Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review.

Objective: Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites. Methods: A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites. Results: Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment. Conclusions: Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.

Minimally invasive procedure for optic disc pit maculopathy: vitrectomy with scleral plug and analysis on pattern of resolution.

Optic disc pit maculopathy (ODP-M) is a rare complication of optic disc pit which can cause irreversible visual impairment. The aim of this study is to evaluate the anatomical and functional outcomes and pattern of resolution of ODP-M following vitrectomy with posterior vitreous detachment (PVD) induction and scleral tissue plug for treatment of ODP-M without ILM peeling, laser or use of long term gas/tamponade or head positioning. This retrospective study included 7 patients with ODP-M, meeting the inclusion criteria. Patients were followed up for 6 months. Complete anatomical success was defined as "Total resolution of all the fluid in retinal compartments". All of the patients had complete resolution of the optic pit maculopathy following surgery. The mean duration for complete resolution was 18.3 weeks. Pattern of resolution of ODP-M was found to be resolution of the subretinal fluid (SRF) followed by disappearance of the retinoschitic lesions (RL) and finally disappearance of macular edema (ME). The proposed minimally invasive procedure (MIP) can produce comparably good and equally reliable results for the treatment of ODP-M.

Multiple myeloma with plasmacytoma of the clivus bone presenting with multiple cranial nerve III, IV, and VI palsy: A diagnostic dilemma.

Central nervous system (CNS) manifestation with cranial nerve palsy in multiple myeloma (MM) is a rare manifestation. Plasmacytoma originates from the bones of the skull base in 3% patients with MM but rarely develops from the soft tissues of the nasal cavity and paranasal sinuses. Here, we present a case of 68-year-old male patient with multiple myeloma, clivus bone plasmacytoma, and cavernous sinus syndrome.

Management of unusual missed diagnosis of a Intra-orbital wooden foreign body: A case report and review of literature.

Introduction: Although intra-orbital foreign bodies (IOrFBs) are commonly seen in daily ophthalmology practice, rarely, they can have very unusual clinical presentations, especially nonmetallic FBs. Presentation of case: A 33-year-old male presented with sudden onset right lower lid swelling and tearing. He was initially tolerating the symptoms, however, it got progressively worse, so he came two weeks after the initiation of symptoms. His eye vitals were within normal limit, including the visual acuity of 6/6 OU. Additionally, slit lamp and fundus examinations were benign. Concern was for infectious etiology with unclear source. After a lengthy conversation, he recalled falling on the ground with face down about 16 months ago. However, he stated that he had remained asymptomatic and never went for treatment after the incident. Non-contrast CT of head and orbit showed hyperdense tract in medial aspect of right eye adjacent to the globe, piercing across the bilateral ethmoidal sinuses. Thus, a diagnosis of retained IOrbFB was made. He underwent surgery where a 5cm rotten wood was extracted. Post-surgical course was uncomplicated. Not all penetrating intra-orbital foreign bodies present immediately after the incident. In our case the patient remained asymptomatic for 16 months. Conclusion: Therefore, when dealing with an ocular infection of unclear source, clinicians should ask about distant histories of ocular or facial injuries to assess intraocular foreign bodies.

Panophthalmitis secondary to retained intraocular foreign body amidst a national lockdown during the COVID-19 pandemic: A case series and review of literature.

Introduction: Intraocular foreign bodies (IOFBs) can be serious as they may result in vision-threatening ocular inflammations and even loss of the eye. Delay in presentation or treatment by more than 24 hours from the time of injury results in a poor prognosis. In penetrating wounds, microorganisms enter the eye through penetrating objects. Both bacterial and fungal organisms are responsible for causing panophthalmitis. At the ocular level, these microorganisms produce irreversible damage which includes keratitis, uveitis, hypopyon, vitreous abscesses, retinal necrosis, detachment, and, finally, panophthalmitis. Case scenarios: In this case series, we report three cases of IOFB presenting with panophthalmitis secondary to delay in seeking medical attention. In our cases, there was a delay in the presentation by more than 24 hours of trauma. All cases had panophthalmitis at the time of presentation. In two cases, the causative organism was coagulase-negative staphylococci and in one case it was staphylococcus. Initially, we planned to manage them with intravitreous, intravenous and topical antibiotics till the inflammation subsides, then IOFB removal surgeries were planned. However, in two cases, the clinical presentation worsens with scleral necrosis. Therefore, they had to undergo evisceration. In one case, the antibiotics therapy was enough without IOFB removal surgery to manage her symptoms. All cases recovered uneventfully after the interventions. Discussion/Conclusion: In developing nations, like Nepal, transportation barriers can affect a person's access to health care services. This can be clearly explained from this case series as limited transportation options in rural regions are a major factor for all patients' delayed presentation to the hospital during the time of national lockdown in the second wave of the COVID-19 pandemic. The concerned authority must pay attention to solving such social determinants of health.

Amyotrophic lateral sclerosis and retinal changes in optical coherence tomography: A systematic review and meta-analysis.

INTRODUCTION: Increasing evidence suggests Amyotrophic Lateral Sclerosis (ALS) as a widespread pathological process comprising nonmotor features like fatigue, mild sensory symptoms, cognitive decline, and visual impairment. Measurements of retinal nerve fiber layer (RNFL) thickness using Optical Coherence Tomography (OCT) may correlate with the neurodegeneration associated with ALS. In addition to RNFL thickness, other OCT parameters have been explored in the context of diagnosing ALS and predicting disease severity. In this study, we explore the possibility that OCT parameters of patients with ALS may differ significantly from those of healthy controls and thus serve as biomarkers for the disease and its progression. MATERIALS AND METHODS: Between 2010 and 2021, the PubMed and EMBASE databases were examined for English language literature. ALS severity was assessed using the revised ALS functional rating scale (ALSFRS-R). The pooled mean differences in RNFL thickness between ALS patients and controls were calculated using the Standard Mean Difference (Hedges's g) with a 95% confidence interval (CI) in STATA software version 16. RESULTS: Eleven studies were reviewed for data collection. RNFL thickness was not statistically significantly different between ALS patients (n = 412) and controls (n = 376) (Hedges's g = -0.22; 95% CI: -0.51 to 0.07, I2 = 73.04%, p = .14). However, the thickness of inner nuclear layer was significantly different between ALS patients and controls (Hedges's g = -0.38; 95% CI: -0.61 to 0.14, I2 = 14.85%, p = .00). CONCLUSION: Our meta-analysis found that RNFL thickness as a whole or by individual quadrants was not significantly different between ALS patients and controls while the inner nuclear layer (INL) was substantially thinner.

Acute mountain sickness induced diabetic ketoacidosis managed with hemodialysis: A case report.

INTRODUCTION: The risk of developing ketoacidosis in patients with type 1 diabetes at high altitude is high. Anorexia associated with acute mountain sickness, dehydration and additional exercise associated with climbing exacerbates the generation of ketones and the development of ketoacidosis. CASE PRESENTATION: A 33-year-old gentleman with known history of uncontrolled type 1 diabetes mellitus trekked to Everest Base Camp at an altitude of 3440 m and became unwell. He developed altered sensorium and shortness of breath. He ingested eight tablets of acetazolamide (250 mg each) to address these symptoms. Upon presentation to emergency, he was diagnosed with severe diabetes ketoacidosis (DKA) with shock. Resuscitation was started with fluid, insulin, vasopressors and mechanical ventilation. Despite adequate fluid resuscitation, insulin, bicarbonates and other supportive measures, his acidosis and shock persisted and then managed with hemodialysis. After the first session of hemodialysis, improvement in acidosis and shock was noted. He was successfully extubated and later discharged. DISCUSSION: In this case report, DKA due to acute mountain sickness was complicated by acetazolamide use and noncompliance to his regular insulin intake. There is no proper guideline regarding the role of renal replacement therapy in management of DKA. However, evidence of hemodialysis in DKA is limited to few case reports. Improvement seen in our patient after dialysis is related to dialyzable nature of acetazolamide. CONCLUSION: We present a case of a severe DKA potentially precipitated by acute mountain sickness, use of acetazolamide, noncompliance to his regular insulin intake and managed with hemodialysis in addition to conventional treatment for DKA.

Staphylococcal toxic shock syndrome in a lactating mother with breast abscess: A case report.

INTRODUCTION: The highest risk for Staphylococcal Toxic Shock Syndrome are female patients with pre-existing Staphylococcal vaginal colonization who frequently use contraceptive sponges, diaphragms or tampons. In addition patients with burns, soft tissue injures, retained nasal packing, post-abortion, post-surgical, post intrauterine device placement and abscess formation are also at high risk. CASE PRESENTATION: A 19 years old female complaint of high fever with altered level of consciousness. She also had history of nausea, vomiting, diarrhea and pain on her left breast for 5 days. She developed desquamation on her palms and soles on the day three of her admission to ICU. Ultrasonography of her left breast showed 2*2*1 cm abscess collection and the culture report from breast abscess showed Staphylococcus aureus, sensitive to clindamycin, vancomycin and resistant to methicillin. She showed clinical improvement after commencing vancomycin and clindamycin as per culture sensitivity report of breast abscess. DISCUSSION: Toxic shock syndrome secondary to breast abscess in adult is infrequently reported. The diagnosis of Toxic shock syndrome is made by the Centers for Disease Control and Prevention (CDC) definition. Antibiotics for treatment of this condition should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) in combination with either clindamycin or linezolid. CONCLUSION: Treatment for breast abscess warrants incision and drainage as important as antibiotics with anti-toxin. Focused history, physical examination, and laboratory investigations are crucial for the diagnosis and management of this condition.

Tubercular meningitis presenting as cerebral salt wasting syndrome in an adult: A case report.

INTRODUCTION: Cerebral salt wasting syndrome (CSWS) is a cause of hyponatremia in the setting of intracranial pathologies such as Central Nervous System (CNS) trauma, infections, and tumors. It is important to differentiate CSWS from the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as their management differs. CSWS leads to hypovolemia as opposed to euvolemia or hypervolemia in SIADH. SIADH is managed with fluid restriction and this could worsen CSWS which is managed with adminstration of intravenous crystalloids to correct hyponatremia. CASE SUMMARY: A 42-year-old male was admitted after a week of low-grade fever with easy fatigability, hypersomnolence, and excessive thirst. He had polyuria which started 5 days before presentation, and unintentionally lost 3 kg of weight in the past month. He had orthostatic hypotension, and was dehydrated, but vital signs were normal with the exception of his temperature. Cerebrospinal fluid (CSF) analysis revealed a glucose of 42 mg/dl, protein 170 mg/dl, cell count 28/mm3 with 65% lymphocytes which was consistant with tubercular meningitis. CSF AFB culture was positive in addition to a positive CSF PCR for M. tuberculosis. DISCUSSION: Presentation of CNS infection with tuberculosis may be non-specific and its insidious onset could lead to delayed or missed diagnosis; however persistent constitutional symptoms and signs with history of weight loss and a close contact with tuberculosis may raise the possibility of tuberculosis. Early diagnosis and treatment has an excellent prognosis, but any delay contributes to death and disability despite anti-tubercular drug therapy.CSWS should be managed with salt and volume replacement, but more importantly, the causative CNS insult should also be confirmed and addressed.

Tuberous sclerosis complex-associated neuropsychiatric disorder (TAND) in a low-resource setting - From seizure to psychosis: A case report.

INTRODUCTION: Tuberous sclerosis complex (TSC) patients commonly present with neuropsychiatric symptoms - grouped as TSC-associated neuropsychiatric disorder (TAND) - incorporating Autism Spectrum Disorder (ASD) symptoms, intellectual and learning disabilities, psychiatric and behavioral problems. A structured symptomatic assessment known as the TAND-checklist can be useful in reviewing these symptoms systematically and comprehensively. CASE SUMMARY: A 21-year-old woman presented with delusions of reference, auditory hallucinations, irritability, restlessness, aggressive behavior, new-onset tremors and rigidity in both upper limbs, and refusal of food and medication intake for 1 week. She has a history of several seizure episodes since 3 years of age which was controlled on oral sodium valproate, carbamazepine, and clobazam. MRI revealed tubers in frontal and insular cortex.Ultrasound of the abdomen showed bilateral renal angiomyolipomas. She was diagnosed with TSC with psychotic symptoms. DISCUSSION: TSC2 mutations usually present early with epileptic spasms (ES), complex epilepsies, intellectual and cognitive deficits, cardiac rhabdomyomas, and sub-ependymal giant-cell astrocytomas (SEGAs) with high tuber-to-brain proportions (TBP). There is also a remarkable symptom overlap between autism spectrum disorder (ASD) and TSC with behavioral/psychiatric disorders. Social and behavioral problems seen in our patient may be a manifestation of either TSC, ASD, or both. Cost-effectiveness and pragmatism must be considered for TAND-patients in low-resource settings. While it may be theoretically valid to seek genetic testing, TBP-measurement, and mTOR-inhibitor therapy to address TAND-symptoms, they are impractical when compared to TAND-checklist during follow-up.

Anorectal tuberculosis as a chronic rectal mass mimicking rectal prolapse in a child-a case report.

Tuberculosis of the colon commonly involves the ascending,transverse, or sigmoid colon while rectal involvement in tuberculosis is uncommon and poorly characterized. We report a six-year-old male from Nepal who presented with abdominal pain and difficulty passing stool for two years. On per rectal examination, palpation revealed a circumferential rectal mass. On further evaluation, CT scan showed mural thickening and luminal narrowing in the ano-rectum. Colonoscopy with biopsy showed caseating granuloma and positive acid fast bacilli culture consistent with tuberculosis. After starting anti-tubercular therapy, the patient's abdominal pain resolved and the patient was able to pass stool normally within two weeks. Colonoscopy three months after starting treatment showed complete resolution of the mass. Gastrointestinal tuberculosis should be considered in cases of children from endemic areas who present with a rectal mass.

Acute renal infarction and cardioembolic stroke in a patient with atrial fibrillation and hyperthyroid-induced cardiomyopathy: a case report.

BACKGROUND: Acute renal infarction is a rare entity with varied misleading manifestations resulting in diagnostic delay, misdiagnosis, and treatment leading to renal damage. CASE PRESENTATION: We report the case of a 28-year-old Dalit Nepalese man who presented with sudden onset occipital headache and later developed severe left flank pain. He was diagnosed with posterior cerebral infarction with hemorrhagic transformation and a subsequent acute renal infarction with atrial fibrillation and hyperthyroid-induced cardiomyopathy. He was managed with oral anticoagulant and antithyroid drug. CONCLUSION: A high index of suspicion of acute renal infarction is required in patients with risk factors of thrombosis presenting sudden onset flank pain.