Evaluation of the epidemiologic, clinical, radiologic, and treatment methods of patients with subacute and chronic meningitis.

BACKGROUND: Meningitis is known as a meningeal inflammation accompanied by pleocytosis in the cerebrospinal fluid (CSF), and can be classified into acute, subacute, and chronic meningitis based on symptoms duration of ≤ 5 days, ≥ 5 days and ≥ 4 weeks, respectively. Subacute and chronic meningitis are caused mainly by indolent infectious agents and noninfectious causes such as autoimmune, and neoplastic. In this study, we investigated the characteristics, diagnosis, and treatment of subacute and chronic meningitis. METHODS: We extracted the medical records of patients with chronic and subacute meningitis who were referred to three tertiary centers from Jun 2011 to Jun 2021. Initially, 2050 cases of meningitis were screened, and then 79 patients were included in the study. RESULTS: Headache (87.3%), nausea and vomiting (74.7%), fever (56.4%), and visual impairments (55.7%) were the most prevalent symptoms. The most common signs were nuchal rigidity (45.3%), altered mental status (26.9%), and papillary edema (37.5%). Brain computed tomography (CT) was normal in 68.6% of the patients while 22.9% of the cases had hydrocephalus. Brain magnetic resonance imaging (MRI) was normal in 60.0% of the patients. The most common abnormal MRI findings were leptomeningeal enhancement (16.0%) and hydrocephalus (16.0%). We had a 44.3% definite diagnosis with bacterial (n:25, 31.6%) and neoplastic (n:8, 10.1%) being the most prevalent etiologies. Mycobacterium tuberculosis (60%) and Brucella spp. (12%) were the most prevalent bacterial pathogens. CONCLUSIONS: The most common etiologies include infectious, neoplastic, and immunologic. Due to insidious presentation and uncommon etiologies, establishing a proper diagnosis, and providing timely targeted treatment for patients with subacute and chronic meningitis remains a challenge for clinicians.

Neurological manifestations as the predictors of severity and mortality in hospitalized individuals with COVID-19: a multicenter prospective clinical study.

BACKGROUNDS: The reports of neurological symptoms are increasing in cases with coronavirus disease 2019 (COVID-19). This multi-center prospective study was conducted to determine the incidence of neurological manifestations in hospitalized cases with COVID-19 and assess these symptoms as the predictors of severity and death. METHODS: Hospitalized males and females with COVID-19 who aged over 18 years were included in the study. They were examined by two neurologists at the time of admission. All survived cases were followed for 8 weeks after discharge and 16 weeks if their symptoms had no improvements. RESULTS: We included 873 participants. Of eligible cases, 122 individuals (13.97%) died during hospitalization. The most common non-neurological manifestations were fever (81.1%), cough (76.1%), fatigue (36.1%), and shortness of breath (27.6%). Aging, male gender, co-morbidity, smoking, hemoptysis, chest tightness, and shortness of breath were associated with increased odds of severe cases and/or mortality. There were 561 (64.3%) cases with smell and taste dysfunctions (hyposmia: 58.6%; anosmia: 41.4%; dysguesia: 100%). They were more common among females (69.7%) and non-smokers (66.7%). Hyposmia/anosmia and dysgeusia were found to be associated with reduced odds of severe cases and mortality. Myalgia (24.8%), headaches (12.6%), and dizziness (11.9%) were other common neurological symptoms. Headaches had negative correlation with severity and death due to COVID-19 but myalgia and dizziness were not associated. The cerebrovascular events (n = 10) and status epilepticus (n = 1) were other neurological findings. The partial or full recovery of smell and taste dysfunctions was found in 95.2% after 8 weeks and 97.3% after 16 weeks. The parosmia (30.9%) and phantosmia (9.0%) were also reported during 8 weeks of follow-up. Five cases with mild headaches and 5 cases with myalgia were reported after 16 weeks of discharge. The demyelinating myelitis (n = 1) and Guillain-Barré syndrome (n = 1) were also found during follow-up. CONCLUSION: Neurological symptoms were found to be prevalent among individuals with COVID-19 disease and should not be under-estimated during the current pandemic outbreak.

Encephalopathy following ingestion of Lead-contaminated opium; magnetic resonance imaging findings.

BACKGROUND: Encephalopathy is an uncommon but serious presentation of lead toxicity. OBJECTIVE: We aimed to determine and follow-up the brain magnetic resonance imaging (MRI) abnormalities in the patients with lead encephalopathy due to ingestion of lead contaminated opium. METHODS: In a cross-sectional study during lead-contaminated opium outbreak, all lead-poisoned patients with any signs/symptoms of encephalopathy were included. RESULTS: Of 19 patients with lead encephalopathy, five died early and other five could not be sent to MRI during their hospitalization period. Mean age was 51 ± 11 years and males were dominant (89%). Median [IQR] blood lead level (BLL) was 101 [81, 108] µg/dL (range; 50 to 200 µg/dL). There was no correlation between MRI findings and signs/symptoms. MRI was normal in six and abnormal in three. Bilateral symmetric involvement of parieto-occipital lobes was observed. Gray matter, gray-white matter junction, and subcortical white matter were also affected. Follow-up MRI was performed in two with abnormal MRI which showed complete and near complete resolution of the abnormalities after cessation of opium use and treatment. CONCLUSION: There was no correlation between MRI findings and BLL. Complete recovery of brain MRI lesions was detected after cessation of opium use.

Evaluation of the effect of erythropoietin + corticosteroid versus corticosteroid alone in methanol-induced optic nerve neuropathy.

PURPOSE: Following methanol intoxication, optic nerve neuropathy may occur, which is currently treated by different therapeutic regimens. Erythropoietin (EPO) has recently been introduced as a good therapeutic option in methanol-induced optic neuropathy. The aim of the current study was to evaluate the efficacy of EPO in improvement of the visual disturbances in methanol-intoxicated patients. MATERIALS AND METHODS: In a case-control study, all patients who had referred to our toxicology centre with confirmed diagnosis of methanol toxicity were considered to be included. Of them, those who had referred with visual disturbances, survived, and their visual disturbances had not improved after haemodialysis were entered. Cases received EPO and corticosteroids while controls only received corticosteroids. They were then compared regarding their visual outcome. RESULTS: All five patients in the control group mentioned that after discharge, their visual acuity had improved while in the cases, three mentioned visual improvement, two mentioned their visual acuity had deteriorated after discharge, two mentioned no change in their visual acuity and three mentioned that their visual acuity had first improved but then deteriorated with a mean two-month interval period. In fundoscopic evaluations, two controls had normal fundospcopy while eight cases had abnormal fundoscopy (p = 0.055). CONCLUSIONS: Protective effect of EPO on methanol-induced optic nerve may be strong at the beginning of the intervention but is probably transient.

Neurologic sequelae of phosphide poisoning: A case report.

Background: Aluminum phosphide (ALP) is extremely toxic with a high mortality rate, mainly due to its cardiovascular complications. Some neurologic effects have also been reported with this pesticide. Case presentation: We present a 23-year-old male who presented with confusion after ingestion of a toxic dose of ALP. Computerized tomography scan demonstrated diffuse bilateral hypoattenuation of the cerebellar hemispheres, midbrain, thalamus, and globus pallidus resulting in tonsillar and transtentorial herniation and eventually brain death four days after admission. Conclusions: This is the first documented case of neurologic sequela following phosphide poisoning that emphasizes the importance of brain imaging studies for patients with loss of consciousness.

A Case of Fingolimod-associated Cryptococcal Meningitis.

BACKGROUND: Leukopenia, a rare adverse effect of Fingolimod therapy, paves the way for opportunistic infections. In this study, we reported rare fingolimod associated cryptococcal meningitis. CASE PRESENTATION: A 39-year-old woman with RRMS was referred to the emergency department. The patient's major complaints were headache, fever, weakness, and progressive loss of consciousness within the last two days prior to the referral. The patient had a history of hospitalization due to RRMS [two times]. In the second hospitalization, interferon Beta-1a was replaced with Fingolimod. Using polymerase chain reaction, Cryptococcus neoformans was detected in CSF. Liposomal amphotericin B and fluconazole [800 mg per day] were started. Six weeks later, the patient was discharged without any major complaints. CONCLUSION: Albeit fingolimod associated cryptococcal meningitis is a rare event, Fingolimod therapy in patients with MS should be performed cautiously. Regular follow-ups may give rise to a timely diagnosis of probable fingolimod associated cryptococcal meningitis. Fingolimod therapy can lead to lymphocytopenia and various infections. We, therefore, suggest that intermittent blood lymphocyte counts as well as monitoring of clinical manifestations among MS patients treated with Fingolimod to avoid additional neurological and physical disabilities in these patients.

Developing a novel prediction model in opioid overdose using machine learning; a pilot analytical study.

Background and Aims: The opioid epidemic has extended to many countries. Data regarding the accuracy of conventional prediction models including the Simplified Acute Physiologic Score (SAPS) II and acute physiology and chronic health evaluation (APACHE) II are scarce in opioid overdose cases. We evaluate the efficacy of adding quantitative electroencephalogram (qEEG) data to clinical and paraclinical data in the prediction of opioid overdose mortality using machine learning. Methods: In a prospective study, we collected clinical/paraclinical, and qEEG data of 32 opioid-poisoned patients. After preprocessing and Fast Fourier Transform analysis, absolute power was computed. Also, SAPS II was calculated. Eventually, data analysis was performed using SAPS II as a benchmark at three levels to predict the patient's course in comparison with SAPS II. First, the qEEG data set was used alone, secondly, the combination of the clinical/paraclinical, SAPS II, qEEG datasets, and the SAPS II-based model was included in the pool of classifier models. Results: Seven out of 32 (22%) died. SAPS II (cut-off of 50.5) had a sensitivity/specificity/positive/negative predictive values of 85.7%, 84.0%, 60.0%, and 95.5% in predicting mortality, respectively. Adding majority voting on random forest with qEEG and clinical data, improved the model sensitivity, specificity, and positive and negative predictive values to 71.4%, 96%, 83.3%, and 92.3% (not significant). The model fusion level has 40% less prediction error. Conclusion: Considering the higher specificity and negative predictive value in our proposed model, it could predict survival much better than mortality. The model would constitute an indicator for better care of opioid poisoned patients in low resources settings, where intensive care unit beds are limited.

Garcin syndrome in a case of acquired immunodeficiency syndrome.

In this study, we report a parapharyngeal diffuse large B-cell lymphoma in a human immunodeficiency virus (HIV) infected patient which had caused the patient to suffer from Garcin syndrome.

A comparison between IVIG and plasma exchange as preparations before thymectomy in myasthenia gravis patients.

Myasthenia gravis (MG) is one of the curable neurologic disorders. Various pharmacological therapies are administered for these patients and a thymectomy plays an important role in the therapy of myasthenia gravis, which develops a permanent or relative remission. We investigated the efficacy of intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) as a preparation before thymectomy in patients with MG. This randomized clinical trial was conducted on 24 patients with MG referred for thymectomy, which were randomized to two groups of IVIG and PLEX. The IVIG group received IVIG 1 g/kg/day for two consecutive days and the PLEX group underwent 1-L plasma exchange five times with 5 % albumin replacement fluid, every other day, 10-30 days before the procedure. The duration of hospitalization (day), length of intensive care unit (ICU) stay after surgery (day), length of intubation period (h), duration of surgery (h) and dose of steroid administered were compared between the two groups. Analysis was performed via SPSS version 20. In the PLEX group, post-operative outcomes (duration of hospitalization, ICU length of stay after surgery, intubation period and duration of surgery) were longer than those in the IVIG group. There was significant difference in intubation period (p value = 0.01) and duration of surgery (p value = 0.05) between the PLEX and IVIG groups. The administration of IVIG in comparison to PLEX can be more effective in the preparation before thymectomy in myasthenia gravis patients.

Myasthenia gravis development and crisis subsequent to multiple sclerosis.

During the last decade, sporadic combination of multiple sclerosis (MS) and myasthenia gravis (MG) has been reported repeatedly. Although these are anecdotal, they are important enough to raise concerns about co-occurrence of MG and MS. Here, we present a case of an MS patient who developed an MG crisis. She had received interferon for relapsing remitting MS. Interestingly, she developed an MG crisis 4 years after the diagnosis of MS. MS and MG have relatively the same distribution for age, corresponding to the younger peak of the bimodal age distribution in MG. They also share some HLA typing characteristics. Furthermore, some evidences support the role of systemic immune dysregulation due to a genetic susceptibility that is common to these two diseases. The association may be underdiagnosed because of the possible overlap of symptoms especially bulbar manifestations in which either MG or MS can mimic each other, leading to underestimating incidence of the combination. The evidence warrants physicians, especially neurologists, to always consider the possibility of the other disease when encountering any patients either with MS or MG. Anecdotal and sporadic reports of combination of multiple sclerosis (MS) and myasthenia gravis (MG) have been raised concerns about co-occurrence of them.