Utility of Brainstem Auditory Evoked Response as a Diagnostic Tool and Rituximab as a Treatment for Severe Bickerstaff Brainstem Encephalitis: A Case Report.

Bickerstaff brainstem encephalitis (BBE) is a rare disorder that is characterized by ophthalmoplegia, ataxia, and disturbance in consciousness. Definite diagnosis is made primarily through clinical presentation and serology testing with anti-GQ1b antibody. However, in a country where access to serologic testing is scarce, electrophysiologic tests such as brainstem auditory evoked response (BAER) may contribute to the diagnosis. Due to its rarity and generally good prognosis, there is no established consensus for the treatment of BBE. Immunomodulatory treatments such as intravenous immunoglobulin (IVIG), plasma exchange, steroids, or a combination of these therapies are often used with good response. However, there are severe cases that respond poorly to these conventional treatments. We report the case of a 26-year-old Filipino man who came in for sudden onset of diplopia, with a one-week history of upper respiratory tract infection. Subsequently, he developed paresthesias, quadriparesis, and an altered level of consciousness. On initial examination, he only had partial third nerve palsy, but eventually became quadriparetic and obtunded during admission. Initial electromyography and nerve conduction velocity (EMG-NCV) study showed a reduced recruitment pattern of the right rectus femoris, absent H reflexes of bilateral posterior tibial nerves, and no abnormal increase in temporal dispersion. Cranial MRI with contrast was unremarkable. Video electroencephalogram (video-EEG) showed intermittent generalized 5-6 Hz and 6-7 Hz theta slowing of the background activity in the stimulated state. BAER was done revealing bilateral partial dysfunction of the auditory pathways to support brainstem involvement of the disease. He received IVIG and methylprednisolone pulse therapy with no significant clinical improvement. Hence, he was given a rituximab infusion. One week post-rituximab, he had sustained wakefulness and was able to move his extremities.

Treatment of stuporous catatonia with repetitive transcranial magnetic stimulation (rTMS) therapy in a Filipino adult patient: A case report.

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive treatment option for psychiatric conditions, including catatonia. Our patient is a 30-year-old Filipino female admitted due to mutism, motor, and behavioral changes. Laboratory tests, cranial magnetic resonance imaging, electroencephalogram and cerebrospinal fluid analysis were unremarkable. The patient was diagnosed with stuporous catatonia and was given psychiatric medications, without significant improvement. The patient underwent 10 sessions of rTMS and showed marked improvement of symptoms. This highlights rTMS as a treatment option for catatonic patients that do not respond to pharmacotherapy or in situations where ECT is contraindicated or not available.

Prolonged Survival Using First-Line Pazopanib in a Filipino Male with Renal Cell Carcinoma and Brain Metastasis: A Case Report.

Renal cell carcinoma is one of the leading causes of cancer worldwide. Brain metastasis is a poor prognostic factor among patients with this disease. The advancements in understanding of the molecular framework behind malignancy and brain metastasis led to more sophisticated treatment regimens which include targeted drugs and immunotherapy. While the role of tyrosine kinase inhibitors in metastatic renal cell carcinoma has been proven in the literature, its specific role among patients with brain metastasis has not yet been fully elucidated. We report a case of a Filipino male with renal cell carcinoma and brain metastasis who underwent stereotactic radiosurgery of his right frontal lesion followed by pazopanib taken initially at 800 mg/day and then decreased to 600 mg/day. A significant increase in creatinine level led to the discontinuation of the medication after >3 years. He had a remarkable progression-free survival of 38 months. This is the first documented case of such significant response to pazopanib in a patient with renal cell carcinoma and brain metastasis. In the Philippine setting where options for cancer treatment are limited by the prohibitive cost of medications, this case can support the use of pazopanib as a potent agent for treating patients with this condition.

Chronic inflammatory demyelinating polyneuropathy with tongue fasciculation: A case report.

Chronic inflammatory demyelinating polyneuropathy is one of the immune-mediated polyneuropathies responsive to immunotherapy. Its usual clinical presentation is a chronic course of symmetric sensorimotor affectation of both proximal and distal extremities with signs of demyelination on electrophysiologic studies. Cranial nerve signs in this condition is not commonly encountered, particularly involvement of the hypoglossal nerve. To date, there are only three published cases of hypoglossal involvement in this condition. This case report presents a patient with tongue fasciculation, which is an uncommon finding in chronic inflammatory demyelinating polyneuropathy. This paper highlights the importance of considering chronic inflammatory demyelinating polyneuropathy in the differential diagnoses of a patient with tongue fasciculation as it has been found to be responsive to immunotherapy in comparison to other lower motor neuron syndromes.

Neuromyelitis optica spectrum disorder in a tertiary hospital in the Philippines: a case series.

Neuromyelitis optica spectrum disorder (NMOSD) is a rare disease that commonly presents with optic nerve and spinal cord inflammation, and it is associated with the presence of aquaporin-4 immunoglobulin G antibody (AQP4-IgG). Information on the clinical profile and occurrence of NMOSD among Filipino patients, however, is not sufficiently documented. In this series, we presented eighteen (18) patients with NMOSD consecutively seen in the Philippine General Hospital, a major tertiary referral center. Demographic data showed a female-to-male ratio of 2.6:1. Median age of onset of symptoms was 26 years. Eight patients (53.3%) were positive for AQP4-IgG. Most patients initially presented with myelitis (56.6%) and followed by optic neuritis (16.7%) and area postrema syndrome (16.7%). All patients had longitudinally extensive transverse myelitis on magnetic resonance imaging (MRI). Cranial MRI rarely demonstrated lesions in the optic nerves (18.2%). CSF pleocytosis (33%) and increased protein (8.3%) were infrequent. These results demonstrated that the profile of Filipino patients with NMOSD seen in our institution strengthens those described in other populations with this disorder. Large scale cross-sectional studies are necessary to fully define the profile of these patients and to determine with accuracy the prevalence and incidence of this disorder in the Philippines. Further investigation regarding the utility of ancillary tests as diagnostic and prognostic indicators in patients with NMOSD are also suggested by the authors.