Purushottam Acharya

A study of clinical profile, radiological and electroencephalographic characteristics of suspected Creutzfeldt-Jakob disease in a tertiary care centre in South India

Introduction: Creutzfeldt-Jakob disease (CJD) is a progressive, fatal, neurodegenerative disease classified under transmissible spongiform encephalopathies (TSE) or prion diseases. It is characterized by long asymptomatic period followed by rapid clinical deterioration leading to the death within months. The disease is still under-reported in India. Objective: The aim of this study was to describe the clinical, radiological and electroencephalographic characteristics of eight cases of CJD encountered in MS Ramaiah Medical college and Hospital, Bangalore over the past 3 years (2010-2013). This was retrospective, observational, hospital-based study. Results: The mean age of patients was 66.6 years (range: 54-82) and there was female predominance (five patients). The main clinical manifestations were cognitive disturbance (8/8) and myoclonus (8/8), followed by behavioral disturbance (5/8), ataxia (5/8) and extra-pyramidal symptoms/signs (4/8). Time interval (mean) between onset of disease to death was 6.6 months (range: 3-14). Brain MRI abnormalities were noted in 6 patients: Fluid-attenuated inversion recovery hyperintensities with restriction on diffusion-weighted image/apparent diffusion coefficient (DWI/ADC) in caudate and putamen, and diffusion hyperintensities without restriction on ADC in parieto-occipital, frontal and temporal regions. Classical electroencephalogram (EEG) changes of periodic triphasic waves were seen in 87% of patients. The CSF 14-3-3 protein assay was positive in two patients (out of four). Seven cases were probable CJD and one was possible CJD. Conclusion: A strong clinical suspicion aided by characteristic brain MRI and EEG abnormalities is essential for timely diagnosis of this fatal disease.

Intravenous thrombolysis for acute ischemic stroke: Review of 97 patients

Background: Intravenous thrombolysis (IVT) has now become a standard treatment in eligible patients with acute ischemic stroke (AIS) who present within 4.5 h of symptom onset. Objective: To determine the usefulness of IVT and the subset of patients who will benefit from IVT in AIS within 4.5 h. Materials and Methods: Patients with AIS within 4.5 h of symptom onset who underwent IVT were studied prospectively. The study period was from October 2011 to October 2015. Results: A total of 97 patients were thrombolysed intravenously. The mean onset to needle time in all patients was 177.2 ± 62 min (range: 60–360). At 3 months follow-up, favorable outcome was seen in 65 patients (67.1%) and poor outcome including death in the remaining 32 patients (32.9%). Factors predicting favorable outcome was age <65 years (P = 0.02), the National Institute of Health Stroke Scale (NIHSS) <15 (P < 0.001), small vessel occlusion (P = 0.006), cardioembolism (P = 0.006), and random blood sugar (RBS) <250 mg/dl (P < 0.001). Factors predicting poor outcome was diabetes mellitus (P = 0.01), dyslipidemia (P = 0.01), NIHSS at admission >15 (P = 0.03), RBS >250 mg/dl (P = 0.01), Dense cerebral artery sign, age, glucose level on admission, onset-to-treatment time, NIHSS on admission score >5 (P = 0.03), and occlusion of large artery (P = 0.02). Conclusion: Milder baseline stroke severity, blood glucose <250 mg/dL, younger patients (<65 years), cardioembolic stroke, and small vessel occlusion benefit from recombinant tissue plasminogen activator.

Use of multiplex PCR based molecular diagnostics in diagnosis of suspected CNS infections in tertiary care setting—A retrospective study

OBJECTIVES CNS infections like meningitis and encephalitis pose enormous healthcare challenges due to mortality, sequelae and socioeconomic burden. In tertiary setting, clinical, microbiological, cytological and radiological investigations are not distinctive enough for diagnosing microbial etiology. Molecular diagnostics is filling this gap. We evaluated the clinical impact of a commercially available multiplex molecular diagnostic system - SES for diagnosing suspected CNS infections. PATIENTS AND METHODS This study was conducted in our tertiary level Neurology ICU. 110 patients admitted during Nov-2010 to April-2014 were included. CSF samples of patients clinically suspected of having CNS infections were subjected to routine investigation in our laboratory and SES test at XCyton Diagnostics. We studied the impact of SES in diagnosis of CNS infections and its efficacy in helping therapeutic management. RESULTS SES showed detection rate of 42.18% and clinical specificity of 100%. It had 10 times higher detection rate than conventional tests. Streptococcus pneumoniae and Mycobacterium tuberculosis were two top bacterial pathogens. VZV was most detected viral pathogen. SES results elicited changes in therapy in both positive and negative cases. We observed superior patient outcomes as measured by GCS scale. 75% and 82.14% of the patients positive and negative on SES respectively, recovered fully. CONCLUSION Detecting causative organism and ruling out infectious etiology remain the most critical aspect for management and prognosis of patients with suspected CNS infections. In this study, we observed higher detection rate of pathogens, target specific escalation and evidence based de-escalation of antimicrobials using SES. Institution of appropriate therapy helped reduce unnecessary use of antimicrobials.

Bilateral cerebral hemorrhage in herpes simplex encephalitis: Rare occurrence

Journal of Neurosciences in Rural Practice ¦ Volume 7 ¦ Supplement 1 ¦ December 2016 and leg pain caused by lumbar annular tears. Zhonghua Yi Xue Za Zhi 2010;90:3198‐202. 4. Hancock M, Maher C, Macaskill P, Latimer J, Kos W, Pik J. MRI findings are more common in selected patients with acute low back pain than controls? Eur Spine J 2012;21:240‐6. 5. Dongfeng R, Hou S, Wu W, Wang H, Shang W, Tang J, et al. The expression of tumor necrosis factor‐a and CD68 in high‐intensity zone of lumbar intervertebral disc on magnetic resonance image in the patients with low back pain. Spine (Phila Pa 1976) 2011;36:E429‐33. 6. Moon HJ, Kim JH, Lee HS, Chotai S, Kang JD, Suh JK, et al. Annulus fibrosus cells interact with neuron‐like cells to modulate production of growth factors and cytokines in symptomatic disc degeneration. Spine (Phila Pa 1976) 2012;37:2‐9. 7. Peng B, Hou S, Wu W, Zhang C, Yang Y. The pathogenesis and clinical significance of a high‐intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain. Eur Spine J 2006;15:583‐7. Access this article online

Role of biomarkers in differentiating new-onset seizures from psychogenic nonepileptic seizures

Introduction: Review of literature revealed very limited studies considering a combination of serum prolactin (PRL) and serum creatine kinase (CK) as markers for differentiating epileptic and psychogenic nonepileptic seizures (PNES). Therefore, in the present study, we analyzed the role of serum PRL and serum CK, individually and in combination. Methodology: This prospective study was conducted in a tertiary care medical teaching hospital over a period of 18 months. Patients aged over 15 years suspected to have new-onset seizures presenting within 5 h of ictus were included in this study. CK, serum PRL was measured at 0–1, 1–3, and 3–5 h after seizures. Results: Hundred subjects were studied for the role of serum PRL and serum CK in differentiating epileptic and PNES. The mean age was 42.24 years with a male:female ratio of 1.27:1. All patients of generalized tonic–clonic seizures (GTCS), who presented within 1 h, had elevated PRL, whereas 75% of patients with partial seizures had elevated PRL within 1 h of presentation. Nearly 91.66% of patients with GTCS who presented within 1 h had elevated CPK, whereas 70% of patients with partial seizures had elevated CPK. None of the patients diagnosed with PNES showed rise in either of the markers. Conclusion: In the present study, none of the patients with PNES showed raise in either serum PRL or CK. However, there was no correlation between the types of seizure and PRL or serum CK levels.

Clinical impression and western aphasia battery classification of aphasia in acute ischemic stroke: Is there a discrepancy?

Background: Language disturbance is a common symptom of stroke, a prompt identifier of the event, and can cause devastating cognitive impairments. There are many inconsistencies and discrepancies between the different methods used for its evaluation. The relationship between Western Aphasia Battery (WAB) and a simple bedside clinical examination is not clear. Aim: The aim of this study is to determine if bedside clinical impression of aphasia type can reliably predict WAB classification of aphasia and to describe the discrepancies between them. Materials and Methods: Eighty-two consecutive cases of acute ischemic stroke and aphasia were evaluated with bedside aphasia assessment, handedness by Edinburgh Handedness Inventory and WAB scoring was done. Kappa statistics was used to find the overall agreement of clinical impression and WAB. Results: Disagreement was seen predominantly for the nonfluent aphasias when the clinical impression was compared with WAB classification. WAB also had diagnosed three cases as having anomic aphasia using taxonomic classification, but same cases had normal language by aphasia quotient scoring of WAB. There was an overall agreement of 63.4% between patients bedside clinical impression and WAB classification of aphasia, with a P < 0.001. Conclusion: Clinical impression was fairly reliable, as compared to WAB in assessing the type of aphasia. Clinical impression was appropriate in an acute setting, but WAB was required to quantify the severity of deficit, which may help in accessing prognosis, monitoring progression, and rehabilitation planning. Along with WAB, a bedside clinical impression should be done for all the patients to strengthen the description of aphasic deficit.

Acute generalized chorea as presenting manifestation of uremic encephalopathy

1 year on medical management. On examination, his tongue was dry, pulse rate of 102/min, blood pressure of 146/86 mmHg, and respiratory rate of 20 breaths/min. Neurologically, he was conscious and responding to verbal commands with mild slurred speech. Fundus examination was normal. There was generalized choreiform movement involving face and all limbs. Asterixis could not be made out due to choreiform movements of limbs. Tone in limbs was decreased with sluggish reflexes. Plantar response was withdrawal. There was no neck rigidity. Complete hemogram showed raised total leukocyte counts (16,000 cells per cumm), normal platelet count, and hemoglobin. Serum electrolytes, random blood glucose, serum ammonia, and liver and thyroid function test were normal. Blood urea nitrogen was 76.4 mg/dl, creatinine of 6.2 mg/dl, and glycosylated hemoglobin of 8.2%. Blood gas analysis showed pH: 7.314, bicarbonate: 17.6 mmol/L, and lactate: 2.1 mmol/L. Brain MRI showed hypointense on T1 and hyperintense lesions on T2 and fluid‐attenuated inversion recovery sequences in bilateral basal ganglia. Diffusion‐weighted imaging showed no restriction in bilateral putamen [Figure 1]. Electroencephalogram showed mild slowing of background rhythm. He was started on sodium valproate (1 g/day) but had no improvement. He Sir, Renal dysfunction results in a clinical metabolic condition known as uremia. It causes altered mental status due to involvement of cerebral cortex termed as uremic encephalopathy. Acute hyperkinetic or hypokinetic extrapyramidal disorder in patients with uremia is a very rare syndrome. It was first described by Wang et al. due to bilateral basal ganglia lesions in uremia.[1] Hereby, we report an elderly patient with diabetic nephropathy who presented with acute‐onset generalized chorea. Brain magnetic resonance imaging (MRI) showed bilateral basal ganglia lesions. Choreiform movements got ameliorated with hemodialysis.

Odorless inhalant toxic encephalopathy in developing countries household: Gas geyser syndrome

Background: Liquefied petroleum gas geysers are used very frequently for heating water in developing countries such as India. However, these gas geysers emit various toxic gases; one among them is colorless, odorless carbon monoxide (CO). In the past few years, there were reports of unexplained loss of consciousness in the bathroom. However, the exact cause for these episodes has been recognized as toxic encephalopathy due to toxic gases inhalation mainly CO. Objective: To analyze the clinical profile and outcome of patients brought with loss of consciousness in the bathroom while bathing using gas geyser. Materials and Methods: Case records of patients with the diagnosis of gas geyser syndrome from 2013 to 2015 were retrieved and analyzed. Twenty-four cases were identified and included in the study. This was a retrospective, descriptive study. Results: Twenty-four patients were brought to our Emergency Department with loss of consciousness in the bathroom while bathing. Twenty-one cases had loss of consciousness during bathing and recovered spontaneously. Two cases were found dead in the bathroom and were brought to the Department of Forensic Medicine for postmortem. One case was brought in deep altered state of consciousness and succumbed to illness within 1 week.Conclusion: Awareness regarding CO intoxication due to usage of ill-fitted, ill-ventilated gas geyser is necessary as they are entirely preventable conditions.