Electroconvulsive therapy [ECT] for the management of neuroleptic malignant syndrome [NMS] in adults

Objective: To determine the efficacy and safety of electroconvulsive therapy [ECT] for the management of neuroleptic malignant syndrome [NMS] in adults. Study Design: Open label, unblinded series. Place and Duration of Study: This study was carried out at the Department of Neurology, Military Hospital Rawalpindi, from Jan 2015 to Dec 2015

Material and Methods: All the patients with the diagnosis of NMS during the study period were included in the study. Consective non-probability sampling technique was used. Patients were divided into two groups; uncomplicated and complicated cases of NMS

Results: A total of nineteen patients were included in this pilot study. Out of all, thirteen [68.4%] were males and six [31.6%] were females. Mean age of the patients was 35.05 [SD 13.362] years. The drug classes causing NMS were antipsychotic medicines in 73.7% of patients and antiemetics in 26.3% of patients. Mean electroconvulsive therapy [ECT] sessions given were 6.16 [SD 2.062]. Following treatment n=16 [84.2%] patients had complete recovery while n=3 [15.3%] patients died

Conclusion: In this small, open label, unblinded study ECT appears effective and safe in treating NMS in adults. Larger randomized studies will help to confirm data emerging from this preliminary study

Characteristics and outcomes in patients with anti N-Methyl-D-Aspartate receptor auto-immune encephalitis

Objective: To study characteristics and outcome in patients with anti-N-Methyl-D-Aspartic Receptor encephalitis. Study Design: Retrospective observational cohort. Place and Duration of Study: Neurology Department Military Hospital Rawalpindi, from Feb 2015 to Sep 2016

Material and Methods: Data of patients admitted with anti-n-methyl-D-aspartate receptor encephalitis was analyzed retrospectively. Patients were classified as having definite or probable anti-N-methyl-D-sspartate receptor encephalitis whether antibody testing in CSF was positive or negative respectively and fulfillment of other defined parameters. Patient characteristics, treatment protocols and outcomes were noted

Results: Eleven patients were included in this cohort. Six [54.5%] were males and 5 [45.5%] were female. Mean age was 31.18 years [SD 14.865]. Mean day to symptom onset was 18.51 days [SD 16.646]. Abnormal behavior was seen in 90.9%, Seizures and movement disorder in 81.8%, speech dysfunction in 72.7%, decreased level of consciousness in 63.6% and autonomic dysfunction in 54.5% anti-N-methyl-D-aspartate receptor antibodies were done in CSF in 3 patients only out of which 2 were positive. In remaining nine patients antibody testing was not done due non availability of facility and or affordability. Out of eleven patients 2 [18.25%] had definite encephalitis and 7 [81.8%] had probable encephalitis. CSF was abnormal in 63.6% with pleocytosis in 18.2% and oligoclonal bands in 45.5%. EEG was abnormal in 72.7% and MRI was annormal in 36.4%. Outcome was favorable in 63.6% and unfavorable in 36.4%

Conclusion: In this study we were able to determine that patients with anti-N-Methyl-D-Aspartate Receptor encephalitis have a favorable outcome if diagnosed and treated aggressively early in the course of disease

Neuro-psychiatric manifestations of hashimoto thyroiditis; a case series

Hashimoto Encephalopathy [HE] or Steroid-Responsive Encephalopathy associated with Autoimmune Thyroiditis [SREAT] is a rare autoimmune disease characterized by encephalopathy and elevated anti-thyroid antibodies in the absence of a central nervous system [CNS] infection, tumour or stroke. Clinical presentation of HE includes amnestic syndrome, seizures including status epilepticus, ataxia, myoclonus and psychiatric manifestations like depression, mania, psychosis and hallucinations. A good clinical response can be achieved with corticosteroid therapy so early diagnosis and treatment is very beneficial for patients. Here we report four patients with Hashimoto encephalopathy who had neuro-psychiatric manifestations of the disease and had detectable thyroid specific antibodies in the serum [thyroperoxidase antibody formerly known as antimicrosomal antibody]. All these patients showed an objectively significant response to methylprednisolone treatment

Neurological manifestations of primary Sjogren's syndrome [Pss]

Objective: To determine prevalence, clinical patterns and outcomes of neurological involvement in a cohort of primary sjogren's syndrome [PSS] patients presenting to a tertiary care hospital

Study Design: Observational retrospective cross-sectional case-control

study. Place and Duration of Study: This study was carried out at Neurology department of Pak Emirates Military Hospital, Rawalpindi, from May 2015 to Jun 2016

Patients and Methods: All patients fulfilling American College of Rheumatology [ACR] criteria of PSS and having neurological involvement, who were admitted in Neurology wards from May 2015 to June 2016, were included in the study. Demographic, clinical and seroimmunological data of the patients was documented

Results: A total of 26 patients with PSS had some degree of neurological involvement. Mean age was 40.50 years. [SD 14.803, min 22, max 78]. Fifteen patients were female and 11 were male. Sicca symptoms [ocular and oral dryness] were present in 38.5 Percent. Serological marker anti Ro and La were present in 76.9 Percent and 42.3 Percent respectively while both Ro and La were present in 34.6 Percent. Lip biopsy was diagnostic in 80.8 Percent and schirmer test was positive in 46.2 Percent. Refractory headache was present in 84.6 Percent. Seizures occurred in 34.6 Percent, which were focal in 23.1 Percent and generalized in 11.5 Percent. Trigeminal neuralgia was present in 26.9 Percent, multiple cranial nerve palsies in 15.4 Percent and recurrent facial nerve palsies in 11.5 Percent. Optic neuritis was seen in 19.2 Percent. Clinical presentation mimicking relapsing and remitting multiple sclerosis was seen in 30.8 Percent of patients among whom 61.5 Percent also met revised McDonald criteria for dissemination in space [DIS] on MRI and 23.1 Percent met criteria for dissemination in time. MRI brain showed cortical lesions in 42.3 Percent. Longitudinally extensive transverse myelitis involving cervical and upper thoracic cords was present in 26.9 Percent of patients

Conclusion: The diagnosis of neuro-sjogren's syndrome [NSS] can be difficult in the absence of sicca symptoms especially when neurological manifestations precede sicca symptoms by many years. This requires a high index of clinical suspicion and low threshold for investigations like lip biopsy and autoantibody profile for the diagnosis. This study highlights the need to revise the overemphasis of sicca symptoms in various current diagnostic criteria in order to improve early recognition and initiation of treatment

Frequency of resistant hypertension in a hypertensive population

To determine the frequency of resistant hypertension in hypertensive population. Descriptive study. CMH Kohat, Pakistan from Aug 2010 to Dec 2010. One hundred and fifty patients were selected for the study. All had blood pressure > 140/90 mmHg despite use of 3 antihypertensive drugs including one diuretic. Once admitted, patients were given the same medicines in the doses which they were taking under DOT [direct observed therapy] programme executed by a nursing assistant to exclude non-compliance to treatment. All the data was analyzed using SPSS version 16. Out of total 150 patients, 96 [64%] patients were males and 54 [36%] were females. Male to female ratio was 1: 1.8. Mean age was 46.93 years [SD +/- 16.38]. Compliance of patients to anti hypertensive treatment was ensures by DOT. There was no step up treatment. Mean BMI was 25.95 kg/m[2] [SD +/- 2.38], patients 71.3% were overweight i.e. BMI > 25 kg/m[2]. Out of total 150 patients, 16 [10.7%] patients had resistant hypertension using the cut off value of BP >140/ 90 mmHg. A significant number of hypertensive patients are suffering from resistant hypertension. Such patients need further evaluation to rule out any genetic, secondary and life style/diet related cause

Sputum neutrophilia in severe persistent asthmatics

Objective: To determine the frequency of sputum neutrophilia in patients with severe persistent bronchial asthma. Study Design: A cross-sectional study. Place and Duration of Study: Department of Medicine, Military Hospital, Rawalpindi, from November 2009 to November 2010

Methodology: Cases of severe persistent bronchial asthma, aged between 12 and 40 years, were included. Sputum samples were collected by induction with hypertonic saline [4.5%]. All samples were centrifuged and differential neutrophil count was calculated. Data was analyzed using SPSS 11

Results: Out of 195 patients, there were 129 [66.2%] males and 66 [33.8%] females. The mean age was 27.01 +/- 6.92 years. Mean sputum neutrophilic count was 126.47 +/- 16.52 x 106/ml and the mean neutrophilic percentage was 63.187 +/- 8.3363. Sputum neutrophilia was present in 84 patients [43.1%], out of whom, 56 were males and 28 females. In patients with sputum neutrophilia, mean neutrophilic count was 142.40 +/- 8.49 x 106/ml and the mean neutrophilic percentage was 71.2024 +/- 4.2441%

Conclusion: Sputum neutrophilia is a frequent finding in cases with severe persistent bronchial asthma. Presence of sputum neutrophilia in such cases can lessen the inappropriate use of corticosteroids with their associated long-term side effects