Spectrum of Neurological Manifestations of COVID-19 Data from a Tertiary Care Hospital.

Background: Coronavirus is a novel virus which has disrupted life in the past year. While it involves the lungs in the majority and this has been extensively studied, it involves other organ systems. More number of studies need to be focused on the extrapulmonary manifestations of the disease. Objective: To delineate the clinical manifestations of coronavirus disease 2019 (COVID-19) virus on the central and peripheral nervous systems and to assess the risk factors and the outcome of COVID-19 patients with neurological manifestations. Materials and Methods: All patients who were SARS-CoV-2 RNA polymerase chain reaction (PCR) positive were assessed, and detailed clinical history and laboratory findings were collected. Data was analyzed using percentage, mean, and frequency. Results: Out of 864 patients, 17 (N = 17, 1.96%) had neurological manifestations. Twelve out of 17 had comorbid conditions. Patients had diverse presentations ranging from acute cerebrovascular accident to paraplegia and encephalopathy. Ten (58.8%) patients presented with acute cerebrovascular accidents. Of the patients who developed stroke, five (50%) died. Conclusions: COVID-19 usually presents as a respiratory disease. The neurological manifestations of COVID-19 are not uncommon. One should be aware of a wide spectrum of neurological signs and symptoms of COVID-19 for early diagnosis and treatment for preventing mortality and morbidity.

Facial muscle contraction in response to mechanical stretch after severe facial nerve injury: Clapham's sign.

INTRODUCTION: Following the onset of facial palsy, physiotherapists routinely inspect the inside of the patient's mouth and cheek for complications such as ulceration or trauma. In several patients with complete facial nerve palsy, it was noticed that when the cheek was stretched there was subsequent spasm of the muscles of facial expression. This also occurred in patients whose facial nerve had been transected. CASE REPORTS: We present four patients in whom this response was demonstrated. We consider the mechanism of this response and its relevance in the management of patients with facial paralysis. CONCLUSION: Following severe or complete denervation, contraction of the facial muscles following mechanical stretch provides evidence of preservation of activity in the facial muscle's excitation-contraction apparatus. Further research will investigate the clinical significance of this sign and whether it can be used as an early predicator of the development of synkinesis, as well as its relevance to facial nerve grafting and repair.

Spectrum of Acute Viral Hepatitis in Southern India.

BACKGROUND: The incidence of hepatitis-A among adults in India is on the decline as majority develops protective immunity to it by late adolescence. Most of these studies are from northern India. Clinical spectrum of sporadic acute viral hepatitis from southern India has not been well documented. METHODS: A prospective hospital based study was conducted in a large military hospital in southern India. 224 consecutive patients with acute viral hepatitis were studied for their presentation, etiology and clinical features. RESULT: Hepatitis-E was detected in 102 (45.4%), hepatitis A in 74 (33%) and hepatitis B in 28 (12.5%) patients. Acute hepatitis C was detected in two patients. 15 patients had a mixed infection. Hepatitis A constituted 41.2% and 31.3% of all cases in the age groups 11-20 and 21-30 years respectively. Cholestasis was present in 68 (30.4%) patients with hepatitis E accounting for most (61.8%) cases. There were four (1.8%) cases of acute liver failure. Two cases were due to hepatitis E and one case each was due to hepatitis A and hepatitis B. A relapsing course was seen in four cases due to hepatitis-A. CONCLUSION: Hepatitis A remains a significant cause of sporadic acute viral hepatitis in young adults in southern India.

Differences in motor activation of voluntary and reflex cough in humans.

OBJECTIVES: To study motor activation patterns of voluntary and reflex cough adjusted for cough flow rates. METHODS: Surface electromyography (EMG) and cough flow rate were measured in 10 healthy volunteers. Voluntary cough was assessed for 20 efforts in each quintile of increasing cough flow rate. Reflex cough was assessed for 25 efforts produced by nebulised l-tartaric acid. EMG was recorded over the expiratory (rectus abdominis, obliques, lower intercostals) and accessory (trapezius, pectoralis major, deltoid, latissimus dorsi) muscles. EMG activity, burst duration and onset were compared for each quintile of voluntary cough, and between voluntary and reflex cough matched for cough flow rate. RESULTS: EMG activity and burst duration of expiratory and accessory muscles during voluntary cough increased in proportion to cough flow. Expiratory muscles had longer EMG burst duration (difference 68 ms (95% CI 34 to 102), p<0.01) and earlier onset of EMG activity (difference 44 ms (95% CI 20 to 68), p<0.0001) compared with accessory muscles. EMG activity in all muscles was increased (mean 110.2% v 56.1%, p<0.001) and burst duration (mean 206 ms v 280 ms, p = 0.013) decreased in reflex cough compared with voluntary cough of equal flow rate. There were no differences in EMG onset (difference 8 ms (95% CI 25 to -9) or burst duration (difference 27 ms (95% CI 58 to -4) between expiratory and accessory muscles. CONCLUSIONS: Functional organisation of motor activity differs between voluntary and reflex cough. Voluntary cough is characterised by sequential activation whereas reflex cough is associated with early and simultaneous activation of expiratory and accessory muscles.

Motor control of rapid sequential finger tapping in humans.

We investigated in 29 healthy subjects a simple model of rapid independent finger movement: the rapid sequential tapping of adjacent fingers. Inter-tap interval (ITI) was measured for adjacent pairs of fingers in each direction. ITI was shorter in the ulnar-->radial direction than in the reverse direction [P < 0.001 for middle to index (M-->I) compared with index to middle (I-->M)]. There was a gradient across the hand such that in the ulnar-->radial direction, little to ring (L-->R) tapping was fastest and M-->I slowest; in the radial-->ulnar direction, the reverse was the case. Rectified surface electromyography (EMG) from finger extensors and flexors was averaged with respect to either the first or second tap. The interval between the flexor EMG burst and the tap was similar irrespective of the order of finger tapping, excluding a mechanical explanation of the timing difference. Transcranial magnetic stimulation (TMS) was applied at 0- to 50-ms intervals after the first tap. Interposed TMS delayed the second tap significantly more (P < 0.001) in the M-->I direction than in the I-->M direction. Motor-evoked potentials (MEPs) evoked by TMS interposed between taps showed a greater facilitation in the M-->I than in the I-->M direction (P < 0.001). Increasing intensity of TMS rendered subjects unable to produce the second tap, more frequently in the I-->M direction than in the M-->I direction. We have demonstrated a consistent pattern across the hand and postulate that finger-order-dependent differences in ITI and the gradient of these across the hand may reflect the mechanism of grasping and further that the cortical programming of finger tapping differs depending on finger order.

Transcutaneous cervical root stimulation in the diagnosis of multifocal motor neuropathy with conduction block.

OBJECTIVES: To determine if transcutaneous electrical stimulation of the cervical roots can be used to diagnose proximal conduction block (CB) in multifocal motor neuropathy (MMN) and whether it can reliably distinguish MMN from amyotrophic lateral sclerosis (ALS). METHODS: Compound muscle action potentials (CMAPs) over the abductor digiti minimi (ADM) were evoked by supramaximal stimulation of the ulnar nerve at the wrist, below elbow, above elbow, axilla, Erb's point, and C8/T1 cervical roots in three groups of patients: 31 patients with ALS, nine patients with MMN, and 31 controls. Supramaximal stimulation at Erb's point and the C8/T1 roots was carried out using a transcutaneous high voltage electrical stimulator. The negative peak amplitude, area, and duration of the CMAP were measured and normalised to that from the wrist. The percentage change in each segment in these parameters was calculated and compared between the different groups. RESULTS: At stimulation sites proximal to the elbow, there were no significant differences in relative CMAP amplitude, area, or duration between controls, ALS patients, and MMN patients with clinically unaffected ulnar nerves. Similarly, the percentage segmental change between adjacent stimulation sites showed no significant differences. In six studies of MMN patients with weakness in ulnar hand muscles, the decrease in CMAP amplitude between the C8/T1 roots and Erb's point exceeded the mean + 2 SD of the control data. CONCLUSION: Cervical root stimulation can quantify CB in the most proximal segment of the ulnar nerve, a fall in CMAP amplitude if greater than 25%, indicating block, and should be used routinely in the evaluation of patients suspected of having MMN, especially when distal stimulation has proved unhelpful.