The emergence of parvovirus B19 as a pathogen in acute encephalitis syndrome.

Despite scarcity of data, in recent years, human parvovirus B19 (PVB19) has been emerging as an important pathogen in acute encephalitis syndrome (AES). But, PVB19 virus is mostly looked for only after the exclusion of other common pathogens implicated in AES. Hence, this study was conducted to correlate clinical, radiological, and sequencing data to establish the crucial role of PVB19 in AES. Cerebrospinal fluid and/or serum samples were collected from AES patients as per WHO criteria and tested by ELISA, real-time PCR and bacterial culture sensitivity for various pathogens. PVB19 positive samples were subjected to sequencing. PVB19 attributed to 5% of total AES cases in the present study with fatalities in two of eight cases. Two isolates of PVB19 belonged to Genotype 1 A whereas one belonged to Genotype 3B. On multivariate analysis of predictive symptoms of PVB19 AES cases, blurring of vision (odds ratio [OR] 20.67; p = 0.001) was found to be significant independent predictor of PVB19 AES. Six of eight patients (two encephalitis specific and four nonspecific) had abnormal radiological findings. Hence, being an emerging viral pathogen, PVB19 should be included in the diagnostic algorithm of AES for prompt diagnosis and definitive management to prevent undesired neurological sequelae.

Diagnostic Accuracy of Ocular Ultrasonography in Identifying Raised Intracranial Pressure among Pediatric Population.

INTRODUCTION: Role of CT scan, MRI, ophthalmoscopy, direct monitoring by a transducer probe in identifying raised intracranial pressure (ICP) in emergency department is limited. There are few studies correlating elevated optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS) with raised ICP in pediatrics emergencies. We studied the diagnostic accuracy of ONSD, crescent sign, and optic disc elevation in identifying increased ICP in pediatrics. METHODS: Prospective observational study was done between April 2018 and August 2019 after ethics approval. Out of 125 subjects, 40 patients without clinical features of raised ICP were recruited as external controls and 85 with clinical features of raised ICP as study subjects. Their demographic profile, clinical examination, and ocular ultrasound findings were noted. This was followed by CT scan. Out of 85 patients, 43 had raised ICP (cases) and 42 had normal ICP (disease controls). Diagnostic accuracy of ONSD in identifying raised ICP was evaluated using STATA. RESULTS: The mean ONSD in case group was 5.5 ± 0.6 mm, 4.9 ± 0.5 mm in disease control group and external control group was 4.8 ± 0.3 mm. Cut-off of ONSD for raised ICP at ≥4.5 mm had a sensitivity and specificity of 97.67% and 10.98%, while ≥5.0 mm showed a sensitivity and specificity of 86.05% and 71.95%. Crescent sign and optic disc elevation had good correlation with increased ICP. CONCLUSION: ONSD ≥5 mm by POCUS identified raised ICP in pediatric population. Crescent sign and optic disc elevation may function as additional POCUS signs in identifying raised ICP.

Multidetector computed tomography evaluation of normal thymus and variations with age.

Background: Thymus is a T-cell-producing lymphoid organ that appears prominent in the paediatric population and involutes in size with ageing. The gland shows a wide variety of appearances across different age groups. The purpose of the study is to evaluate the computed tomography (CT) appearance of thymus gland in the normal population with a focus on size, CT attenuation and fatty infiltration in different age groups. Patients and Methods: This is a retrospective study done after taking approval from the Institutional Ethics Committee. Patients undergone CT scans of the thorax were identified from our database. All evaluations were done in non-contrast CT scans. Patients having underlying diseases that may have associated thymic abnormality were excluded. The appearance of thymus and the presence of fatty replacement were assessed. The size of thymus (length and thickness of right limb and left limb) and non-contrast CT Hounsfield unit (HU) value of thymic tissue were measured and compared in various age groups. Results: Four hundred and fifty patients were included, 262 (58.2%) were male. Mean age was 33.6 ± 17.1 years, range (3 months-80 years). The size of thymus was observed to decrease with increasing age. The mean age of complete fatty replacement in our study was 45 years. Complete fatty replacement was noted in all cases with an age of more than 60 years. The most common shape was arrowhead, and the most common location was pre-aortic and para-aortic location. Non-contrast CT HU value was maximum in infants and gradually decreased with advancing age. Conclusion: Even normal thymus can show varied appearance on CT which changes with the age of the patient being imaged. A comparison with normative data could help differentiate normal from abnormal glands to avoid unnecessary intervention.

Guillain-Barre syndrome as the initial presentation of systemic lupus erythematosus: Case report with a systematic and literature review.

Systemic lupus erythematosus (SLE) can affect multiple systems in which central nervous system (CNS) involvement is common, but peripheral nervous system involvement is also increasingly being recognized. Guillian-Barre syndrome (GBS) as the first manifestation of SLE has been reported, but rare and not well understood. A 39-year female presented with GBS-like illness but on evaluation found to have features of SLE. Cerebrospinal fluid (CSF) showed characteristic albuminocytological dissociation and nerve conduction study (NCS) was suggestive of demyelinating polyradiculoneuropathy. On evaluation, she was found to have polyarthralgia, autoimmune hemolytic anemia, class I Lupus nephritis, mild splenomegaly, and pleural effusion. Serum antinuclear antibody was 4+ positive (coarse speckled) and extractable nuclear antigen profile revealed anti-dsDNA and anti-Sm antibody positivity, with low complement level. She fulfilled the diagnostic criterion of SLE and was managed with both plasmapheresis and pulse steroids followed by cyclophosphamide monthly pulse and oral hydroxychloroquine maintenance and showed significant improvement. The literature review showed only 26 cases reported till now. GBS without any obvious trigger should be extensively evaluated, as the underlying etiology will affect the treatment protocol as well as the prognosis. Our report highlights the significance of early recognition of SLE as a trigger of GBS, which changes conventional GBS treatment.

Factors predicting perioperative outcomes in patients with myasthenia gravis or thymic neoplasms undergoing thymectomy by video-assisted thoracoscopic approach.

BACKGROUND: The purpose of this study was to identify the factors which predict the perioperative outcomes after video-assisted thoracoscopic surgery (VATS) thymectomy in patients with myasthenia gravis (MG) or thymic neoplasms. PATIENTS AND METHODS: Data of consecutive patients who had undergone VATS thymectomy in our institution from August 2016 to April 2018 were collected retrospectively from a prospectively maintained database followed by prospective recruitment of patients who underwent VATS thymectomy from April 2018 to February 2020. RESULTS: A total of 31 patients were included. Females were more common (51.6%), and 29 patients (93.5%) had MG. The most common indication for thymectomy was the presence of both MG and thymoma (51.6%). Most MG patients had moderate disease (55.2%) or severe (24.1%) disease preoperatively. Mean operative time and blood loss were 196.9 ± 63.5 min and 122.5 ± 115.3 ml, respectively. Mean hospital stay was 7.9 ± 6.7 days. The rate of major and minor complications was 16.18% and 35.4%, respectively. Multivariate linear regression analysis established that MG symptoms >12 months, prolonged invasive ventilation (intubation ≥24 h), and complications were associated significantly with a prolonged hospital stay. Adjusting for outliers, pre-operative disease severity (MG Foundation of America class), and intubation ≥24 h were the only factors that had a significant impact on perioperative outcomes. CONCLUSION: Pre-operative disease severity and post-operative invasive ventilation are strong determinants of perioperative outcomes. Pre-operative optimisation and early extubation protocols can further reduce morbidity in patients undergoing thymectomy by the VATS approach.

A Study of Hyponatremia in Acute Encephalitis Syndrome: A Prospective Study From a Tertiary Care Center in India.

PURPOSE:: To evaluate the frequency and causes of hyponatremia in acute encephalitis syndrome (AES) and its effect on outcome. PATIENTS AND METHODS:: Consecutive patients with AES were subjected to neurological evaluation including Glasgow Coma Scale, focal weakness, movement disorder, and reflex changes. The etiology of AES was based on blood and cerebrospinal fluid enzyme-linked immunosorbent assay and polymerase chain reaction. We have categorized patients into neurological or systemic AES. Hyponatremia was diagnosed if 2 consecutive serum sodium levels were below 135 mEq/L, 24 hours apart. Serum and urinary osmolality and electrolytes were measured on alternate days. Fluid intake, output, and body weight were measured daily. The hyponatremia was categorized into syndrome of inappropriate secretion of antidiuretic hormone (SIADH), cerebral salt wasting (CSW), or miscellaneous group. Outcome at 1 month was assessed by modified Rankin scale. RESULTS:: Of 79 patients, 34 had neurologic AES and 45 had systemic AES; 22 (27.8%) patients had hyponatremia. The neurologic AES as compared to systemic AES was more commonly associated with hyponatremia (38.2% vs 20%, P = .07), need longer hospitalization (25.0 vs 12.5 days, P = .003), and longer time for sodium correction (13.3 vs 8.2 days, P = .05). The hyponatremia was due to CSW in 12 patients, SIADH in 2 patients, and indeterminate in 8 patients. Thirty-six patients had poor outcome (15 died) and 43 had good outcome which was not related to hyponatremia. CONCLUSION:: Hyponatremia occurs in one-third of patients with AES, being commoner in neurologic AES, and CSW is the commonest cause.

Early and rapid detection of UCHL1 in the serum of brain-trauma patients: a novel gold nanoparticle-based method for diagnosing the severity of brain injury.

The clinical diagnosis of traumatic brain injury (TBI) is based on neurological examination and neuro-imaging tools such as CT scanning and MRI. However, neurological examination at times may be confounded by consumption of alcohol or drugs and neuroimaging facilities may not be available at all centers. Human ubiquitin C-terminal hydrolase (UCHL1) is a well-accepted serum biomarker for severe TBI and can be used to detect the severity of a head injury. A reliable, rapid, cost effective, bedside and easy to perform method for the detection of UCHL1 is a pre-requisite for wide clinical applications of UCHL1 as a TBI biomarker. We developed a rapid detection method for UCHL1 using surface plasmon resonance of gold nanoparticles with a limit of detection (LOD) of 0.5 ng mL-1. It has a sensitivity and specificity of 100% each and meets an analytical precision similar to that of conventional sandwich ELISA but can be performed rapidly. Using this method we successfully detected UCHL1 in a cohort of 66 patients with TBI and were reliably able to distinguish mild TBI from moderate to severe TBI.

Role of MR spectroscopy in diagnosis of intracranial neuroenteric cyst.

INTRODUCTION: Neuroenteric cysts are rare benign endodermal lesions of the central nervous system that result from incomplete resorption of neuroenteric canal and mostly found in cervical and upper thoracic spinal canal. Intracranial neuroenteric cysts are extra axial and commonly located anteriorly in the posterior cranial fossa. MRI demonstrates variable intensity within the lesion on T1, T2W, and DWI sequences. METHODS: Three cases of posterior fossa non-enhancing cystic lesions of variable signal intensity underwent MRI with MR spectroscopy, where MR spectroscopy demonstrated dominant peak at 2 ppm, mimicking normal Nacetyl aspartate (NAA). CONCLUSION: MR spectroscopy in addition to conventional MRI may help in differentiating intracranial neuroenteric cyst from its close differentials.

Does adjunctive corticosteroid and aspirin therapy improve the outcome of tuberculous meningitis?

BACKGROUND: Stroke is common in tuberculous meningitis (TBM), and aspirin has been shown to reduce mortality. A combination of aspirin and corticosteroid may be more useful in this condition. AIM: To evaluate the effect of aspirin and corticosteroid adjunctive therapy alone or in combination in determining the outcome of TBM. MATERIALS AND METHODS: One hundred and fifty-three patients with TBM were evaluated from a prospectively maintained registry. The diagnosis of TBM was based on the clinical, magnetic resonance imaging (MRI)/computed tomography (CT), and cerebrospinal fluid criteria. The baseline clinical, laboratory, and radiological findings were noted. All patients received the standard 4-drug antituberculous (rifampicin, isoniazid, pyrazinamide, and ethambutol) treatment. Group I patients received in addition, aspirin, in the dose of 150 mg daily; group II patients received aspirin 150 mg plus prednisolone 40 mg daily; and, group III patients received none of these adjunctive therapies. The outcome at 3 months was defined in terms of death or functional disability. RESULTS: Group I had 44, group II had 50, and group III had 41 patients. The baseline characteristics of all these patients were similar, except in group II, where patients had more severe meningitis and focal deficits compared to the patients in group I and III. At 3 months, 32 (23%) patients died; 8 (18.2%) in group I, 9 (18%) in group II, and 14 (34.1%) in group III. There was insignificant survival benefit in group II (hazard ratio [HR], 1.55; 95% confidence interval (CI), 0.96-26.49; P = 0.07). The three-month functional outcome and side effects were not significantly different in the three groups. CONCLUSION: Aspirin with corticosteroid adjunctive treatment seems to be beneficial in reducing mortality in TBM.

Cerebral Venous Sinus Thrombosis Presenting Feature of Systemic Lupus Erythematosus.

BACKGROUND: CVST (cerebral venous sinus thrombosis) may sometimes be associated with autoimmune disorders that require specific treatment. The clinical and magnetic resonance imaging (MRI) findings of systemic lupus erythematosus (SLE) patients with CVST are presented and contrasted with CVST without SLE. METHODS: Consecutive patients with CVST admitted in neurology service during 2012-2016 were included. The diagnosis of CVST was confirmed by MR venography or digital subtraction angiography. SLE was diagnosed according to American College of Rheumatology criteria. The clinical and MRI findings of CVST with SLE and those without SLE were compared. RESULTS: Forty-three consecutive patients with CVST were included during the study period, 3 of whom had SLE .Their age ranged between 20 and 35 years and all were females. The clinical markers of SLE were present in all and included oral ulceration in 3 patients, serositis in 2 patients, and arthritis and psychosis in 1 patient. The SLE patients did not have antiphospholipid antibodies or lupus anticoagulant. The manifestation of CVST in SLE was similar to the other patients with CVST. The CVST in SLE required long-term anticoagulation and immunosuppression with cyclophosphamide pulse in 1 patient and oral prednisolone in 2 patients. The outcome was good, partial, and poor in 1 patient each. CONCLUSIONS: CVST may be the presenting feature of SLE, but these patients often have clinical clues to SLE. These patients need prolonged anticoagulation and immunosuppression.

Correlation between Vertebral Marrow Fat Fraction in MRI Using DIXON Technique and BMD in DXA in Patients of Suspected Osteoporosis.

Aim Osteoporosis is a common metabolic bone disease accounting for low back pain (LBP). It is diagnosed by dual-energy X-ray absorptiometry (DXA). Magnetic resonance imaging (MRI), a routine investigation for LBP, is also sensitive to detect fat fraction (FF) of the vertebral body that increases with increasing age. This study aimed to correlate vertebral marrow FF using MRI and bone mineral density (BMD). Material and Methods Patients presenting with low backache and suspected osteoporosis were included. All patients underwent an MRI of lumbosacral spine and DXA. Patients were categorized into an osteoporotic and a nonosteoporotic group based on the T-score obtained from DXA. "T-scores" of < -2.5 on BMD were considered as osteoporotic spine. T-score of > -2.5 was considered as nonosteoporotic. The FF obtained from the DIXON sequence of MRI was correlated between the two groups. Result Thirty-one patients were included with a mean age of 54.26 ± 11.6 years. Sixteen patients were osteoporotic based on the defined criteria in the methods. The mean vertebral marrow FF was significantly higher in the osteoporotic patients (64.98 ± 8.8%) compared with the nonosteoporotic (45.18 ± 13.2%) ( p = 0.001). The mean FF of the vertebra having fracture (69.19 ± 7.73%) was significantly higher than that of patients without fracture (57.96 ± 5.75%) ( p = 0.03). Taking a cutoff value of vertebral marrow FF of 54.85, the sensitivity and specificity of diagnosing osteoporosis were 93 and 80%, respectively, with a confidence interval of 95%. The area under the curve was 0.925. Conclusion Increased vertebral marrow FF is noted in the osteoporotic spine. FF has an inverse correlation with the T-score obtained from BMD. MRI with FF measurement can provide indirect evidence of osteoporosis, which can be done under one roof, especially in young patients where we need to avoid ionizing radiation.

Perfusion MRI in Cerebral Venous and Sinus Thrombosis.

BACKGROUND AND PURPOSE: Cerebral venous and sinus thrombosis (CVST) leads to perfusion abnormality in the brain. Our aim was to assess perfusion abnormalities in the center and periphery of the parenchymal lesion in CVST patients and correlate with the clinical outcome. MATERIALS AND METHODS: Dynamic susceptibility contrast (DSC) perfusion imaging was performed in patients with CVST. Relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and mean transit time (MTT) values were obtained in the center and periphery of the parenchymal lesion. RESULTS: A total of 30 consecutive patients of CVST were included in the study. Parenchymal lesion was present in 21 (70%) patients. In rest 9, perfusion map was showing some abnormality although conventional MRI was normal. Mean rCBV and MTT were increasing from periphery of the lesion to the center (rCBV 69.93 ± 29.79 at periphery (PL2) to 92.49 ± 32.07 at center of the lesion and 69.19 ± 25.52 at normal appearing contralateral brain parenchyma (NABP). MTT 11.83 ± 3.76 at periphery (PL2) to 15.27 ± 5.49 at center of the lesion and 10.63 ± 3.37 at NABP). rCBV and MTT from abnormal perfusion areas from 9 patients without parenchymal abnormalities are 92.89 ± 17.76 and 15.92 ± 3.66 respectively. CONCLUSION: There is an increasing trend of MTT and rCBV from periphery to center of the parenchymal lesion. MTT is the most consistent parameter to be abnormal in patients of CVST even in patients without parenchymal lesion. Residual neurological deficit was found in patients with increased rCBV and having large hemorrhagic infarct.

From periphery to center, untold story of pure neuritic leprosy: an electrophysiological study.

BACKGROUND: Pure neuritic leprosy (PNL) is uncommon form of leprosy involving peripheral nerves. Some isolated case reports have shown imaging changes in the central nervous system (CNS) and also impairment in visual evoked potential (VEP), somatosensory evoked potential (SSEP) and brain stem auditory-evoked potentials (BAEPs) parameters in PNL, but there is lack of large study. This prospective observational study evaluates impairment in these central conduction studies among PNL patients. METHODS: We screened patients with leprosy presenting with features of neuropathy and/or thickened nerves. Patients with bacilli-positive nerve biopsies were included in the study and subjected to routine tests along with nerve conduction study (NCS), VEP, tibial SSEP and BAEPs. Parameters of these studies were analyzed based on data from previous studies. RESULTS: Of 76 patients screened for PNL 49 had positive findings in biopsy. Most of patients were male and mean age group was 46.35 ± 15.35 years. Mononeuritis multiplex was most common NCS pattern in 46.93% (23/49) patients. We found abnormal VEP in 13 out of 35 patients (37.14%). Similarly abnormal SSEP and BAEPs among 42.85% and 40% patients respectively. DISCUSSION: This study shows that in PNL significant number of patients have subclinical CNS involvement. Exact pathophysiology of CNS involvement is not known till now but study of VEP, SSEP and BAEPs parameter may help in early diagnosis of PNL.

Diffusion-Weighted Imaging and Chemical Shift Imaging to Differentiate Benign and Malignant Vertebral Lesion: A Hospital-Based Cross-Sectional Study.

Objective The aim of this study was to evaluate the role of diffusion-weighted imaging (DWI) and chemical shift imaging (CSI) for the differentiation of benign and malignant vertebral lesions. Methods Patients with vertebral lesions underwent routine magnetic resonance imaging (MRI) along with DWI and CSI. Qualitative analysis of the morphological features was done by routine MRI. Quantitative analysis of apparent diffusion coefficient (ADC) from DWI and fat fraction (FF) from CSI was done and compared between benign and malignant vertebral lesions. Results Seventy-two patients were included. No significant difference was noted in signal intensities of benign and malignant lesions on conventional MRI sequences. Posterior element involvement, paravertebral soft-tissue lesion, and posterior vertebral bulge were common in malignant lesion, whereas epidural/paravertebral collection, absence of posterior vertebral bulge, and multiple compression fractures were common in benign vertebral lesion ( p < 0.001). The mean ADC value was 1.25 ± 0.27 mm 2 /s for benign lesions and 0.9 ± 0.19 mm 2 /s for malignant vertebral lesions ( p ≤ 0.001). The mean value of FF was 12.7 ± 7.49 for the benign group and 4.04 ± 2.6 for the malignant group ( p < 0.001). A receiver operating characteristic (ROC) curve analysis showed that an ADC cutoff of 1.05 × 10 -3 mm 2 /s and an FF cutoff of 6.9 can differentiate benign from malignant vertebral lesions, with the former having 86% sensitivity and 82.8% specificity and the latter having 93% sensitivity and 96.6% specificity. Conclusion The addition of DWI and CSI to routine MRI protocol in patients with vertebral lesions promises to be very helpful in differentiating benign from malignant vertebral lesions when difficulty in qualitative interpretation of conventional MR images arises.

Shoulder Dysfunction and Quality of Life Following Modified Radical and Selective Neck Dissection: A Prospective Comparative Study.

Head and neck cancers are fairly common in India due to the widespread consumption of tobacco and neck dissection is a major component in the surgical management. The objective of this study is to analyze the effect of MRND and SND on shoulder function and quality of life in patients of head and neck cancer. Our study is a prospective comparative study on 65 head and neck cancer patients divided into 2 groups-33 in group A (MRND group) and 32 in group B (SND group). Clinical evaluation of shoulder function was done pre-operatively, 1 week, 1 month, 3 month and 6 month post-operatively using arm abduction scores (AAS) and shoulder pain and disability index (SPADI). Nerve-conduction study (NCS) was done pre-operatively and 3 months post-operatively for assessment of SAN. Neck dissection quality of life questionnaire (NDQOL) was used as a quality-of-life measure. A total of 65 neck dissections were included in the analysis (33 in group A and 32 in group B) out of which 53 were males and 12 were females. The mean AAS on the 6th post-operative month in group A was significantly lower than that of group B (p = 0.01). The mean SPADI scores on the 6th post-operative month was significantly worse in group A than group B (p value 0.01). On NCS, a significant decrease in amplitude was seen in group A (p = 0.02) and a significant increase in latency was noted in group B (p = 0.005). Quality of life score on 6th post-operative month showed no significant difference between both the groups (p > 0.05). Level V dissection in MRND is associated with higher incidence and greater severity of shoulder dysfunction. AAS and SPADI score are useful tools in post operative follow up of shoulder dysfunction. NCS helps in the detection of neuropathy and to determine its severity. Early rehabilitation promotes long term recovery.

Super refractory status epilepticus as a possible manifestation of COVID-19 disease.

Coronavirus disease 2019 (COVID-19) is one of the worst pandemics in history, caused by severe acute respiratory syndrome coronavirus-2, a novel zoonotic coronavirus. COVID-19 disease can present from asymptomatic or mild infection to rapidly progressive, acute respiratory distress syndrome, and death. Neurological presentation is not so uncommon now. Super refractory status epilepticus (SRSE) can be a possible manifestation of COVID-19 disease. Here, we report a patient affected by COVID-19 who presented with SRSE.

Craniospinal MRI Findings in Neuromelioidosis.

Background: Melioidosis is a bacterial infection caused by Burkholderia pseudomallei that is endemic in Southeast Asia, northern Australia, and Africa. Neurological involvement is rare and reported in 3-5% of total cases. Objective: The purpose of this study was to report a series of cases of melioidosis with neurological involvement and a brief review of the literature. Materials and Methods: We collected the data from six melioidosis patients having neurological involvement. Clinical, biochemical, and imaging findings were analyzed. Result: All patients in our study were adults (age range 27 to 73 years). The presenting symptoms were fever of varying duration (range 15 days to 2 months). Altered sensorium was noted in five patients. Four cases had brain abscess, one had meningitis, and one had a spinal epidural abscess. All cases of brain abscesses were T2 hyperintense with an irregular wall showing central diffusion restriction and irregular peripheral enhancement. The trigeminal nucleus was involved in one patient, but there was no enhancement of the trigeminal nerve. Extension along the white matter tract was noted in two patients. Magnetic resonance (MR) spectroscopy done in two patients showed increased lipid/lactate and choline peak in both of them. Conclusion: Melioidosis can present as multiple micro-abscesses in the brain. Involvement of the trigeminal nucleus and extension along the corticospinal tract may raise the possibility of infection by B. pseudomallei. Meningitis and dural sinus thrombosis, although rare, can be presenting features.