Neurohospitalist最新文献

Introduction: Rapid correction of hyponatremia can result in osmotic demyelination syndrome (ODS). Sheehan's syndrome, a rare pituitary disorder caused by severe postpartum hemorrhage, is a potential cause of chronic hyponatremia. This case report describes a rare progression of extrapontine myelinolysis to central pontine myelinolysis, ultimately leading to ODS, following the correction of chronic hyponatremia associated with Sheehan's syndrome. Notably, this event occurred a decade after the initial postpartum hemorrhage due to placenta previa.

Case report: A 40-year-old woman from rural West Bengal, India, presented in a comatose state after five years of progressively worsening symptoms, including fatigue, gastrointestinal disturbances, cold intolerance, hair loss, and severe apathy, which had been misdiagnosed as psychogenic and treated with selective serotonin reuptake inhibitors. Two days before her admission to our hospital, she was diagnosed with a lower respiratory tract infection, dehydration, and severe hyponatremia (118 mEq/L) at a local private healthcare facility. Despite treatment with 3% sodium chloride and intravenous antibiotics, her condition deteriorated, prompting her transfer. At the time of hospitalization, the patient was diagnosed with chronic hyponatremia and hypopituitarism consistent with Sheehan's syndrome. This condition was attributed to a severe postpartum hemorrhage that occurred a decade prior, resulting from placenta previa. Initial MRI revealed extrapontine myelinolysis, and the correction of her "compensated" hyponatremia was identified as the cause of her neurological decline. Follow-up MRIs at 7 and 14 weeks confirmed the development of cavitating ODS.

Discussion: This case highlights several key points: First, even a relatively gradual correction of hyponatremia can precipitate ODS, especially in patients with chronic conditions like Sheehan's syndrome. Second, it underscores the importance of meticulous management of chronic hyponatremia to prevent severe neurological outcomes. Third, it illustrates the diagnostic challenges of differentiating Sheehan's syndrome from primary psychiatric disorders, particularly in low-resource settings where the syndrome remains prevalent. The case also emphasizes the need for awareness among healthcare providers about the potential for severe complications arising from even minor corrections in serum sodium levels in such patients.

A 38-year-old woman presented in the emergency department with acute abdominal pain. She underwent laparoscopic cholecystectomy. Postoperatively, she developed worsening abdominal pain, tachycardia, flaccid tetraparesis, urinary retention, constipation and SIADH. She also developed red-colored urine. Porphobilinogen was requested in an isolated urine sample, with the test result showing 256 mg/g of creatinine. This case didactically emphasizes the necessity of considering differential diagnosis in acute abdomen pain associated with neurological disorders.

Background: Scrub typhus is an acute febrile infectious disease highly prevalent in the Asia Pacific region, often referred to as the "tsutsugamushi triangle." This mite-borne rickettsial zoonosis is caused by Orientia tsutsugamushi, an intracellular Gram-negative organism that primarily targets endothelial cells. The resulting vasculitis leads to multisystem involvement. In terms of neurological manifestations, meningoencephalitis is the most common presentation of scrub typhus. Other frequent neurological manifestations include cranial nerve paresis, transverse myelitis, and polyneuropathy. Status epilepticus, while reported, is a rare presenting feature of this infection. Although scrub typhus has been documented to present as limbic encephalitis, there have been no previous descriptions in the literature of neuroradiological patterns affecting the basal ganglia or extra-limbic cortices in this condition.

Case report: We report a case of a 23-year-old previously healthy woman who presented with scrub typhus meningoencephalitis. The condition manifested as encephalitis with involvement of the basal ganglia and extra-limbic cortices. She presented with generalized convulsive status epilepticus, which was complicated by cortical multifocal myoclonus.

Discussion: Scrub typhus can be a significant diagnostic challenge, potentially presenting with generalized convulsive status epilepticus and mimicking both clinical and radiological features of arboviral encephalitides, such as those caused by West Nile and Japanese encephalitis viruses. Furthermore, as demonstrated in this case, its radiological presentation can resemble that of autoimmune encephalitis. Given that scrub typhus is amenable to treatment with antibiotics, such as doxycycline and azithromycin, which do not increase seizure risk, it should be considered in the differential diagnosis for patients presenting with seizures or encephalitis, especially in endemic areas.

Objectives: To highlight the importance of recognizing different presentations of respiratory failure due to myasthenic and non-myasthenic etiologies in myasthenia gravis (MG) patients.

Methods: We describe 3 patients with different presentations of respiratory failure in MG.

Cases: Patient 1 is a 49-year-old female with longstanding MG who presented with lethargy and neck weakness without notable respiratory distress. She was found to be in hypercarbic respiratory failure, which improved with plasmapheresis treatment. Patient 2 is a 58-year-old female who presented with ptosis, dysphagia, and dyspnea requiring intubation. Her hypophonia and dyspnea persisted despite escalation in MG treatment, and further workup revealed glottal stenosis secondary to granulomatosis with polyangiitis. Patient 3 is an 85-year-old female with MG presenting with refractory hypoxia, which was secondary to a large patent foramen ovale resulting in right-to-left shunting.

Discussion: All 3 cases emphasize the role of clinical reasoning and careful analysis based on thorough history taking, detailed neurologic exam and comprehensive laboratory findings to determine the etiologies for respiratory dysfunction in MG and provide appropriate treatment.

Conclusion: A lack of overt signs of respiratory distress in MG does not rule out the presence of respiratory failure due to the sedating effect of hypercapnia. There is a need to consider alternative etiologies of hypoxia in MG patients if typical symptoms or signs of MG exacerbations are absent.

Foot drop is a condition characterized by impairment of the ability to dorsiflex the foot at the ankle joint. We aim to review the literature and report a case of isolated unilateral foot drop of central causes. A 59-year-old male previously healthy presenting with a right foot drop was admitted. Severe weakness of ankle dorsiflexion with intact plantar flexion was observed. Deep tendon reflexes were normal, no clonus was appreciated, and a plantar response resulted in flexion of all toes. Neuroimaging showed a lesion in the high left frontal lobe, centered along the medial aspect of the precentral gyrus. Levetiracetam and dexamethasone were started, and after four days, the patient reported a slight improvement in his ability to dorsiflex his ankle. Abdominal imaging showed a large right renal mass with invasion of the renal pelvis fat, suggestive of renal cell carcinoma, and cytology diagnosed clear cell renal cell carcinoma. There are 25 articles containing 33 individuals with unilateral foot drop secondary to non-traumatic central causes in the literature. The mean and median age were 50.26 (SD = 20.57) and 55.5 years old (12 - 79 years). Most of the patients were males, which accounted for 55.88% (19/34). The side of the foot drop was right at 58.82% (20/34).

Background: Patients with neuromuscular disorders often require gastrostomy tube placement for feeding but routinely have contraindication to sedation due to poor airway control with intubation avoided at the risk of ventilator dependence.

Purpose: To assess the feasibility of percutaneous gastrostomy tube (G-tube) placement using only local anesthesia in patients with neuromuscular dysfunction.

Research design: A retrospective chart review was performed from 2013 to 2019 for all patients who underwent percutaneous G-tube placement under local anesthesia only.

Study sample: 12 patients (6 females, 6 males; mean age = 52.3 ± 21.8) with neuromuscular disorders underwent G-tube placement with only local anesthesia.

Data collection: Data collected included demographic data, medical history (source of neuromuscular dysfunction), procedural information, and complications.

Results: Technical success was achieved in 100% of patients with no major complications.

Conclusion: Placement of a percutaneous gastrostomy tube using only local anesthesia is safe and feasible in patients who have a contraindication to sedation due to poor airway control and for whom intubation is avoided due to risk of ventilator dependence.

We present a 22-year-old male with a subacute course of chin numbness, ophthalmoplegia, headache and left leg numbness in the setting of fever, chills and night sweats. Initial imaging investigations revealed cauda equina enhancement plus an infiltrative process at the basis of the skull associated with extensive bone marrow infiltration and lymphadenopathy elsewhere. We discuss the localization, differential diagnosis, and appropriate investigations for this unique clinical scenario. Important laboratory findings and treatment considerations are reviewed for this unusual final diagnosis.

Acute focal neurological deficits demand immediate evaluation. In this report, we present the case of a woman 20-some years of age with a history of hemolytic anemia and thrombocytopenia who presented with altered mental status and focal neurological deficits including aphasia, acute left gaze preference, right homonymous hemianopsia, right lower facial weakness, and right arm and leg weakness. Extensive neurological and hematological workup revealed that the patient suffered from focal status epilepticus associated with an extreme delta brush patten on electroencephalogram, likely secondary to thrombotic thrombocytopenic purpura. This case underscores the connection between hematological disorders and the neurological axis, emphasizing the critical role of integrating the neurological examination and neuroimaging findings to formulate an effective management plan.

Anti-leucine rich glioma inactivated 1 (LGI-1) autoimmune encephalitis (AE) typically presents with cognitive impairment, faciobrachial dystonic seizures (FBDS) and hyponatraemia. Reports are growing of neurological complications following coronavirus disease 2019 (COVID-19) vaccination. Here we describe a 50 year old man who developed anti-LGI-1 limbic encephalitis and autoimmune epilepsy 4 days following a dose of the mRNA Pfizer COVID-19 vaccine (of note, his first two vaccinations were viral vector ChAdOX1-S). He presented with focal aware seizures characterised by short-lived episodes of confusion, emotional distress and déjà vu associated with palpitations. He also reported subacute progressive amnesia. He responded well to high-dose steroid and subsequent immunoglobulin therapy. To our knowledge, this is the first reported case of anti-LGI-1 AE following a mixed COVID-19 vaccination regimen. We aim to complement the early literature on this post-COVID-19 vaccination phenomenon.

We present a case report of a 38-year-old woman who presented to the hospital with acute onset high amplitude, non-rhythmic, hyperkinetic movements of the right upper extremity, abnormal sensation of the right upper extremity from the elbow to the hand, and the inability to recognize her hand without visual input. This case discusses the differential diagnoses of acute hyperkinetic movement disorders and concurrent alien-limb in a patient presenting within the time window for vascular intervention. Readers are led through the reasoning behind acute interventional decision-making in a patient with a rare presentation. Workup reveals the eventual diagnosis.