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.

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 patient's 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.

Newborn with congenital facial palsy and bilateral anotia/atresia of external auditory canal: Rare occurrence.

Congenital facial palsy (CFP) is clinically defined as facial palsy of the seventh cranial nerve which is present at birth or shortly thereafter. It is generally considered to be either developmental or acquired in origin. Facial palsy of developmental origin is associated with other anomalies including those of pinna and external auditory canal, which range from mild defects to severe microtia and atresia. We report a 2-day-old male newborn that had right CFP with bilateral anotia and atresia of external auditory canals which is rare.

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.

Acute seizures in cerebral venous sinus thrombosis: What predicts it?

BACKGROUND: Seizures are the presenting feature of cerebral venous sinus thrombosis (CVST) in 12-31.9% of patients. 44.3% of patients have seizures in the early stage of the disease. Acute seizures (AS), refers to seizures which take place before the diagnosis or during the first 2 weeks afterward. OBJECTIVE: To report the predictors of acute seizures in cerebral venous sinus thrombosis (CVST). METHODS: 100 patients with CVST were included in the study. The occurrence of acute seizures was noted. The predictors of acute seizure were evaluated by univariate analysis including the demographic (gender, age), clinical (headache, focal neurological deficit, papilloedema, GCS score), type and number of risk factors, MRI findings (Type of lesion: hemorrhagic infarction or hematoma, location of lesion) and MRV findings (superficial or deep sinus, cortical veins). RESULTS: A total of 46 patients had acute seizures. On univariate analysis, altered mental status (p<0.001), paresis (p=0.03), GCS score <8 (p=0.009), hemorrhagic infarct on imaging (p=0.04), involvement of frontal lobe (p=0.02), superior sagittal sinus (p=0.008), and high D-dimer levels (p=0.03) were significantly associated with acute seizure. On multivariate analysis, the hemorrhagic infarct on MRI and high D-dimer was independently predictive for early seizure. CONCLUSION: The predictive factors for the acute seizures are altered mental status (GCS<8), focal deficits, hemorrhagic infarct, involvement of frontal lobe and superior sagittal sinus with high D-dimer levels.

Diffuse corpus callosum infarction - Rare vascular entity with differing etiology.

INTRODUCTION: Infarctions of the corpus callosum are rare vascular events. It is relatively immune to vascular insult because of its rich vascular supply from anterior and posterior circulations of brain. OBJECTIVE: Report of 3 patients with largely diffuse acute corpus callosum infarction. METHODS: 3 patients with largely diffuse acute corpus callosum infarction were studied and each of these 3 patients had 3 different aetiologies. RESULTS: The 3 different aetiologies of largely diffuse acute corpus callosum infarction were cardioembolism, tuberculous arteritis and takayasu arteritis. CONCLUSION: Diffuse corpus callosum infarcts are rare events. This case series narrates the three different aetiologies of diffuse acute corpus callosum infarction which is a rare vascular event.

"Nine" syndrome: A new neuro-ophthalmologic syndrome: Report of two cases.

"Eight-and-a-half" syndrome is a rare condition involving the ipsilateral abducens nucleus or paramedian pontine reticular formation (PPRF), the ipsilateral medial longitudinal fasciculus (MLF), and the adjacent facial colliculus/facial nerve fascicle. The condition is often caused by a lesion (vascular or demyelinating) in the dorsal tegmentum of the caudal pons. There are new variants of this syndrome caused by extension of lesion to involve new adjacent structures in pontine tegmentum. We report two patients with different etiology presenting with clinical features suggestive of eight-and-a-half syndrome associated with hemiataxia representing "nine" syndrome (8½ + ½ = 9) adding new dimension to "eight-and-a-half" syndrome.