Myasthenic crisis-induced Takotsubo cardiomyopathy: a case report.

Introduction and importance: Myasthenic crisis (MC) is characterized by severe weakness in the bulbar and respiratory muscles. Takotsubo cardiomyopathy (TC) is a rare clinical entity mainly associated with postmenopausal women. We report a case of both these conditions in a premenopausal woman. Case presentation: A 31-year-old woman with hypothyroidism presented with dyspnea. Bedside echocardiography in the ICU revealed an apical ballooning with an ejection fraction of 25%, and she was treated with losartan, furosemide, and spironolactone. She was intubated after 2 days as she developed respiratory distress and type II respiratory failure. Upon investigation, the patient tested positive for anti-acetylcholine receptor antibody. Treatment with five doses of IVIG (intravenous immunoglobulin) was given, and she made a remarkable recovery. Repeat echocardiography revealed her ejection fraction is normal and cardiac function is resolved. Clinical discussion: The association between TC and MC is unusual and not commonly observed. MC can be a natural progression of myasthenia gravis or due to stressors, such as infection, medicine, pregnancy, and surgery. Stressful events can lead to TC. This leads to the possibility of TC, along with other cardiac complications, in patients with MC. Conclusion: Patients with MC may be at potential risk of developing TC, thus careful cardiac monitoring is necessary while treating them for a better prognosis.

Diabetes Mellitus among Patients with Acute Ischemic Stroke Admitted to the Department of Medicine in a Tertiary Care Center.

Introduction: Diabetes mellitus is a major public health concern and a continuously growing chronic disease worldwide. Diabetes mellitus is one of the modifiable, independent, and major risk factors of ischemic stroke. This study aimed to find the prevalence of diabetes mellitus among patients with acute ischemic stroke admitted to the Department of Medicine in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted among patients with acute ischemic stroke admitted to the Department of Medicine from 19 July 2023 to 19 November 2023 after obtaining ethical approval from the Institutional Review Committee. Detailed clinical history, random blood sugar and glycated haemoglobin were used to define diabetes mellitus. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 80 patients, diabetes mellitus was seen in 25 (31.25%) (21.09-41.41, 95% Confidence Interval). Among them, 19 (76%) had previously diagnosed and 6 (24%) had newly diagnosed diabetes mellitus. The poor glycemic control was seen in 11 (44%). Conclusions: The prevalence of diabetes mellitus among patients with acute ischemic stroke was found to be higher than in studies done in similar settings. Keywords: diabetes mellitus; glycated hemoglobin; ischemic stroke.

Safety and efficacy of rituximab for relapse prevention in myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG)-associated disorders (MOGAD): A systematic review and meta-analysis.

INTRODUCTION: Myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG)-associated disorders (MOGAD) is neuroimmunological disorder manifesting as episodes of ADEM, optic neuritis, transverse myelitis, brainstem encephalitis, and other CNS manifestations and notably, distinct from multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD). Current treatment strategy is high-dose intravenous methylprednisolone followed by maintenance immunotherapy for relapse prevention. The purpose of this study is to systematically create compelling evidence addressing the role of rituximab in relapse prevention among patient with MOGAD. METHODS: This study follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. We searched PubMed, Embase, and Google Scholar for English language papers published between 2010 and 2021. Individual study proportions were meta-analyzed to yield the pooled relapse-free patient proportion. Individual studies' mean pre- and post-treatment annualized relapse ratio (ARR) and Expanded Disability Status Scale (EDSS) were used to calculate the overall mean difference. RESULTS: Our meta-analysis includes 13 studies with 238 subjects. After rituximab treatment, 55% (95% CI: 0.49-0.61) of MOGAD patients remained relapse-free. Our study found that after rituximab therapy, ARR was lowered by 1.36 (95% CI 1.02-1.71, p < 0.001). Similarly, we detected a 0.52 (95% CI: 0.08 to 0.96, p = 0.02) difference in EDSS score after starting rituximab medication. Because only a handful of the included studies documented adverse events, the safety profile of rituximab for the treatment of MOGAD could not be effectively determined. CONCLUSION: Our meta-analysis shows that rituximab effectively prevents relapses in MOGAD patients.

Evaluating cognitive outcomes in adult patients with acute encephalitis syndrome: a prospective study from a tertiary care center in Nepal.

Purpose: Although cognitive impairment is a known complication of acute encephalitis syndrome (AES), few studies have evaluated cognitive outcomes in patients with encephalitis. The primary objective of this study was to assess the cognitive profiles of patients diagnosed with AES, which is pivotal for improving rehabilitation strategies and prognostic measures. Methods: This study was conducted at the Tribhuvan University Teaching Hospital. Adult patients with AES who met inclusion criteria were enrolled. The Montreal Cognitive Assessment (MoCA) tool was used to assess cognitive function at admission, discharge, and 3-month follow-up. Results: Thirty-six patients were enrolled in our study. The mean age of the participants was 43 ± 18 years. Fourteen patients (38.9%) were female, and 22 (61.1%) were male. Tuberculous (TB) meningoencephalitis was present in 14 cases (38.9%), with herpes simplex virus (HSV) encephalitis in 14 (38.9%), bacterial meningoencephalitis in 4 (11.1%), autoimmune encephalitis in 2 (5.6%), and Japanese encephalitis in 2 (5.6%). Patients with bacterial meningoencephalitis had the highest MoCA scores at admission, whereas those with HSV encephalitis had the highest scores at discharge and follow-up. Compared with the scores at admission, the scores at discharge and follow-up increased significantly in patients with TB meningoencephalitis and HSV encephalitis. The MoCA score at discharge was established as a significant predictor of cognitive function at follow-up. Conclusion: We found that active treatment can improve the outcomes of AES patients with cognitive impairment. Although infectious etiologies are most common in low-income countries such as Nepal, autoimmune etiologies should not be overlooked.