Ravi C. Sharma

A probable association of acute dystonia with gemifloxacin administration

Gemifloxacin is a recently introduced fluoroquinolone antibiotic frequently used for its broad spectrum and once-daily dosing. Fluoroquinolones are associated with various neuropsychiatric side effects, such as seizures, insomnia, confusion, lightheadedness, psychosis, paranoia and hallucinations. We report a case of a 36-year-old woman given gemifloxacin for an upper respiratory tract infection who developed acute dystonia on the third day following therapy initiation. The clinical implications are discussed.

Delirium Associated with Olanzapine Therapy in an Elderly Male with Bipolar Affective Disorder

Atypical antipsychotic medications are commonly used to treat symptoms of delirium. Olanzapine has been successfully used in the treatment of delirium. However, there have been few case reports of delirium associated with olanzapine. We hereby report a case of delirium associated with olanzapine therapy. Possible risk factors and underlying pathogenesis is discussed.

Mutism as the presenting symptom: Three case reports and selective review of literature

Mutism, defined as an inability or unwillingness to speak, resulting in an absence or marked paucity of verbal output, is a common clinical symptom seen in psychiatric as well as neurology outpatient department. It rarely presents as an isolated disability and often occurs in association with other disturbances in behavior, thought processes, affect, or level of consciousness. It is often a focus of clinical attention, both for the physician and the relatives. Mutism occurs in a number of conditions, both functional and organic, and a proper diagnosis is important for the management. We hereby present three cases, who presented with mutism as the presenting symptom and the differential diagnosis and management issues related to these cases are discussed. The authors also selectively reviewed the literature on mutism, including psychiatric, neurologic, toxic-metabolic, and drug-induced causes.

First episode mania at 75 years of age

Late onset psychiatric disorders are often associated with organic factors, either medical or neurological. Mania occurring for the first time in the elderly population is rarely reported. We hereby report a patient with first episode mania who was investigated in detail, but no organic factors were found. He was diagnosed as first episode mania and was managed with divalproex and olanzapine.

Starvation in obsessive-compulsive disorder due to scrupulosity

This report describes an unusual presentation of obsessive–compulsive disorder (OCD) with predominant religious obsessions and compulsions (scrupulosity) in which the patient starved himself by keeping fast excessively to the extent of emaciation and extreme weakness even in walking and became bedridden.

Effectiveness of fluoxetine in the treatment of skin-picking

The case of an 18-year-old girl with skin-picking is reported. The patient used to pick at healthy skin and small skin lesions, leading to ulceration, hyperpigmentation and disfigurement. She recovered almost fully with fluoxetine. The implications of diagnosis and the need for early treatment are discussed.

Topiramate induced pruritus in a patient with alcohol dependence

Topiramate is an antiepileptic medication frequently used for the management of alcohol dependence and in other psychiatric disorders. Though cutaneous side effects are known to occur with it, isolated pure pruritus is rarely reported with topiramate in the literature. We wish to report a case of pruritus associated with topiramate use in a male with alcohol dependence syndrome.

Homocystinuria: A rare condition presenting as stroke and megaloblastic anemia

Homocystinuria is an inborn error of amino acid metabolism in which homocystine accumulates in the blood and produces a slowly evolving clinical syndrome. We are presenting a case of a 4-year-old female child who presented to us with stroke and also had megaloblastic anemia. She was diagnosed as having homocystinuria type-1, and she responded to treatment.

Scrub typhus with visual hallucinations

The occurrence of psychiatric symptoms in scrub typhus is not commonly reported in literature. We present a case of scrub typhus with visual hallucinations.

Letter to the Editor. Postcranioplasty changes in cerebral blood perfusion and its impact on neurological and clinical outcomes

TO THE EDITOR: We studied with keen interest the article by Shahid et al.2 regarding their experience of the effects of cranioplasty on neurological and clinical outcomes and its relationship with cerebral blood flow (Shahid AH, Mohanty M, Singla N, et al: The effect of cranioplasty following decompressive craniectomy on cerebral blood perfusion, neurological, and cognitive outcome. J Neurosurg [epub ahead of print March 3, 2017. DOI: 10.3171/2016.10.JNS16678]). We commend the authors for undertaking an evaluation of this commonly performed neurosurgical procedure beyond the cosmesis and mechanical protection it provides. The authors found that all tests of cognition showed statistically significant improvement after cranioplasty, but the effect was limited regarding improvement in hemodynamic parameters. There was a significant increase in blood flow only to the occipital lobe, while the frontal lobe showed only a nonsignificant increase. It is difficult to explain the improvement in the cognitive parameters based on these findings, as most of the neuropsychological tests that were administered are of functions executed by the frontal lobe. Even the immediate and delayed recall showed improvement while SPECT revealed a decrease in blood flow to the temporal lobe, although not significant, which is opposite to the obvious expectation. Also, we suspect that there might be an indirect relationship between the decrease in blood flow to the basal ganglia and improvement in motor functions of all 10 of the 34 patients who had weakness before cranioplasty. It would have been useful if the authors had discussed the possible explanations for these counterintuitive findings. We also note that in this study an arbitrary time interval of 3 months was chosen to evaluate the effect of cranioplasty on all outcome variables, but there was no biologically plausible rationale or reference provided for this choice. It has been noted that 2 patients had to undergo titanium mesh cranioplasty due to autologous bone infection. It would have been very interesting for the readers to know the outcomes of these 2 patients in particular. It would have helped in gaining insights regarding the differences different materials may make in the blood flow changes, and finally in the outcomes across various parameters. Another very important aspect of cranioplasty that was not mentioned in the article was in regard to the postcranioplasty complications. It has been found by different studies that there is significant risk of resorption of the bone used for cranioplasty, sometimes as high as 20%.3 The effect that such resorption has on the cerebral hemodynamics and consequently its effect on clinical and neurological outcome variables should have been evaluated and discussed, considering its significant rate. For this, a longer follow-up duration is needed with blood flow measurements and neuropsychological testing repeated at well-defined intervals. The initial indication for performing decompressive craniectomy was not mentioned anywhere in the article. We suspect that the initial diagnosis may have a major bearing on the final outcome of the patients. It must be mentioned whether patients with frontal lobe injury or contusion, infarct involving frontotemporal region, etc., were included without any selection bias. If not, then it will be erroneous to extrapolate the findings of this study to all patients with traumatic brain injury. It is appreciable that the authors have compared the early (less than 6 months) and the late cranioplasty groups separately with matching. Although they found greater improvement in the neurological outcomes in the early group, they have noted that this may be confounded by the greater rate of spontaneous recovery early in the postcraniectomy phase as noted by Di Stefano et al.1 The question of longterm impact of early cranioplasty thus goes unanswered in spite of the prima facie advantage. The improvement attributable to cranioplasty over and above the expected spontaneous recovery has not been evaluated for either group. Although ideally a control group not undergoing cranioplasty must be considered, if the outcomes of the late cranioplasty group are also measured around the time of early cranioplasty, these may serve as controls for the early cranioplasty group. Ravi Sharma, MBBS Sachin A. Borkar, MCh Manoj Phalak, MCh Sumit Sinha, MCh Ashok K. Mahapatra, MCh All India Institute of Medical Sciences, New Delhi, India