RESUMO
Longitudinally extensive transverse myelitis (LETM) is a rapidly progressing demyelinating disease affecting the spinal cord over three or more vertebral segments. Most causes are idiopathic, while others include infections, autoimmune causes, central nervous system demyelinating diseases, and post vaccination. Here, we report a 37-year-old male who presented with a fever for six days with no source of infection and complained of pain and weakness in the bilateral lower limbs eight hours after admission. Though the neurological examination of the lower limbs was normal at that time, reduced power was detected 16 hours later, with loss of proprioception and sensation of pain with a sensory level at T4 vertebrae. Then, the patient became unable to vocalize, and the chest X-ray showed an elevated left hemidiaphragm. Thirty hours after admission, the patient went into type 2 respiratory arrest and was intubated. The magnetic resonance imaging (MRI) showed a longitudinally extensive transverse myelitis extending from the C2 vertebrae to the conus medullaris. Febrile illness is common in the medical setting in Sri Lanka, but its association with LETM is unusual. Since LETM is very rare and is a rapidly progressive disease, a high degree of clinical suspicion is crucial for early diagnosis and the initiation of treatment. This case underscores the importance of early diagnosis, which would require timely MRI, and prompt treatment with intravenous (IV) glucocorticoids or plasma exchange to reduce morbidity and mortality.
RESUMO
Diabetic striatopathy is a rare neurological complication of diabetes mellitus that presents with sudden onset hemichorea or hemiballismus and is associated with hyperglycemia and striatal abnormality, either by hyperdensity on non-contrast computer tomography or hyperintensity on T1-weighted magnetic resonance imaging. Here we report a 55-year-old female, from Sri Lanka, who presented with involuntary movements of the left upper and lower limbs. Her past medical history included diabetes mellitus and she was on warfarin 5 mg daily for a mechanical mitral and tricuspid valve replacement. The random blood sugar on admission was 462 mg/dL and the last INR was 3.03. While hemiballismus has multiple etiologies, intracranial hemorrhage would be the main differential in a patient on anticoagulation. Other differentials include drug-induced dyskinesia, metabolic abnormalities, and autoimmune etiologies. Hemiballismus in the presence of high blood glucose should always raise the suspicion of diabetic striatopathy. The non-contrast computed tomography of the brain showed hyperdensity in the right-side caudate nucleus, lentiform nucleus, and globus pallidus which is a characteristic of diabetic striatopathy but could have been mistaken for an intracranial hemorrhage. The involuntary movements improved with glucose control and treatment with clonazepam and tetrabenazine. This case highlights the potential for misdiagnosis of diabetic striatopathy as an intracranial hemorrhage in a patient on warfarin, which can lead to delays in appropriate management and erroneous omission of warfarin. Early recognition and treatment of diabetic striatopathy can lead to significant improvement in the quality of life.
RESUMO
BACKGROUND: Early recognition and the optimal management of anaphylaxis saves lives but studies from different countries have demonstrated gaps in knowledge and practices between healthcare workers. There is a paucity of such data from Sri Lanka. We assessed knowledge, perception and self-confidence in the diagnosis and management of anaphylaxis amongst pre-intern medical graduates who would soon become first-contact doctors attending emergencies. METHODS: This cross-sectional study included pre-interns who graduated with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees in 2019 from three Sri Lankan universities with differing undergraduate curricula. Using consecutive sampling data were collected within four months of the final-MBBS examinations with a self-administered questionnaire and the answers on case diagnosis and management were used as the basis of outcome scores. RESULTS: 385 participants responded (response rate: 91.5%). 16.4% correctly identified all anaphylaxis triggers. Only 7.3% correctly diagnosed all ten case scenarios and 34.5% all seven cases of anaphylaxis. 98.2 and 97.9% correctly identified 1:1000 adrenaline as the first-line treatment and the intramuscular route. 9.9% would preferentially but incorrectly use the intravenous route if access was available. Only 79.2 and 55.6% knew the correct adult and paediatric doses of adrenaline and 50% agreed that follow-up care was needed. The mean scores for case diagnosis and management of anaphylaxis were 7.7/10 ± 1.4 and 16.9/20 ± 1.9, respectively. Multiple linear regression indicated that the final MBBS results classification (class of degree or no class indicated) was a positive predictor of case diagnosis score [class vs no class: B = 0.662 (95% CI 0.347-0.978), p < 0.001] and being a graduate of University 2 [B = 1.568 (95% CI 1.182-1.953), p < 0.001] and passing with a class at final MBBS [B = 0.716 (95% CI 0.319-1.113), p < 0.001] were positive predictors of management score. Self confidence in diagnosing and managing anaphylaxis were rated as 79.7 and 62.1% and there was a positive correlation between knowledge and perception scores and self-confidence (case-diagnosis: rpb = 0.111, p = 0.03; management: rpb = 0.164, p = 0.001). CONCLUSIONS: Knowledge, perception and self confidence in the diagnosis and management of anaphylaxis was sub optimal amongst pre-interns and we identified areas that need improvement. A higher MBBS qualification classification was a predictor for correct diagnosis and management and confidence in diagnosis and management positively correlated with knowledge and perception scores. Further and enhanced educational and training strategies are needed for this life threatening emergency condition.
