Lost in space(s): Multimodal neuroimaging of disorientation along the Alzheimer's disease continuum.

Orientation is a fundamental cognitive faculty and the bedrock of the neurologic examination. Orientation is defined as the alignment between an individual's internal representation and the external world in the spatial, temporal, and social domains. While spatial disorientation is a recognized hallmark of Alzheimer's disease (AD), little is known about disorientation beyond space in AD. This study aimed to explore disorientation in spatial, temporal, and social domains along the AD continuum. Fifty-one participants along the AD continuum performed an ecological orientation task in the spatial, temporal, and social domains while undergoing functional MRI. Disorientation in AD followed a three-way association between orientation domain, brain region, and disease stage. Specifically, patients with early amnestic mild cognitive impairment exhibited spatio-temporal disorientation and reduced brain activity in temporoparietal regions, while patients with AD dementia showed additional social disorientation and reduced brain activity in frontoparietal regions. Furthermore, patterns of hypoactivation overlapped different subnetworks of the default mode network, patterns of fluorodeoxyglucose hypometabolism, and cortical atrophy characteristic of AD. Our results suggest that AD may encompass a disorder of orientation, characterized by a biphasic process manifesting as early spatio-temporal and late social disorientation. As such, disorientation may offer a unique window into the clinicopathological progression of AD. SIGNIFICANCE STATEMENT: Despite extensive research into Alzheimer's disease (AD), its core cognitive deficit remains a matter of debate. In this study, we investigated whether orientation, defined as the ability to align internal representations with the external world in spatial, temporal, and social domains, constitutes a core cognitive deficit in AD. To do so, we used PET-fMRI imaging to collect behavioral, functional, and metabolic data from 51 participants along the AD continuum. Our findings suggest that AD may constitute a disorder of orientation, characterized by an early spatio-temporal disorientation and followed by late social disorientation, manifesting in task-evoked and neurodegenerative changes. We propose that a profile of disorientation across multiple domains offers a unique window into the progression of AD and as such could greatly benefit disease diagnosis, monitoring, and evaluation of treatment response.

Emotions at diagnosis in patients with bullous diseases.

BACKGROUND: Diagnosis of a severe condition may have a strong emotional impact on patients. Specific emotions experienced when receiving the diagnosis of a bullous disease have not been investigated. METHODS: Adult patients diagnosed with a bullous condition were recruited through the Italian Association of patients with pemphigus and pemphigoid (ANPPI). Information was collected online on sociodemographic and clinical data. We asked which emotions the patient experienced at the time of the diagnosis, i.e., isolation, anger, confusion, sadness, despair, disregard, fear, avoidance, and challenge. Also, the patients reported to whom they talked as soon as they had the diagnosis. RESULTS: Data were collected on 105 patients, most of whom were affected by pemphigus vulgaris. The emotion most frequently experienced at diagnosis was confusion (47.6% of patients). More than 30% of patients reported sadness and fear, 12.5% anger, and 10.5% despair. A significantly higher percentage of women than men experienced isolation and despair. Despair was more frequent in patients who were older at diagnosis. Patients with children experienced more sadness and despair, and less avoidance and challenge, while those who had a relative with a bullous disease reported less fear, and more challenge. CONCLUSIONS: Clinicians should be aware of the emotions of the patient when communicating the diagnosis of severe conditions, such as bullous diseases. Active listening and empathy are necessary to provide patients with correct information on the disease, so that they are not overwhelmed with negative emotions.

Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus: A multicenter study.

INTRODUCTION: Neuropsychiatric (NP) involvement is a restricted area in juvenile-onset systemic lupus erythematosus (jSLE). AIM: To investigate the prevalence, demographic and clinical features, and outcomes of the neurological involvement in the Turkish jSLE population. METHODS: This study was based upon 24 referral centers' SLE cohorts, multicenter and multidisciplinary network in Turkey. Patient data were collected by a case report form which was standardized for NP definitions according to American Collage of Rheumatology (ACR). Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) neuropsychiatric part was used to determine NP damage. Variables were evaluated Ward's hierarchical clustering analyses, univariate, and multivariate logistic regression analyses. RESULTS: A hundred forty-nine of 1107 jSLE patients had NP involvement (13.5%). The most common NPSLE findings were headache (50.3%), seizure (38.3%), and acute confusional state (33.6%). Five clusters were identified with all clinical and laboratory findings. The first two clusters involved neuropathies, demyelinating diseases, aseptic meningitis, and movement disorder. Cluster 3 involved headache, activity markers and other SLE involvements. Idiopathic intracranial hypertension, cerebrovascular disease, cognitive dysfunction, psychiatric disorders and SLE antibodies were in the fourth, and acute confusional state was in the fifth cluster. In multivariate analysis, APA positivity; OR: 2.820, (%95CI: 1.002-7.939), P: 0,050, plasmapheresis; OR: 13.804 (%95CI: 2.785-68.432), P: 0,001, SLEDAI scores; OR: 1.115 (%95CI: (1.049-1.186), P: 0,001 were associated with increased risk for neurologic sequelae. CONCLUSION: We detected the prevalence of juvenile NPSLE manifestations in Turkey. We have identified five clusters that may shed light pathogenesis, treatment and prognosis of NP involvements. We also determined risk factors of neurological sequelae. Our study showed that new definitions NP involvements and sequelae for childhood period are needed.

How vestibular dysfunction transforms into symptoms of depersonalization and derealization?

BACKGROUND: Psychiatric Depersonalization/Derealization (DPDR) symptoms were demonstrated in patients with peripheral vestibular disorders. However, only semicircular canals (SCCs) dysfunction was evaluated, therefore, otoliths' contribution to DPDR is unknown. Also, DPDR symptoms in patients with central vestibular dysfunction are presently unknown. DPDR was also studied in the context of spatial disorientation and anxiety, but the relation of these cognitive and emotional functions to vestibular dysfunction requires clarification. METHODS: We tested patients with peripheral Bilateral Vestibular Hypofunction (pBVH), Machado Joseph Disease (MJD) with cerebellar and central bilateral vestibular hypofunction, and healthy controls. Participants completed the video Head Impulse Test (vHIT) for SCCs function, cervical Vestibular Evoked Myogenic Potentials test (cVEMPt) for sacculi function, Body Sensation Questionnaire (BSQ) for panic anxiety, Object Perspective-Taking test (OPTt) for spatial orientation and Cox & Swinson DPDR inventory for DPDR symptoms. RESULTS: pBVH patients showed significant SCCs and sacculi dysfunction, spatial disorientation, elevated panic anxiety, and DPDR symptoms. MJD patients showed significant SCCs hypofunction but preserved sacculi function, spatial disorientation but normal levels of panic anxiety and DPDR symptoms. Only pBVH patients demonstrated a positive correlation between the severity of the DPDR and spatial disorientation and panic anxiety. CONCLUSIONS: DPDR develops in association with sacculi dysfunction, either with or without SSCs dysfunction. Spatial disorientation and anxiety seem to mediate the transformation of vestibular dysfunction into DPDR symptoms. DPDR does not develop in MJD with central vestibular hypofunction but a normal saccular response. We propose a three-step model that describes the development of DPDR symptoms in vestibular patients.

Confusion and Hallucination in a Geriatric Patient. Pitfalls of a Rare Differential: Case Report of an Anti-LGI1-Encephalitis.

Background: Confusion and hallucinations in geriatric patients are frequent symptoms and typically associated with delirium, late-life psychosis or dementia syndromes. A far rarer but well-established differential in patients with rapid cognitive deterioration, acute psychosis, abnormal movements and seizures is autoimmune encephalitis. Exemplified by our case we highlight clinical and economic problems arising in management of geriatric patients with cognitive decline and psychotic symptoms. Case Presentation: A 77-year-old female caucasian patient with an unremarkable medical history was hospitalized after a fall in association with diarrhea and hyponatremia. Upon adequate therapy, disorientation and troubled short-term memory persisted. Within a week the patient developed visual hallucinations. Basic blood and urine samples and imaging (cranial computed tomography and magnetic resonance imaging) were unremarkable. With progressive cognitive decline, amnestic impairment, word finding difficulty and general apathy, psychiatric and neurologic expertise was introduced. Advanced diagnostics did not resolve a final diagnosis; an electroencephalogram showed unspecific generalized slowing. Extended clinical observation revealed visual hallucinations and faciobrachial dystonic seizures. A treatment with anticonvulsants was initiated. Cerebrospinal fluid ultimately tested positive for voltage-gated potassium channel LGl1 (leucine-rich-inactivated-1) antibodies confirming diagnosis of autoimmune anti-LGI1 encephalitis. Immediate immunotherapy (high-dose glucocorticoids and administration of intravenous immunoglobulin G) led to a rapid improvement of the patient's condition. After immunotherapy was tapered, the patient had one relapse and completely recovered with reintroduction of glucocorticoids and initiation of therapy with rituximab. Conclusion: Rapidly progressive dementia in geriatric patients demands a structured and multidisciplinary diagnostic approach. Accurate management and financially supportable care is a major issue in rare diseases such as anti-LGI1-encephalitis. Education and awareness about autoimmune encephalitis of all physicians treating a geriatric population is important in order to involve expertise and establish treatment within reasonable time.

Postural Control and Psychophysical State Following of Flight Simulator Session in Novice Pilots.

Flight simulators can cause side effects usually called simulator sickness. Scientific research proves that postural instability can be an indicator of the occurrence of simulator sickness symptoms. This study aims to assess changes of postural control and psychophysical state in novice pilots following 2-h exposure to simulator conditions. The postural sway was quantified based on variables describing the displacement of the Center of Pressure (COP) generated in a quiet stance with eyes open (EO) and closed (EC). The psychophysical state was assessed using the Simulator Sickness Questionnaire (SSQ). The research was carried out in a group of 24 novice pilots who performed procedural and emergency flight exercises in the simulator at Instrument Meteorological Conditions. Each subject was examined twice: immediately before the simulator session (pre-exposure test), and just after the session (post-exposure test). The differences in postural stability between pre- and post-exposure to simulator conditions were assessed based on the normalized Romberg quotients, calculated for individual variables. The lower median values of all Romberg quotients confirmed the decreasing difference between the measures with eyes open and with eyes closed in the post-exposure tests. After the flight simulator session in both measurements (EO and EC) the values of the length of sway path (SP), the mean amplitude (MA), the sway area (SA) have changed. The visual contribution to postural sway control was reduced. The median values for all SSQ scores (total, nausea, oculomotor, and disorientation scales) were significantly higher in post-exposure tests. The largest increase was noted in the oculomotor SSQ scores (from 7.6 ± 7.6 to 37.9 ± 26.5). Over 50% of pilots participating in this study expressed symptoms typical of simulator sickness connected with visual induction: fatigue, eyestrain, difficulty focusing and difficulty concentrating. The severity of oculomotor and disorientation symptoms were rated as moderate (total SSQ score of more than 25 and <60). This study concludes that changes noted in the postural control and psychophysical state of the studied pilots after exposure to the flight simulator confirm the occurrence of the simulator sickness symptoms. Although, we did not find significant correlation of postural stability with SSQ scores.

Aspects of Cognitive Impairment Associated with Agitated Behaviour during Post-traumatic Amnesia.

OBJECTIVES: Post-traumatic amnesia (PTA) is a transient period of recovery following traumatic brain injury (TBI) characterised by disorientation, amnesia, and cognitive disturbance. Agitation is common during PTA and presents as a barrier to patient outcome. A relationship between cognitive impairment and agitation has been observed. This prospective study aimed to examine the different aspects of cognition associated with agitation. METHODS: The sample comprised 82 participants (75.61% male) admitted to an inpatient rehabilitation hospital in PTA. All patients had sustained moderate to extremely severe brain injury as assessed using the Westmead Post-Traumatic Amnesia Scale (WPTAS) (mean duration = 42.30 days, SD = 35.10). Participants were assessed daily using the Agitated Behaviour Scale and WPTAS as part of routine clinical practice during PTA. The Confusion Assessment Protocol was administered two to three times per week until passed criterion was achieved (mean number assessments = 3.13, SD = 3.76). Multilevel mixed modelling was used to investigate the association between aspects of cognition and agitation using performance on items of mental control, orientation, memory free recall, memory recognition, vigilance, and auditory comprehension. RESULTS: Findings showed that improvement in orientation was significantly associated with lower agitation levels. A nonsignificant trend was observed between improved recognition memory and lower agitation. CONCLUSIONS: Current findings suggest that the presence of disorientation in PTA may interfere with a patient's ability to understand and engage with the environment, which in turn results in agitated behaviours. Interventions aimed at maximizing orientation may serve to minimize agitation during PTA.

Apraxia of speech and the study of speech production impairments: Can we avoid further confusion? Reply to Romani (2021).

We agree with Cristina Romani (CR) about reducing confusion and agree that the issues raised in her commentary are central to the study of apraxia of speech (AOS). However, CR critiques our approach from the perspective of basic cognitive neuropsychology. This is confusing and misleading because, contrary to CR's claim, we did not attempt to inform models of typical speech production. Instead, we relied on such models to study the impairment in the clinical category of AOS (translational cognitive neuropsychology). Thus, the approach along with the underlying assumptions is different. This response aims to clarify these assumptions, broaden the discussion regarding the methodological approach, and address CR's concerns. We argue that our approach is well-suited to meet the goals of our recent studies and is commensurate with the current state of the science of AOS. Ultimately, a plurality of approaches is needed to understand a phenomenon as complex as AOS.

[Non-aphasic misnaming: a case report and literature review].

A 71-year-old, right-handed woman was admitted to our hospital due to a sudden difficulty with conversation. On admission, she was alert, but had a euphoric mood, disorientation, and a disturbance of recent memory. Her speech was fluent. Her repetition and auditory word cognition were excellent, but she had a slight difficulty with naming visual objects. She frequently showed word-finding difficulty and irrelevant paraphasia during free conversation and a word fluency task. Her irrelevant paraphasia was observed more frequently when she was asked to explain her outbreak of anger at the hospital, i.e., it was situation-dependent. She also had anosognosia. MRI showed an infarct in the territory of the left tuberothalamic artery. Single-photon emission computed tomography revealed low-uptake lesions in the left thalamus and orbital frontal, medial frontal, and medial temporal lobes. The patient was diagnosed with non-aphasic misnaming. The clinical characteristics of patients with non-aphasic misnaming in the literature were reviewed. All of the patients with non-aphasic misnaming had word-finding difficulty and irrelevant paraphasia. Additionally, they had either emotional disturbance or anosognosia.

A young man presenting with encephalopathy and seizures secondary to SARS-CoV-2.

COVID-19 has now emerged from a respiratory illness to a systemic viral illness with multisystem involvement. There is still a lot to learn about this illness as new disease associations with COVID-19 emerge consistently. We present a unique case of a neurological manifestation of a patient with structural brain disease who was COVID-19 positive and developed mental status changes, new-onset seizures and findings suggestive of viral meningitis on lumbar puncture. We also review the literature and discuss our case in the context of the other cases reported. We highlight the value of considering seizures and encephalopathy as one of the presenting features of COVID-19 disease.

Disorientation in Time and Place in Old Age: Longitudinal Evidence from Three Old Age Cohorts in Germany (AgeDifferent.de Platform).

BACKGROUND: Only little evidence is available on disorientation, one of the most challenging symptoms of Alzheimer's disease and related dementias. OBJECTIVES: The aim of this study was to investigate the prevalence of disorientation in older age in association with the level of cognitive status, personal characteristics, and life events. METHODS: Three longitudinal population-based cohort studies on cognitive health of elderly adults were harmonized (LEILA 75 + , AgeCoDe/AgeQualiDe, AgeMooDe). Participants who completed a baseline and at least one follow-up assessment of cognitive functioning and who did not have stroke, Parkinson's disease, atherosclerosis, kidney disease, and/or alcoholism were included in the analysis (n = 2135, 72.6% female, mean age 80.2 years). Data was collected in standardized interviews and questionnaires with the participant, a proxy informant, and the participant's general practitioner. RESULTS: Making three errors in the MMSE other than in the questions on orientation (MMSEwo) came with a probability of 7.8% for disorientation, making ten errors with a probability of 88.9%. A lower MMSEwo score (HR 0.75, CI 95 0.71-0.79, p < 0.001), older age (HR 1.11, CI 95 1.08-1.14, p < 0.001), and living in a nursing home (HR 1.64, CI 95 1.02-2.64, p = 0.042) were associated with incident disorientation. Impairments in walking (OR 2.41, CI 95 1.16-4.99, p = 0.018) were associated with a greater probability for prevalent disorientation. None of the life events were significant. CONCLUSION: Our findings suggest that disorientation is primarily associated with cognitive status. Regular walking activities might possibly reduce the risk for disorientation but further research is necessary.

Real-Time Detection of Spatial Disorientation in Persons with Mild Cognitive Impairment and Dementia.

BACKGROUND: Detecting manifestations of spatial disorientation in real time is a key requirement for adaptive assistive navigation systems for people with dementia. OBJECTIVE: To identify predictive patterns of spatial disorientation in cognitively impaired people during unconstrained locomotion behavior in an urban environment. METHODS: Accelerometric data and GPS records were gathered during a wayfinding task along a route of about 1 km in 15 people with amnestic mild cognitive impairment or clinically probable Alzheimer's disease dementia (13 completers). We calculated a set of 48 statistical features for each 10-s segment of the acceleration sensor signal to characterize the physical motion. We used different classifiers with the wrapper method and leave-one-out cross-validation for feature selection and for determining accuracy of disorientation detection. RESULTS: Linear discriminant analysis using three features showed the best classification results, with a cross-validated ROC AUC of 0.75, detecting 65% of all scenes of spatial disorientation in real time. Consideration of an additional feature that informed about a person's distance to the next traffic junction did not provide an additional information gain. CONCLUSIONS: Accelerometric data are able to capture the uniformity and activity of a person's walking, which are identified as the most informative locomotion features of spatially disoriented behavior. This serves as an important basis for real-time navigation assistance. To improve the required accuracy of real-time disorientation prediction, as a next step we will analyze whether location-based behavior is able to inform about person-centered habitual factors of orientation.

Síndrome de cefalea transitoria con déficits neurológicos asociados y pleocitosis en líquido cefalorraquídeo (HaNDL) con cuadro confusional, EEG compatible con afectación difusa y datos de vasoespasmo bilateral en estudio Doppler transcraneal: presentación de un caso y revisión de la literatura / Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review

Introducción: El síndrome de cefalea y déficits neurológicos transitorios con pleocitosis en líquido cefalorraquídeo (acrónimo en inglés, HaNDL) se caracteriza por la presencia de uno o más episodios de cefalea y déficits neurológicos transitorios asociados con linfocitosis en líquido cefalorraquídeo. Hasta la fecha actual se han reportado escasos episodios de HaNDL con clínica compatible con cuadro confusional, y no se encuentran descritas mediciones de Doppler transcraneal (DTC) en pacientes afectos de HaNDL y cuadro confusional. En los registros DTC realizados en pacientes con afectación focal se han objetivado datos indicativos de alteraciones vasomotoras. Desarrollo: Presentamos el caso clínico y los resultados de pruebas complementarias de un varón de 42años afecto de cefalea, síndrome confusional, pleocitosis, electroencefalograma (EEG) con enlentecimiento difuso, DTC con elevación de velocidades en ambas arterias cerebrales medias y tomografía computarizada por emisión de fotón único compatible con afectación difusa de predominio hemisférico izquierdo. Conclusiones: Aportamos a la literatura el primer paciente descrito que aúna síndrome de HaNDL, cuadro confusional, EEG compatible con afectación difusa y DTC con aceleración de velocidades. Nuestros hallazgos sugieren una relación entre las alteraciones vasomotoras y la fisiopatología del HaNDL, y consideramos que el DTC es una herramienta útil para el diagnóstico precoz del HaNDL

Introduction: HaNDL syndrome (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) is characterised by one or more episodes of headache and transient neurological deficits associated with cerebrospinal fluid lymphocytosis. To date, few cases of HaNDL manifesting with confusional symptoms have been described. Likewise, very few patients with HaNDL and confusional symptoms have been evaluated with transcranial Doppler ultrasound (TCD). TCD data from patients with focal involvement reveal changes consistent with vasomotor alterations. Development: We present the case of a 42-year-old man who experienced headache and confusional symptoms and displayed pleocytosis, diffuse slow activity on EEG, increased blood flow velocity in both middle cerebral arteries on TCD, and single-photon emission computed tomography (SPECT) findings suggestive of diffuse involvement, especially in the left hemisphere. Conclusions: To our knowledge, this is the first description of a patient with HaNDL, confusional symptoms, diffuse slow activity on EEG, and increased blood flow velocity in TCD. Our findings suggest a relationship between cerebral vasomotor changes and the pathophysiology of HaNDL. TCD may be a useful tool for early diagnosis of HaNDL

Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review. / Síndrome de cefalea transitoria con déficits neurológicos asociados y pleocitosis en líquido cefalorraquídeo (HaNDL) con cuadro confusional, EEG compatible con afectación difusa y datos de vasoespasmo bilateral en estudio Doppler transcraneal: presentación de un caso y revisión de la literatura.

INTRODUCTION: HaNDL syndrome (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) is characterised by one or more episodes of headache and transient neurological deficits associated with cerebrospinal fluid lymphocytosis. To date, few cases of HaNDL manifesting with confusional symptoms have been described. Likewise, very few patients with HaNDL and confusional symptoms have been evaluated with transcranial Doppler ultrasound (TCD). TCD data from patients with focal involvement reveal changes consistent with vasomotor alterations. DEVELOPMENT: We present the case of a 42-year-old man who experienced headache and confusional symptoms and displayed pleocytosis, diffuse slow activity on EEG, increased blood flow velocity in both middle cerebral arteries on TCD, and single-photon emission computed tomography (SPECT) findings suggestive of diffuse involvement, especially in the left hemisphere. CONCLUSIONS: To our knowledge, this is the first description of a patient with HaNDL, confusional symptoms, diffuse slow activity on EEG, and increased blood flow velocity in TCD. Our findings suggest a relationship between cerebral vasomotor changes and the pathophysiology of HaNDL. TCD may be a useful tool for early diagnosis of HaNDL.

Close encounters of the blurred kind.

We present a visually arresting scout image obtained during a CT head scan of an elderly patient for assessment of new onset confusion. The patient moved during the scout image acquisition resulting in distortion of the cranial vault that never the less remained largely in focus.

Acute kidney injury and other factors associated with mortality in hiv-infected patients.

OBJECTIVE: HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS: This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS: A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.

Confusional state in a pregnant woman: A case of NMDA receptor encephalitis during pregnancy.

We report the case of a pregnant female presenting with behavioral change and hallucinations followed by focal seizures with impaired awareness. EEG revealed generalized slowing interspersed with extreme delta-brush pattern and MRI brain was normal. Both Serum and CSF anti-N-methyl-d-aspartate receptor (NMDAR) antibodies were positive. Patient had a prolonged hospital stay with full recovery and delivered a healthy baby, highlighting the significance of early diagnosis and management in this disorder.