A study on the clinical and electrographic profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG).

Background: Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods: In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results: Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3-8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value < 0.05). The EEG recordings of patients with NCSE showed dynamicity with fluctuating rhythms and ictal-EEG patterns associated with spatiotemporal evolution. All twelve cases showed reversal of EEG changes with AED administration. In 5 out of 12, transient improvement in GCS (>2 points) after administration of AED' was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions: NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.

Severe hypocalcaemia episodes in a patient of primary hypoparathyroidism precipitated by underlying stress due to haemophagocytic lymphohistiocytosis (HLH) secondary to pulmonary tuberculosis.

A man in his 20s who had previously experienced multiple episodes of transient loss of consciousness, majorly attributable to the seizures, presented with a 1-month history of increased seizure frequency, high-grade fever and weight loss. Clinically, he had postural instability, bradykinesia and symmetrical cogwheel rigidity. His investigations revealed hypocalcaemia, hyperphosphataemia, inappropriately normal intact parathyroid hormone, metabolic alkalosis, normomagnesemic magnesium depletion, and increased plasma renin activity and serum aldosterone concentration. CT scan of the brain revealed symmetrical calcification of the basal ganglia. The patient had primary hypoparathyroidism (HP). A similar presentation of his brother indicated a genetic cause, most likely autosomal dominant hypocalcaemia with Bartter's syndrome type 5. The patient's fever was caused by underlying haemophagocytic lymphohistiocytosis secondary to pulmonary tuberculosis, which triggered acute episodes of hypocalcaemia. This case represents a complex interplay of a multifaceted relationship between primary HP, vitamin D deficiency and an acute stressor.

Is it atopic asthma, chronic eosinophilic pneumonia, or eosinophilic granulomatosis with polyangiitis?

A 45-year-old man, used to work in a cement factory, presented to us with a history of adult-onset sub-optimally controlled asthma and was initially managed as a case of acute exacerbation of allergic asthma. However, his repeated evaluation revealed raised eosinophil count, raised serum total IgE and persistent chest infiltrates on imaging. He was provisionally managed empirically with a short course of oral steroids and advised follow-up on an out-patient basis to rule out the possibility of idiopathic eosinophilic pulmonary syndromes. The patient was then lost to follow-up, and after four years, he presented with a vasculitic presentation and was diagnosed with Eosinophilic Granulomatosis with Polyangiitis (EGPA). He improved with corticosteroids and cyclophosphamide pulse therapy. This case depicts the importance of evolving nature of EGPA wherein the eosinophilic phase of the disease can mimic other pulmonary eosinophilic diseases and vasculitic symptoms can be delayed as much as by four years.

Utility of ambulatory blood pressure monitoring in detection of masked hypertension and risk of hypertension mediated organ damage in normotensive patients with type 2 diabetes mellitus.

PURPOSE: In patients with diabetes, unrecognised hypertension is a serious problem risk factor for the development and progression of chronic complications. The study aimed to determine the prevalence of masked hypertension in normotensive diabetic patients, the factors affecting it, and its association with diabetes complications using ambulatory blood pressure monitoring (ABPM). MATERIALS AND METHODS: A cross-sectional observational study was conducted on 150 normotensive diabetic patients. Patients were subjected to an interview and clinical examination to record demographic data, epidemiological data, and significant past history. ABPM was performed for each patient. Urine samples, echocardiogram, and ophthalmologic fundoscopy were done to check for diabetes-related complications. RESULTS: The mean age of all participants was 56.7 ± 7.8 years. A total of 93 patients (62%) were males. 99 (66%) patients had masked hypertension. A total of 85 (56.7%) were non-dippers, 49 (32.7%) were dippers, 1 (0.7%) was extreme dipper and 15 (10%) were reverse dippers. Non-dipping and reverse dipping were associated with concentric left ventricular hypertrophy LVH (p < .001). Masked hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.008) whereas, nocturnal hypertension was associated with concentric LVH (p = .001) and nephropathy (p =.003). CONCLUSIONS: A single office blood pressure (BP) reading cannot rule out hypertension in patients with diabetes. Regardless of hypertension, clinicians should have all patients, especially patients with diabetes, undergo ABPM at least once. Masked hypertension, changes in nocturnal dipping and other phenomena that raise the risk of diabetes complications but cannot be measured by office BP can be measured by ABPM, and thus ABPM can provide a good prognostic benefit.

Vogt-Koyanagi-Harada disease during prolonged intermittent steroid therapy for chronic obstructive pulmonary disease: a case report.

Vogt-Koyanagi-Harada Disease (VKHD) is a rare systemic granulomatous autoimmune condition that affects melanocyte-rich organs including the eyes, inner ears, meninges, skin, and hair. VKHD causes chronic uveal inflammation and a loss in visual acuity in some patients. Patients generally respond well to steroid therapy. In our patient, we evidenced VKHD in the chronic recurrent stage at the time of presentation while the patient was on intermittent systemic steroid therapy. To date, no cases of VKHD have been reported in patients who were taking immunosuppressive medications. This study sheds light on the possibility that, in addition to the complex multisystem autoimmune phenomenon, other variable factors may also be implicated in the etiopathogenesis of this disease. Also, if a patient presents with subacute vision loss and an acute onset headache and encephalopathy, this differential diagnosis should be kept in mind, and the patient should be treated as soon as possible if the diagnosis is confirmed.

Psoriatic Arthritis With Dactylitis: A Case Report and Concise Review of Treatment Options.

Dactylitis is characterized by generalized swelling of a finger or toe. Though it is commonly seen, the literature on psoriatic dactylitis is scant, with the majority consisting of solitary case reports. The literature on the treatment of dactylitis is considerably more limited. Dactylitis usually responds to non-steroidal anti-inflammatory drugs (NSAIDs) or traditional disease-modifying antirheumatic drugs (DMARDs). Numerous randomized studies have lately shown the effectiveness of different biological agents in the treatment and maintenance of psoriatic arthritis (PsA) and associated dactylitis. In primary care practice, a patient may present with dactylitis without a history of psoriasis. In such cases, an attempt should be made to detect the underlying psoriasis by looking for a psoriatic patch in hidden areas viz. skin folds, groin or scalp. Here, we describe a case of PsA with dactylitis in this case report, with an emphasis on treatment and outcome. We also attempted to focus on the various treatment options for dactylitis.

Fulminant subacute sclerosing panencephalitis (SSPE) presented with acute hemiparesis in a 13-year-old girl with perinatally acquired HIV infection.

A 13-year-old girl with perinatally acquired HIV infection was admitted to us with acute onset, right-sided hemiparesis of 30 days duration and right-sided myoclonic jerks of 2 days duration affecting the face, upper and lower limbs. On examination, she exhibited increased tone and a pyramidal pattern of weakness in her right upper and lower limbs, along with spontaneous multifocal myoclonic jerks in the affected area. IgG levels in the serum and cerebrospinal fluid for measles were significantly elevated. Brain MRI depicted T2-weighted-hyperintensities in the subcortical white matter. The electroencephalogram demonstrated evidence of lateralised long interval periodic discharges. This patient had no past behavioural problems or poor academic performance. This case underlines the fact that, though subacute sclerosing panencephalitis (SSPE) is a chronic disease, a rare fulminant form of SSPE might develop acutely and atypically, with an increased proclivity for HIV-infected patients.

Very late-onset Friedreich's ataxia with rapid course mimicking as possible multiple system atrophy cerebellar type.

This 55-year-old man was admitted to the hospital with an insidious onset, progressive backward fall (due to severe truncal ataxia), dysarthria, stiffness in extremities, distal dominant muscle wasting along with behavioural changes and urinary incontinence. Clinical assessment indicated mild cognitive decline (Mini-Mental State Examination 22/27) with cerebellar, pyramidal and peripheral nerves involvement. On investigations, nerve conduction studies revealed symmetrical, sensorimotor peripheral neuropathy affecting both lower limbs. Brain and whole spine MRI revealed widespread cerebral and mild cerebellar atrophy, pons and medulla volume loss, and a normal spinal cord. Transthoracic echocardiography revealed concentric left ventricular hypertrophy. His gene analysis revealed eight GAA repeats on allele 1, and 37 GAA repeats on allele 2 in the first intron of the frataxin gene. Considering his clinical profile and genetic analysis, he was diagnosed as a case of very late-onset Friedreich's ataxia with likely compound heterozygous genotype.

Recurrent Encephalopathy with Transverse Myelitis: An Uncommon Presentation of Neurobrucellosis.

Brucellosis (malta fever) is a zoonotic infection caused by a gram-negative coccobacillus which is a facultative intracellular pathogen. It causes a chronic granulomatous infection, similar in histology to tuberculosis. Brucellosis remains a diagnostic dilemma due to misleading, nonspecific manifestations and increasing trend of unusual presentations. In brucellosis, the nervous system involvement occurs in only 5 to 7% of untreated patients, and it may manifest with encephalitis, meningoencephalitis, radiculitis, and peripheral and cranial neuropathies. Transverse myelitis is an unusual occurrence. Here, the authors are reporting an unusual case of neurobrucellosis in an elderly male patient who visited multiple hospitals with recurring febrile encephalopathy and paraparesis. The diagnosis was suspected by his occupational history of working as an abattoir worker and was confirmed by the presence of high titers of Brucella immunoglobulin (Ig) M and IgG antibodies in the serum. The patient was managed with injection gentamicin for 2 weeks along with oral course of doxycycline and rifampicin for 6 weeks. He made a good clinical recovery and went back to work with mild residual deficits.

Multiple Splenic Abscesses in a Case of Enteric Fever: Salvaging Spleen through Pigtail Drainage and Antibiotics is a Good Alternative Approach.

Splenic abscess is a rare complication of enteric fever in developing countries. This is seen mostly solitary rather than being multiple and can be fatal if untreated. In general clinical practice, multiple splenic abscesses or thick pus with septations may require splenectomy. Here, we report a rare case of enteric fever with multiple splenic abscesses in a young immunocompetent male who was successfully managed with antibiotics and percutaneous pigtail drainage of pus from the larger cavity.