Relationship between Low and High Anti-acetylcholine Receptor Antibody Titers and Clinical Severity in Myasthenia Gravis.

OBJECTIVE: To determine the frequency of low and high anti-AChR (acetylcholine receptor) antibody titers and to evaluate their relationship with clinical severity in myasthenia gravis. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Department of Neurology, King Edward Medical University/Mayo Hospital, Lahore from April 2017 to March 2018. METHODOLOGY: Fifty-six seropositive patients, aged between 18-75 years, were included. A blood sample was obtained from each patient to assess for the anti-AChR antibody titers by enzyme-linked immunosorbent assay (ELISA) technique and classified as low (0.4-<50 nmol/L) and high AChR antibody titers (>50 nmol/L). Clinical severity was graded according to the Osserman's classification. RESULTS: Out of 56 patients, 51.79% (n=29) were males and 48.21% (n=27) were females, and mean age was 32.73 +8.48 years. Mean anti-AChR antibody titer was found 40.45 + 13.54; 60.71% (n=34) had low and 39.29% (n=22) had high titers. Upon grading the severity, 1.79% (n=1) had grade I, 25% (n=14) had grade IIa, 26.79% (n=15) had grade IIb, 37.5% (n=21) had grade III, and 8.93% (n=5) had grade IV. These grades were significantly associated with high/low titers of anti-AChR antibody (p<0.001) but no significant association was found with age and gender (p=0.39 and 0.19 respectively). CONCLUSION: Serum concentration of anti-AChR antibodies has significant association with the clinical severity in myasthenia gravis. Key Words: Anti-acetylcholine receptor antibody, Myasthenia gravis, Neuromuscular junction diseases.

Structural Imaging Characteristic, Clinical Features and Risk Factors of Cerebral Venous Sinus Thrombosis: A Prospective Cross-Sectional Analysis from a Tertiary Care Hospital in Pakistan.

Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke that accounts for 0.5-1.0% of all strokes. Clinical presentation, predisposing factors, neuroimaging findings, and outcomes of CVST are extremely diverse, which causes a high index of suspicion in diagnosis. Therefore, early diagnosis of CVST is crucial for prompt treatment to prevent morbidity and mortality. OBJECTIVE: The purpose of this prospective study is aimed at assessing the clinical characteristics, potential risk factors, and neuro-radiological features along with the topography of venous sinus involved in CVST patients in a tertiary care hospital, Lahore, Pakistan. MATERIAL AND METHODS: Consecutive patients enrolled in this study had a computed tomography (CT) scan, magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) along with a clinical presentation to confirm the diagnosis of CVST. Categorical data were presented as percentages. Continuous variable and categorical data were compared (parenchymal lesions vs. non-parenchymal lesions) using the Student's t-test and Chi-square test, respectively. RESULTS: A total of 3261 patients with stroke were presented during the study period. Out of all patients, 53 confirmed patients with CVST (1.6%) were recruited; the predominant population was female (84.91%), having a male to female ratio of 1:4. Mean age of the cohort was 28.39 ± 7.19 years. Most frequent symptoms observed were headache (92.45%) followed by vomiting (75.47%), seizures (62.26%), papilledema (54.72%), visual impairment (41.51%), and altered consciousness disturbance (52.83%). The presumed risk factors associated with CVST were puerperium (52.83%), use of oral contraceptives (13.21%), antiphospholipid syndrome (7.55%), elevated serum levels of protein C and S (5.66%), and CNS infection (3.77%). On cranial CT scans, 50 patients (94.33%) showed abnormalities while 32 patients exhibited various parenchymal lesions. Seizures were more frequent in CVST patients with parenchymal lesions compared with subjects lacking parenchymal lesions. Seventy-two sinuses, either single or in combination, were involved in CVST patients, being more common in patients with parenchymal lesions than those without parenchymal lesions. The most frequent locations of CVST were the superior sagittal and transverse sinus. CONCLUSION: In short, non-contrast CT brain may be used as a first line investigation in suspected cases of CVST. Our study also demonstrates some regional differences in the clinical features, risk factors, and neuroimaging details of CVST as described by some other studies. Therefore, care must be taken while diagnosing and predicting the outcome of the CVST.

Recognizing Movement Disorder Emergencies - A Practical Review For Non-Neurologist.

Neurology still remains one of the most underserved specialties of medicine in Pakistan with roughly one neurologist per million people. Movement disorders (MD) are neurological problems that interfere with patient's motor abilities and diagnosis is typically clinical. In this review, we describe a practical approach to common MD emergencies that may be encountered by a non-neurologist physician, emphasizing on formulating a working diagnosis and their immediate management. Movement disorder emergencies can be classified based on MD phenomenology and we will provide a brief overview of dystonia including acute dystonic reaction, PAID syndrome and dystonic storm; chorea, myoclonus including serotonin syndrome and startle disease; and rigidity including neuroleptic malignant syndrome and malignant hyperthermia.

Frequency of Metabolic Syndrome and Its Components in Patients with Carpal Tunnel Syndrome.

OBJECTIVE: To determine the frequency of metabolic syndrome and its components in patients with carpal tunnel syndrome. STUDY DESIGN: Case-series. PLACE AND DURATION OF STUDY: Department of Neurology, Mayo Hospital, Lahore, from January to June 2012. METHODOLOGY: Seventy-five (64 females and 11 males) patients with clinically diagnosed and electrodiagnostically confirmed carpal tunnel syndrome were inducted. Their waist circumference, blood pressure, fasting blood glucose, fasting triglycerides and high density lipoprotein cholesterol levels were recorded. Patients were categorized having metabolic syndrome according to Adult Treatment Panel III criteria, if any 3 were present out of hypertension, elevated fasting triglycerides, reduced high density lipoprotein cholesterol, elevated fasting blood glucose, and elevated waist circumference. RESULTS: Mean age of the patients was 42.04 ±9.31 years, mean waist circumference was 95.32 ±9.03 cm, mean systolic blood pressure was 134.13 ±13.72 mmHg, mean diastolic blood pressure was 89.13 ±8.83 mmHg, mean fasting blood glucose was 94.35 ±21.81 mg/dl, mean fasting triglycerides was 177.48 ±48.69 mg/dl, and mean high density lipoprotein cholesterol was 41.95 ±11.17 mg/dl. Metabolic syndrome was found in 54 (72%) patients including 9 (16.7%) males and 45 (83.3%) females. Out of 75 patients, 54 (72%) had elevated waist circumference, 52 (69.3%) had elevated blood pressure, 19 (25.3%) had elevated fasting blood glucose, 53 (70.6%) had elevated fasting triglycerides and 54 (72%) had reduced high density lipoprotein cholesterol. Highest frequency of metabolic syndrome was found in age range of 40 - 49 years in both genders. CONCLUSION: Metabolic syndrome is frequently found in the patients with carpal tunnel syndrome.