Acute disseminated encephalomyelitis after mixed malaria infection (Plasmodium falciparum and Plasmodium vivax) with MRI closely simulating multiple sclerosis.

INTRODUCTION: Acute disseminated encephalomyelitis (ADEM) is a monophasic, inflammatory, immune-mediated disorder of the central nervous system. It is particularly difficult to distinguish between ADEM and an initial attack of multiple sclerosis (MS) clinically and based on magnetic resonance imaging (MRI) or cerebrospinal fluid. ADEM is quite rare after malaria infection. Our patient, although diagnosed provisionally of ADEM after mixed malaria infection, had neuroimaging closely simulating MS. CASE REPORT: We report a case of a woman with an adult type 2 diabetes presenting with fever and diagnosed by antigen assay to be suffering from mixed malaria infection (Plasmodium falciparum, Plasmodium vivax). While recovering with artesunate and doxycycline therapy, she developed acute onset bladder retention followed by paraparesis. On examination she had evidence of Upper Motor Neuron (UMN) signs in all the 4 limbs along with truncal sensory loss. DISCUSSION: Her MRI of spine showed T2 hyperintensities suggestive of resolving myelitis. MRI of the brain showed multifocal and confluent areas of demyelination mostly involving the corpus callosum and periventricular region. Lesions, particularly the callosal ones, closely simulated MS. In accordance with the McDonald Criteria and Barkhof's MRI Criteria, this patient did not fit into the diagnosis of MS. Our provisional diagnosis was ADEM.

Cryptogenic cirrhosis: metabolic liver disease due to insulin resistance.

OBJECTIVE: Etiopathogenesis of cryptogenic cirrhosis (CC) is not yet well established. Up to 20% of non-alcoholic fatty liver disease (NAFLD) may progress to cirrhosis, mostly termed as cryptogenic. Insulin resistance and altered metabolic parameters form a major pathogenic link between NAFLD and CC. CC may thus be actually a metabolic liver disease. MATERIALS AND METHODS: Thirty-four patients of CC and 32 patients having cirrhosis due to chronic hepatitis B (Hep B) were assessed in a cross-sectional study in a tertiary hospital for insulin resistance, % ß-cell activity, obesity indices, plasma glucose, lipid profiles, and many other parameters. RESULTS: CC patients had higher homeostasis model assessment (HOMA)-IR compared to Hep B group (P = 0.000016). A positive correlation between IR values and Child-Pugh score among CC patients was found ("r" = 0.87; P < 0.00001). Out of 34 CC patients, 15 (44.1%) had obesity contrary to 6 (18.8%) in the control group (P = 0.0022). Differences were observed in subcutaneous fat (P = 0.0022), intra-abdominal fat (P = 0.0055), waist circumference (P = 0.014), and percentage body fat (P = 0.047) between the two groups. Significant differences were observed in the levels of triglyceride, total cholesterol, and very low density lipoprotein (VLDL). CONCLUSION: Most of the CC patients showed significantly higher prevalence of HOMA-IR, obesity indices, and various parameters of "lipotoxicity" and metabolic syndrome, suggesting that CC may be the long-term consequence of a type of "metabolic liver disease." Further studies are required to evaluate the role of therapeutic interventions to enhance insulin sensitivity in such patients.