Verajit Chotmongkol

Corticosteroid Treatment of Eosinophilic Meningitis

The role of corticosteroids in the treatment of eosinophilic meningitis has not been definitely established. Patients given a 2-week course of prednisolone (treatment group), 60 mg/day, were compared with those given placebo (control group) in a randomized, double-blind trial. Fifty-five patients were enrolled in each group. There were significant differences between the treatment and control groups, with regard to the number of patients who still had headache after 14 days (5 vs. 25, respectively; P=.00004), the median length of time until complete disappearance of headache (5 vs. 13 days, respectively; P=.00000), and the number of patients who had repeat lumbar puncture (7 vs. 22, respectively; P=.002). Serious side effects were not detected. These results indicate that a 2-week course of prednisolone was beneficial in relieving headache in patients with eosinophilic meningitis.

Seizures in nonketotic hyperglycaemia

Dear Sir, The association between focal seizures and hyperglycaemia was first reported in 19651. The disorder is characterized by hyperglycaemia, no ketoacidosis, full consciousness (or minimal depression of sensorium) and focal seizures. We report 21 patients, who presented with seizures and nonketotic hyperglycaemia (NKH). This is a large case series. The aim of this report is to study clinical and laboratory characteristics of seizures in NKH. A retrospective study was done in a teaching hospital. Inclusion criteria were (1) hyperglycaemia (plasma glucose more than 11.11 mmol/l), (2) seizures, and (3) seizure stopping after control of the hyperglycaemia. Patients with seizures explained by causes other than hyperglycaemia were excluded from the study. Of the 21 patients, 9 were men (43%) and 12 were women (57%) who developed seizures and NKH (23 events). One patient had three events. Six patients had a previous history of diabetes mellitus (DM). Fifteen patients had no previous history of DM. They presented with seizures and NKH, and were diagnosed with DM in the index admission. Of the 21 patients, 3 were DM type 1 (14.3%) and 18 were DM type 2 (85.7%). The average duration of seizures before admission was 5 days (range 1–14 days). The average duration of seizures in each episode was 3 minutes (range 1–5 minutes). Total of 22 events (95.65%) were partial seizures, and 1 event was an unclassified tonic-clonic seizure. Among the 22 partial onset seizures, 14 were epilepsia partialis continua, 6 became secondarily generalized tonic-clonic seizures, and 2 were complex partial seizures (CPS). In all 20 events of partial seizures without CPS, seizures started in one extremity or the face: 14 started in an upper extremity, 5 in the face, and 1 in a lower extremity. Partial seizures started slightly more often on the left side (12 cases) than the right side (8 cases). At the time of the seizure, the average plasma glucose value was 32.61 mmol/l (range 16.11–61.33 mmol/l). The average calculated serum osmolarity was 302 mOsm/l (range 288–323 mOsm/l). When the seizures stopped, the average plasma glucose value was 11.3 mmol/l (range 4.11–21.67 mmol/l). Neurologic manifestations, particularly seizures, may provide the first clinical clue to the presence of NKH. Focal motor seizures are the most common type2. However, seizures in NKH are still not fully appreciated by physician and patient. Our patients took an average of 5 days before they got the correct diagnosis and treatment. Knowledge of this condition may shorten the time to diagnosis and decrease the discomfort of patients. Every patient who presents with seizures especially focal seizures should have an immediate determination of plasma glucose levels. Seizures in NKH happen equally in both sexes. In 15 of the 21 patients (71.4%), seizures were the earliest manifestation of DM and led to discovery of DM in these patients. Most of patients had type 2 DM. Although 3 of the 21 patients had type 1 DM, none of them had ketoacidosis during the seizure. This finding may be explained by the fact that ketosis has an anticonvulsant action, due to intracellular acidosis increasing glutamic acid and decarboxylase activity leading to increased levels of GABA3. Epilepsia partialis continua was the most common type (60.87%) of seizure in our series, as previously reported2. Interestingly, we found 2 (8.7%) of our patients presented with CPS. Our finding confirmed previous reports of CPS induced by hyperglycaemia4. The mechanism of seizures in NKH is still debated. The possible mechanisms are hyperglycaemia or hyperosmolarity, a low level of gamma aminobutyric acid (GABA), and focal ischaemia. Each mechanism, considered alone, is unsatisfactory. Mean plasma glucose value in our report was 32.61 (16.11–61.33 mmol/l), and osmolarity ranged from normal to a moderate value (288–323 mOsm/l). Almost all of our seizures in NKH patients have plasma osmolarity less than the classical diagnostic level (320 mOsm/l) of NKH. In addition, mean plasma glucose ranged from normal to hyperglycaemia (4.11–21.67 mmol/l) when seizures stopped. So, the explanation of hyperglycaemia or hyperosmolarity alone is unsatisfactory. In addition, the Krebs cycle in NKH is inhibited, GABA metabolism is increased and the levels may be decreased, thus lowering the threshold for seizure activtiy3, 5.

Neurognathostomiasis, a Neglected Parasitosis of the Central Nervous System

Gnathostomiasis is a foodborne zoonotic helminthic infection caused by the third-stage larvae of Gnathostoma spp. nematodes. The most severe manifestation involves infection of the central nervous system, neurognathostomiasis. Although gnathostomiasis is endemic to Asia and Latin America, almost all neurognathostomiasis cases are reported from Thailand. Despite high rates of illness and death, neurognathostomiasis has received less attention than the more common cutaneous form of gnathostomiasis, possibly because of the apparent geographic confinement of the neurologic infection to 1 country. Recently, however, the disease has been reported in returned travelers in Europe. We reviewed the English-language literature on neurognathostomiasis and analyzed epidemiology and geographic distribution, mode of central nervous system invasion, pathophysiology, clinical features, neuroimaging data, and treatment options. On the basis of epidemiologic data, clinical signs, neuroimaging, and laboratory findings, we propose diagnostic criteria for neurognathostomiasis.

Immunoblot Diagnostic Test for Neurognathostomiasis

Neurognathostomiasis is a rare but severe form of human gnathostomiasis. Diagnosis of neurognathostomiasis is made presumably by using clinical manifestations. Serologic tests for neurognathostomiasis are not widely available and limited. We studied 12 patients with diagnoses of neurognathostomiasis at Srinagarind Hospital, Khon Kaen University, Thailand. There were three types of neurognathostomiasis (five patients with intracerebral hemorrhage, one patient with subarachnoid hemorrhage, and six patients with myelitis). All patients were tested for antibodies against Gnathostoma spinigerum by an immunoblotting technique. The sensitivity and specificity of the 21-kD and 24-kD diagnostic bands were 83.3% and 100%, and 91.7% and 100%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 21-kD and 24-kD diagnostic bands were all 100%. Both diagnostic bands are a helpful diagnostic tool for neuro gnathostomiasis and show good diagnostic properties.

Clinical factors predictive of encephalitis caused by Angiostrongylus cantonensis.

Angiostrongylus cantonensis is mainly caused eosinophilic meningitis in humans, whereas a minority of patients develop encephalitic angiostrongyliasis (EA). EA is an extremely fatal condition, and the clinical factors predictive of EA have never been reported. A comparison study was conducted in a hospital situated in an endemic area of Thailand. We enrolled 14 and 80 angiostrongyliasis patients who developed encephalitis and meningitis, respectively. Logistic regression analysis was used to assess the clinical variables predictive of encephalitis. Age (adjusted odds ratio [OR], 1.22; 95% confidence interval [CI], 1.05-1.42), duration of headache (adjusted OR, 1.26; 95% CI, 1.03-1.55), and fever > 38.0 degrees C (adjusted OR, 37.05; 95% CI, 1.59-862.35) were identified as statistically significant factors for EA prediction. Elderly patients with angiostrongyliasis experiencing fever and prolonged headaches were at the highest risk of developing EA.

Clinical Manifestations of Eosinophilic Meningitis Due to Infection with Angiostrongylus cantonensis in Children

Eosinophilic meningitis, caused by the nematode Angiostrongylus cantonensis, is prevalent in northeastern Thailand, most commonly in adults. Data regarding clinical manifestations of this condition in children is limited and may be different those in adults. A chart review was done on 19 eosinophilic meningitis patients aged less than 15 years in Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand. Clinical manifestations and outcomes were reported using descriptive statistics. All patients had presented with severe headache. Most patients were males, had fever, nausea or vomiting, stiffness of the neck, and a history of snail ingestion. Six patients had papilledema or cranial nerve palsies. It was shown that the clinical manifestations of eosinophilic meningitis due to A. cantonensis in children are different from those in adult patients. Fever, nausea, vomiting, hepatomegaly, neck stiffness, and cranial nerve palsies were all more common in children than in adults.

A comparative study of neuroimaging features between human neuro-gnathostomiasis and angiostrongyliasis

Gnathostoma spinigerum and Angiostrongylus cantonensis are human parasites that can cause neurological symptoms. The human diseases produced by these parasites can usually be differentiated by clinical symptoms. The aim of this study was to report neuroimaging abnormalities detected with computed tomography (CT) and MR in patients with gnathostomiasis and angiostrongyliasis. We enrolled 15 and 12 patients with serologically proven gnathostomiasis and angiostrongyliasis, respectively, who had brain or spinal imaging done. The neuro-gnathostomiasis group had significantly more patients with intracerebral hemorrhage and myelitis patterns. The angiostrongyliasis group had no specific findings and most patients had normal CT brain images. The variety of neuroimaging findings is shown here. This study emphasizes that neuroimaging studies may be useful to differentiate gnathostomiasis and angiostrongyliasis particularly in patients with indistinct clinical presentations.

Molecular Identification of Trichinella papuae from a Thai Patient with Imported Trichinellosis

Previously, we reported the presence of imported trichinellosis in a Thai worker returning from Malaysia, who presented with progressive generalized muscle hypertrophy and weakness after eating wild boar meat. This work analyzed a partial small subunit of a mitochondrial ribosomal RNA gene of Trichinella larvae isolated from the patient. The results showed complete identity with a mitochondrial RNA gene of Trichinella papuae (GenBank accession no. EF517130). This is the first report of imported trichinellosis in Thailand caused by T. papuae. It is possible that T. papuae is widely distributed in the wildlife of Southeast Asia.

Chapter 15 – Eosinophilic meningitis

Eosinophilic meningitis is defined by the presence of at least 10% eosinophils in the total cerebrospinal fluid (CSF) leukocyte count. Although there are several possible causes of eosinophils in the CSF, parasitic infection is the main cause. The three common parasites causing eosinophilic meningitis include Angiostrongylus cantonensis, Gnathostoma spinigerum, and Taenia solium. Even though these parasites are endemic in tropical countries, they are now spreading globally due to extensive traveling, and physicians worldwide should pay more attention to this condition. This chapter will review risk factors, clinical manifestations, and treatment of these three parasites.

Correlation of Causes and Outcomes in Stroke in the Young

BACKGROUND We studied the association of causes and stroke outcome of stroke in the young in Thailand. METHODS A retrospective study was performed at Srinagarind Hospital, Khon Kaen University, Thailand. All patients under 45 years of age who were diagnosed with stroke between 1996 and 2010 and who had complete workups for causes of stroke in the young were enrolled. Stroke outcome was defined as favorable or nonfavorable at approximately 1 year of follow-up. If the patient had normal functional ability or mild disability but the patient was fully employed, the outcome was classified as favorable. Clinical features of strokes and the potential stroke risk factors were compared between the favorable and nonfavorable groups. RESULTS Eighty-five patients were enrolled. About half of patients were male (47 patients; 55.3%). The mean age (SD) was 35.9 (6.2) years. Three-fourths of male patients had a stroke after 30 years of age, while female patients developed stroke in all age ranges equally. More than half of patients (45 patients; 52.9%) had cardiac causes of stroke. Rheumatic mitral stenosis accounted for 68% (31 patients), and 45% (14 patients) had atrial fibrillation. There were 64 patients (79%) who had a favorable outcome. Cardiac causes, particularly mitral stenosis and alcohol intake, were significantly associated with a nonfavorable outcome. CONCLUSIONS Stroke in the young generally has a favorable outcome. Factors associated with a nonfavorable outcome of stroke in the young were cardiac abnormalities and alcohol intake. A prospective study to evaluate the association of causes and outcome is needed.