Is there a delay in seeking medical care after the first seizure in "resource limited settings": a pilot study from Sri Lanka.

OBJECTIVES: Current guidelines suggest that patients presenting with the first seizure should be assessed by a specialist, preferably with investigations such as electroencephalography and imaging to reach a definitive diagnosis. We conducted a cross sectional study among patients with confirmed epilepsy, at a tertiary level neurology clinic in Sri Lanka with the aim of assessing delays in first contact with a medical doctor and in performing key investigations after the first seizure. RESULTS: Majority had sought medical attention within 24 h of the first seizure (71.2%) and had seen a specialist within the 1st week since the seizure (61%). Also a significant proportion had completed key investigations such as electroencephalography (63.2%) and brain imaging within a month (51%) since the first medical consultation. Of many socio-demographic and illness related factors examined, only a non-generalized tonic-clonic presentation was significantly associated with delay in seeking medical help.

Obstetric outcomes and effects on babies born to women treated for epilepsy during pregnancy in a resource limited setting: a comparative cohort study.

BACKGROUND: Management of epilepsy during pregnancy in a resource-limited setting (RLS) is challenging. This study aimed to assess obstetric outcomes and effects on babies of women with epilepsy (WWE) exposed to Anti-epileptic drugs (AEDs) compared to non-exposed controls in a RLS. METHODS: Pregnant WWE were recruited from antenatal and neurology clinics of a tertiary care hospitals in Sri Lanka. Patients were reviewed in each trimester and post-partum. Medication adherence, adverse effects, seizure control and carbamazepine blood levels were monitored. Post-partum, measurements for anthropometric and dysmorphic features of the babies and congenital abnormalities were recorded. Age and sex matched babies not exposed to AED recruited as controls were also examined. RESULTS: Ninety-six pregnant WWE were recruited (mean period of gestation 22.9 weeks). Mean age was 28 years and 48(50%) were primigravidae. Fifty percent (48) were on monotherapy, while 23.8, 15.9 and 4.1% were on two, three and four AEDs respectively. AEDs in first trimester (TM1) were carbamazepine (71%), valproate (25.8%) clobazam (29.5%), lamotrigine (7%) topiramate (5%) and others (3.4%). Sodium valproate use reduced significantly from T1 to T2(p < 0.05). Sub-therapeutic carbamazepine levels correlated positively (r = 0.547) with poor medication adherence (p = 0.009) and negatively (r = 0.306) with adverse effects (p = 0.002). Seventy-six WWE completed follow-up reporting w 75 (98.6%) live births and one T1 miscarriage (1.3%). Three (4.3%) were preterm. Majority (73.33%) were normal vaginal deliveries. Cesarean sections were not increased in WWE. Fifty-nine (61.45%) babies were examined. For those examined during infancy, 53 age and sex matched controls were recruited and examined.. Congenital abnormalities occurred in 5 (9.43%) babies of WWE [atrio-ventricular septal defect (2), renal hypoplasia (1), cryptorchidism (1), microcephaly (1)] compared to 2 (3.77%) in controls (2 microcephaly; p = 0.24). Fetal exposure to AEDs increased a risk of low birth weight (RR 2.8; p = 0.049). Anthropometric parameters of AED exposed babies were lower at birth but not statistically significant between the two groups (weight p = 0.263, length p = 0.363, occipito-frontal circumference (OFC) p = 0.307). However, weight (p = 0.009), length (p = 0.016) and OFC (p = 0.002) were significantly lower compared to controls at an average of 3.52 months. CONCLUSION: Most pregnancies are unplanned in the RLS studied, and AEDs were altered during pregnancy. Congenital anomalies occurred at rates comparable to previous reports. Fetal exposure to AED had growth retardation in infancy compared to non-exposed babies.

Prevalence and associations for symptoms of depression in patients with Parkinson's disease: a Sri Lankan experience.

BACKGROUND: The prevalence and associations for depression in patients with Parkinson's disease vary widely between studies. This reflects the influence of cultural, demographic and socioeconomic confounders within communities that make generalizations invalid. Therefore it is important to identify unique attributes within a community on this phenomenon. This is the first study from Sri Lanka on the prevalence and associations for co-morbid depression in patients with Parkinson's disease. METHODS: We conducted this cross sectional study at the Institute of Neurology, National Hospital of Sri Lanka. All patients with a diagnosis of idiopathic Parkinson's disease followed up at the movement disorder clinic of the institute were enrolled. The patients were interviewed by investigators (medical practitioners) with an interviewer administered questionnaire that collected data on (a) demography, (b) clinical symptoms of Parkinson's disease and (c) socioeconomic background. Symptoms of depression were assessed with Hamilton rating scale for depression. RESULTS: We enrolled 75 patients [males; 54 (75 %), mean age; 63.6 years, SD ± 6.8]. Forty-six (61.3 %) patients had been either formally diagnosed with depression or showed symptoms of depression. Bradykinesia, monthly income below Rs. 10,000 and having a family history of depression were significantly associated with a diagnosis of life-time post Parkinson's disease depression (p < 0.05). CONCLUSION: Given the potential benefit in treatment (for depression), all patients with Parkinson's disease should be screened for depression regularly. HAM-D would be a good screening tool for this purpose as it has good reliability, validity and can be administered within a reasonable time limit.

Cryptococcal meningitis presenting with bilateral complete ophthalmoplegia: a case report.

BACKGROUND: Cryptococcus neoformans is saprophytic encapsulated yeast. Infection is acquired by inhalation of the organism and could be asymptomatic or limited to the lungs, specially in the immunocompetent host. Cryptococcal meningitis is a serious opportunistic infection among post transplant recipients. Cranial nerve palsies and ophthalmoplegia are well known complications of this disease, but bilateral complete ophthalmoplegia is a very rare presentation. CASE PRESENTATION: A Sri Lankan young male, who is a post kidney transplant recipient, presented with bilateral complete ophthalmoplegia and subsequently was diagnosed to have cryptococcal meningitis based on Indian ink stain and culture of cerebrospinal fluid (CSF). His magnetic resonance imaging (MRI) showed bilateral multiple nodular lesions in both basal ganglia and thalami. Brainstem imaging was normal. CONCLUSIONS: Cryptococcal meningitis is a serious fungal infection in post transplant patients. It should be suspected in any immunocompromised patient with fever, headache and focal neurological signs. Bilateral thalamic lesions, inflammation and invasion of the cranial nerves and raised intracranial pressure were thought to be possible mechanisms resulting in bilateral complete ophthalmoplegia in this patient.

Isolated trigeminal nerve palsy with motor involvement as a presenting manifestation of multiple sclerosis in an equatorial region - a case report.

INTRODUCTION: Isolated cranial nerve palsies are considered to be an uncommon presenting feature of multiple sclerosis. Involvement of the trigeminal nerve, particularly its motor component as part of a clinically isolated syndrome of multiple sclerosis has rarely been reported in equatorial regions and no cases have been described in Sri Lanka thus far. CASE PRESENTATION: We report a case of isolated right sided trigeminal nerve palsy (Motor and Sensory) in a 34 year old previously well lady from urban Sri Lanka who was found to have characteristic lesions on Magnetic Resonance Imaging highly suggestive of multiple sclerosis. CONCLUSIONS: Multiple sclerosis should be considered in the differential diagnosis of patients who present with isolated cranial nerve palsies. Clinicians should have a high index of suspicion when evaluating such patients especially in low prevalence regions close to the equator. Early recognition and treatment of such a "Clinically Isolated Syndrome" may prevent early relapse.

Young strokes in Sri Lanka: an unsolved problem.

Stroke in young adults is more common in India and Sri Lanka and the reasons for this are not well understood. The current study was conducted to elucidate the risk factors and radiologic features in young people (age < 45 years) with ischemic stroke. Sociodemographic data, stroke risk factor information, and laboratory investigations were recorded in 41 cases with first-ever ischemic stroke. Most common risk factors for stroke in the 15- to 45-year-old age group were: hypertension, 8 (21%); family history of stroke, 7 (18%); transient ischemic attack, 6 (16%); hyperlipidemia, 3 (8.0%); and diabetes, two (5%). Age group younger than 15 years included 3 girls and one had a mass attached to the posterior mitral valve leaflet. Our observations underscore the importance of the presence of hypertension, family history of stroke, and transient ischemic attack in young adults and thus to adopt preventative strategies.