Refractory Immune-Mediated Cysticercal Meningitis and Role of B Cell Depleting Therapy.

BACKGROUND: Extraparenchymal neurocysticercosis (NCC) commonly presents with symptoms of raised intracranial pressure such as headache, nausea, vomiting, or delirium. Intraventricular NCC is frequently associated with obstructive hydrocephalus as well as recurrent inflammatory cascade leading to chronic meningitis. OBJECTIVE: The aim of this study was to report the novel use and benefit of B cell depleting therapy in a case of treatment-refractory cysticercal meningoencephalitis. CASE: In this article, we report about a young male with intraventricular NCC, who had recurrent meningitis (with encephalitis) and kept relapsing despite multiple cerebrospinal fluid diversion procedures, cysticidal therapy, and high-dose steroids. He finally showed clinical and radiological resolution with pulsed rituximab therapy. CONCLUSION: This off-label use of a monoclonal antibody against CD20 may be considered as a rescue therapy in steroid-refractory immune-mediated cysticercal meningitis.

Open-label randomized control trial of hydroxychloroquine in patients with moderate to severe coronavirus disease 2019 infection.

BACKGROUND: At onset of coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) was repurposed for treatment of patients based on reports that it had in vitro activity. The aim of this study was to find out if HCQ reduces number of days of hospitalization when given to patients with moderate to severe COVID-19 infections who require hospitalized care. METHODS: This was an open-label randomized control trial of HCQ administered 400 mg twice on day 1, then 400 mg once daily from day 2 to day 5 in patients with moderate to severe COVID-19 infection. Assessment was not blinded. Standard of care was given to both arms.Primary outcome was number of days of hospitalization till discharge or death. RESULT: One hundred ten patients (55 in each arm) were included. Mean age was 58 years. Baseline characteristics were well matched. There was no difference in the primary outcome (13.67 vs 13.89; p = 0.98). Number of deaths were more in HCQ arm (RR: 1.81; 95% CI: 1.13-2.93; p = 0.03). There was no difference in number of days on oxygen or normalization of oxygen saturation, number who needed ventilator, days to ventilator requirement and days on ventilator. Twenty-nine patients in control arm received remdesivir. When adjusted analysis was done after removal of these patients, there was no difference in primary or secondary outcomes. Number of deaths in adjusted analysis were not significant (RR: 1.28; 95% CI: 0.87-1.88; p = 0.37). CONCLUSION: HCQ does not change the number of days of hospitalization when compared with control.

A Study of the Clinical Profile, Radiologic Features, and Therapeutic Outcomes in Neurosarcoidosis from Two Tertiary Care Centers in Southern India.

BACKGROUND: Sarcoidosis is an inflammatory granulomatous disease affecting multiple organ systems. Neurological manifestations are rare and seen in approximately 5% cases of sarcoidosis. They may commonly precede the diagnosis of sarcoidosis. Since there is paucity of Indian literature on this subject, we decided to review the clinical and radiological profile, laboratory abnormalities, treatment and long-term outcomes in our patients with neurosarcoidosis (NS). METHODS: The study was done by retrospective review of medical records for all cases diagnosed as NS during the period Jan 2014-Jan 2018. These cases were classified as definite, probable, and possible NS, on the basis of established diagnostic parameters (Zajicek criteria). The follow-up record in these cases ranged from 6 months to 3 years, with special emphasis on monitoring the response to treatment and long-term disability. RESULTS: The cases showed varied clinical abnormalities and imaging findings. Cranial neuropathies and myelopathy were the most common clinical presentations. Optic neuritis was most common cranial neuropathy, followed by facial nerve palsy and lower cranial nerve palsies. Most common magnetic resonance imaging findings were T2 hyperintense parenchymal lesions and meningeal enhancement. There was strong correlation between baseline clinico radiological parameters and long-term outcomes, as evidenced by relatively poor prognosis seen in cases with bilateral optic neuritis, myelopathy and imaging evidence of hydrocephalus, or leptomeningitis. CONCLUSION: The diagnosis of NS requires a high degree of suspicion, coupled with exclusion of alternate diagnosis. It commonly precedes the onset of systemic sarcoidosis. Central nervous system involvement in sarcoidosis is associated with poor clinical outcomes.

Recurrent Encephalopathy with Transverse Myelitis: An Uncommon Presentation of Neurobrucellosis.

Brucellosis (malta fever) is a zoonotic infection caused by a gram-negative coccobacillus which is a facultative intracellular pathogen. It causes a chronic granulomatous infection, similar in histology to tuberculosis. Brucellosis remains a diagnostic dilemma due to misleading, nonspecific manifestations and increasing trend of unusual presentations. In brucellosis, the nervous system involvement occurs in only 5 to 7% of untreated patients, and it may manifest with encephalitis, meningoencephalitis, radiculitis, and peripheral and cranial neuropathies. Transverse myelitis is an unusual occurrence. Here, the authors are reporting an unusual case of neurobrucellosis in an elderly male patient who visited multiple hospitals with recurring febrile encephalopathy and paraparesis. The diagnosis was suspected by his occupational history of working as an abattoir worker and was confirmed by the presence of high titers of Brucella immunoglobulin (Ig) M and IgG antibodies in the serum. The patient was managed with injection gentamicin for 2 weeks along with oral course of doxycycline and rifampicin for 6 weeks. He made a good clinical recovery and went back to work with mild residual deficits.