Neuroborreliosis in India – A Diagnostic Challenge and a Great Mimicker: A Case Series

Background: Many studies found that only hypomagnesemia, but not hypermagnesemia is linked with increased mortality. However, reports of mortality due to magnesium dysregulation in the critical care setting are controversial. Objectives: To study serum magnesium levels in critically ill patients on admission in intensive care unit (ICU) and its correlation with patient’s need and duration for ventilator support, duration of ICU stay, incidence of cardiac arrhythmias and mortality. Methods: Two hundred forty six critically ill patients admitted in ICU with Acute Physiology and Chronic Health Evaluation (APACHE) II scores>10, were included for this prospective observational study. Serum total magnesium level was measured at the time of admission to ICU. Primary outcome measure was ICU mortality whereas, secondary outcome measures were patient’s need and duration for ventilator support, duration of ICU stay, and incidence of cardiac arrhythmias. Categorical and continuous variables were tested using Chi-square/Fisher’s exact test and analysis of variance respectively. Multivariate logistic regression analysis was carried out to determine association of serum magnesium levels with ICU mortality. Results: Incidence of ICU mortality was significantly higher in group of patients with hypomagnesemia compared to those with normal magnesium levels. Hypomagnesemia was associated with need and longer duration of ventilator support, longer duration of ICU stay, higher APACHE II score, QTc prolongation, higher incidence of cardiac arrhythmias compared to patients with normal magnesium levels. Hypomagnesemia was an independent and statistically significant determinant of ICU mortality. Conclusions: Hypomagnesemia was associated with higher mortality rate, longer duration of ventilator support and ICU stay, and higher APACHE II score in critically ill patients.

Diverse presentations of phenytoin toxicity-presenile cataract, encephalopathy and peripheral neuropathy: a case series

One of the most commonly used antiepileptic drugs, phenytoin, has a narrow therapeutic index, high plasma protein binding, non-linearpharmacokinetics and inter-individual variability. It can also present with adverse drug reactions due to phenytoin toxicity with diverse presentations mimicking symptoms of other diseases thus causing diagnostic predicament. This case series reports three such cases of uncommon presentation of phenytoin toxicity like presenile cataract, fluctuating encephalopathy with diurnal variation and peripheral neuropathy. Monitoring of serum drug levels in such cases aids in confirming drug toxicity. Adverse drug reaction monitoring helps in early detection and appropriate management of drug related morbidity.

Artery Of Percheron Infarct - A Missed Opportunity Of Stroke Thrombolysis

Acute ischemic infarction in the territory of the artery of Percheron (AOP). AOP is a relatively uncommon neurovascular anatomical variant of the posterior circulation. It is a single arterial trunk supplying bilateral paramedian thalami and the rostral midbrain, a crucial structure responsible for regulation of alertness, consciousness, and sleep. The clinical presentation may deviate from the typical sensorimotor deficits seen with classical stroke syndromes. Without a high index of suspicion, AOP infarcts can be missed clinically and radiologically, thereby missing the crucial window of thrombolytic therapy. We discuss a case of a 60-year-old male, who was presented with acute onset altered sensorium due to AOP infarction and missed the opportunity for intravenous thrombolysis due to delayed diagnosis

Subarachnoid hemorrhage with transient ischemic attack: Another masquerader in cerebral venous thrombosis.

Cerebral venous thrombosis has a wide spectrum of clinical manifestations that may mimic many other neurological disorders and lead to frequent misdiagnoses or delay in diagnosis. The most frequent symptoms and signs are headache, seizures, focal deficits, and papilledema. A number of rare atypical manifestations have been described. Cerebral venous thrombosis may present with an isolated intracranial hypertension type picture, thunderclap headache, attacks of migraine with aura, isolated psychiatric disturbances, pulsatile tinnitus, isolated or multiple cranial nerve involvement, and occasionally as subarachnoid hemorrhage (SAH) or transient ischemic attack. Our patient presented with thunderclap headache and transient ischemic attack like episode with obvious SAH on CT scan. Acute SAH suggests the presence of a vascular lesion, such as ruptured aneurysm, and CVT is not generally considered in the diagnostic workup of SAH. The case emphasizes the importance of cerebral venous study in nonaneurysmal cases of SAH. It is important to have a high index of suspicion in such atypical cases to avoid delay in diagnosis.