered diagnostic in these cases. Epicrania fugax is an interesting headache variant with strictly unilateral, shooting pain paroxysms starting in a focal area of the posterior parietal or temporal region and rapidly spreading forward to the ipsilateral eye or nose along a linear or zigzag trajectory, lasting 1-10 seconds. More detailed studies can be planned taking into consideration the possibility of ictal phenomena underlying these paroxysmal events. EEGs should be conducted in all such cases. It would not be surprising if epicrania fugax and cephalgic seizures turn out to be similar entities. Moreover, in the recent times, evidence suggesting an association of migraine with childhood epileptic syndromes like benign occipital epilepsy and benign epilepsy with centrotemporal spikes strengthens the speculation of existence of shared underlying mechanisms involving neuronal hyper-excitability in these seemingly diverse phenomena.