Somatosensory evoked potentials aid prediction after hypoxic-ischaemic brain injury.

Cardiopulmonary resuscitation, basic life support and early defibrillation are leading to more survivors of out-of-hospital cardiac arrest reaching hospital. Once stabilised on an intensive care unit, it can be difficult to predict the neurological outcome using clinical criteria alone, particularly with modern management using sedation, neuromuscular blockade and hypothermia. If we are to prevent ongoing futile life support, it is important to try to identify the majority of patients who, despite best efforts, will not make a meaningful recovery. Somatosensory evoked potentials are widely available electrophysiological tests that can provide an objective biomarker of a poor neurological outcome and assist in predicting the prognosis.

Inflammatory Myositis Secondary to Anti-Retroviral Therapy in a Child; Case Report and Review of the Literature.

Here, we describe a five year old girl with congenital HIV who had a six-week onset of rapidly deteriorating mobility and progressive proximal muscle weakness, associated with a raised Creatine Kinase (CK) level of 4330 U/L [25-200 U/L], subsequently diagnosed with an inflammatory myositis. Potential causes were investigated by paediatric neurology and immunology teams. Her viral load had been undetectable over the preceding two years, excluding a primary HIV myositis. While MRI scanning did not show evidence of definite myositis, a muscle biopsy showed evidence of an inflammatory process, comprising a moderate endomysial, perimysial and perivascular mononuclear (CD8 + T cell) infiltrate with increased MHC expression. No particular features of dermatomyositis or immune-mediated necrotising myopathy were identified and there were no features of an inclusion body myositis.Given the absence of active HIV infection, the role of anti-retroviral medications was considered. She had had a recent switch in medication, from twice daily Raltegravir (an Integrase Strand Transfer Inhibitor, INSTI) to once daily Dolutegravir (an INSTI) while continuing on an established daily protocol of Abacavir and Lamivudine (Nucleoside Reverse Transcriptase Inhibitors). Changing the Dolutegravir back to Raltegravir, in combination with continuing Lamivudine and Abacavir for two months made no difference to her weakness or CK levels. Moreover, this drug regimen had been well-tolerated over the preceding 19 month period. Changing the anti-retroviral regime completely to a single drug class (Protease Inhibitors) of Ritonavir and Darunavir, resulted in a dramatic improvement in her symptomatology. Within ten days she regained the ability to stand and walk, with a reduction in her CK from 1700 U/L at time of switch to 403 U/L [25-200]. This case highlights the potential risk of developing inflammatory myositis from anti-retrovirals even 19 months into treatment.

De-novo simple partial status epilepticus presenting as Wernicke's aphasia.

Language disturbances manifesting as brief periods of speech arrest occur with seizures originating in the frontal or temporal lobes. These language disturbances are usually present with other features of seizures or may occur in an episodic fashion suggesting their likely epileptic origin. Sustained but reversible aphasia as the sole manifestation of partial status epilepticus is rare, particularly without a history of prior seizures. A few cases have been described in the literature where Broca's or mixed aphasia seems to be more common than Wernicke's aphasia. Here we describe a patient who presented with Wernicke's aphasia secondary to simple partial status epilepticus but without any other features of seizures. The diagnosis was confirmed on EEG and the aphasia reversed after antiepileptic treatment.

Distal ulnar neuropathy in a golf player.

A 51-year-old right-handed amateur golfer has developed fasciculations in the left first dorsal interosseous muscle for 3 weeks. He did not have any pain or motor or sensory deficit. The nerve conduction study and electromyography showed that he had mononeuropathy of the deep palmar branch of the ulnar nerve in his left palm. The forceful grasp of golf club handle in the left palm contributes to this rare focal neuropathy. He was advised to change his grip on the golf club, and the symptom resolved almost immediately.