RESUMO
OBJECTIVE: Data on cognitive changes in patients with tuberculous meningitis (TBM) are sparse. We aimed to study the cognitive profiles of patients with grade I TBM and correlate them with the cytokine values. METHODS: Prospectively, 60 patients (M:F-31:29) with grade I TBM were recruited. Clinical details were collected; CSF estimation of cytokines, neuropsychological assessment, and correlation were performed. RESULTS: Mean age at presentation was 32.2 years (32.2 ± 10.1), and the duration of symptoms was 29.9 days (29.9 ± 25.9), respectively. Definitive evidence of mycobacterial infection was observed in 28.3% of the patients. Mean levels of tumor necrosis factor-α (TNF-α), interferon (IFN-γ), and interleukin-6 (IL-6) were 11.57 ± 30.35, 197.02 ± 186.64, and 127.03 ± 88.71 pg/mL, respectively. TNF-α levels were significantly elevated in definitive TBM (p = 0.044). Neuropsychological tests revealed an impaired auditory verbal learning test (88.3%), followed by complex figure test (50%), spatial span test (50%), clock drawing test (48.3%), digit span test (35%), color trail tests 1 and 2 (30% and 33.3%, respectively), and animal naming test (28.3%). Elevated levels of IFN-γ and IL-6 in TBM directly correlated with the number of impaired neuropsychological tests. During follow-up, significant improvement was noticed in animal naming test (p = 0.005), clock drawing test (p = 0.003), color trail test 2 (0.02), spatial span test (p = 0.012), and digit span test (0.035). Verbal learning did not show any significant change. Overall, the neuropsychological tests showed better recovery of attention, working memory, and category fluency and showed minimal recovery of verbal learning. CONCLUSIONS: There is subclinical evidence of cognitive impairment in patients with TBM, and this correlated with elevated cytokines. Both the frontal and temporal lobes showed varying degrees of cognitive impairment.
RESUMO
OBJECTIVE: Morvan syndrome is characterized by central, autonomic, and peripheral hyperexcitability due to contactin-associated protein 2 (CASPR2) antibody. Our objective was to study the clinical spectrum, electrophysiologic, autonomic, polysomnographic, and neuropsychological profile in patients with CASPR2-related Morvan syndrome. METHODS: Serum and CSF samples that were CASPR2 antibody positive from 2016 to 2019 were assessed. Among them, patients with Morvan syndrome diagnosed based on clinical and electrophysiologic basis were included. RESULTS: Fourteen (M:F = 10:4) patients with Morvan syndrome were included with age at onset of 37.1 ± 17.5 years. The clinical features were muscle twitching (12), insomnia (12), pain (11), paresthesias (9), hyperhidrosis (7), hypersalivation (6), double incontinence (3), spastic speech (2), dysphagia (2), behavioral disturbances (2), seizures (1), and cold intolerance (1). Neurologic examination revealed myokymia (12), hyperactive tendon reflexes (10), and tremor (6). EMG revealed neuromyotonia (12) and increased spontaneous activity (7). Autonomic function tests conducted in 8 patients revealed definite autonomic dysfunction (4), orthostatic hypotension (2), early dysfunction (1), and postural orthostatic tachycardia syndrome (1). Polysomnography findings in 6 patients revealed insomnia (3), absence of deep sleep (1), high-frequency beta activity (1), REM behavior disorder (1), and periodic leg movements (1). Neuropsychological evaluation showed subtle involvement of the left frontal and temporal lobe. Malignancy workup was negative. All patients were treated with steroids. There was complete neurologic resolution in follow-up with persistent neuropathic pain in 5 patients. CONCLUSIONS: This study has contributed to the growing knowledge on CASPR2-related Morvan syndrome. It is important for an increased awareness and early recognition as it is potentially treatable by immunotherapy.