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@#<p style="text-align: justify;"><strong>INTRODUCTION</strong><strong>:</strong> Both myasthenia gravis (MG) and autoimmune thyroid diseases (AITDs) are autoimmune diseases. Graves'disease (GD) is the most common AITD reported to be associated with MG. Currently, there is limited data on prevalence and clinical features/outcomes of MG in various thyroid diseases in a large database report.</p><p style="text-align: justify;"><strong>METHODOLOGY:</strong> A total of 872 patients with MG and 97,251 patients with thyroid disorders had been recorded by the tertiary hospital database. The study period was between 1997 and 2017. Patients with a thyroid disorder and MG were identified by the ICD-10-CM code. Clinical courses of MG accompanied by thyroid disorders were studied.</p><p style="text-align: justify;"><strong>RESULTS:</strong> During the 20-year study period, there were 872 patients with MG and 97,251 patients with thyroid disorders. In the group with thyroid disorders, 28,886 patients (29.70%) had GD, 1,612 patients (1.66%) had Hashimoto's thyroiditis, 13,172 patients (13.54%) had toxic goiter and 53,581 patients (55.10%) had nontoxic goiter. 97 patients had been diagnosed with both MG and thyroid disorders. Among the four types of thyroid disorders, the rate of MG was highest in HT group (9.92/1,000 HT patients). There were four significant factors among four groups of thyroid disorders including age of onset of thyroid disease (p 0.004), MG classification (ppp 0.034). Among the four groups of thyroid disorders, patients with MG and HT were diagnosed with thyroid disease at the youngest age (27 years) compared with other thyroid diseases. Additionally, the MG patients with HT also had the highest proportion of MG class 4-5 a/b (7 patients, 43.75%), received prednisolone treatment (15 patients, 93.75%), received immunosuppressants (9 patients, 56.25%), received IVIG or PLEX (5 patients, 31.30%), and had thymoma (6 patients, 46.15%).</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> MG is most prevalent in patients with HT. Patients with both MG and HT had more severe MG status and had higher rate of thymoma.</p>
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Humans , PrevalenceABSTRACT
Background & Objective: Acute ischemic stroke (AIS) has been shown to be effectively treated with thrombolytic therapy. Thailand and other developing countries have limited stroke specialists to prescribe this treatment. Data regarding stroke outcomes in AIS patients who received thrombolytic therapy prescribed by neurologists compared with non-neurologists are limited. Methods: This was a large, multicenter, retrospective study conducted in 9 hospitals across the northeastern part of Thailand. The inclusion criteria were AIS patients who were admitted and treated with thrombolytic therapy between January 2010 and December 2012. Patients were categorized into two groups by physician specialty; neurologist and non-neurologist. Clinical outcomes and in-hospital mortality were compared between the groups. Results: There were 915 AIS patients who participated in the study; 175 patients were treated by the non-neurologists (19.1%). The mean age of all patients was 64 years and 55.1% were men. The median onset to needle time in both groups were similar at 180 minutes. The National Institutes of Health Stroke Scale (NIHSS) at discharge were significantly higher in neurologist group than non-neurologist group (NIHSS 6 vs 3, p value 0.03). The in-hospital mortality was also higher in neurologist group (9.5% vs 4.0%; p value 0.02). Conclusions: Non-neurologists may be able to thrombolyze AIS patients safely and effectively.
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Stroke , Thrombolytic TherapyABSTRACT
Four cases of Guillain-Barré syndrome (GBS) after diphtheria and tetanus vaccine (dT) during diphtheria outbreak in Thailand are reported. Three cases had an age over 60 years, and developed GBS after the second dose of dT vaccine. Two cases received intravenous immunoglobulin and had improvement after treatment. The autoantibodies or anti-ganglioside antibodies are believed to be the possible explanation of GBS associated with vaccination. Data regarding post-dT vaccine GBS are limited in Asian populations particularly on clinical presentation and outcomes.
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Isolated acute bulbar palsy has been described as one of the more rare variants of Guillain-Barré syndrome. IgG anti-ganglioside antibodies are associated with axonal subtypes of Guillain-Barré syndrome as well as Fisher syndrome. However, IgG against GM3 and GT1b in relation to bulbar palsy is uncommon. In this case report, we describe a 64 year-old male patient presenting with isolated bulbar weakness and generalized hyporeflexia without limb weakness. Serological testing for antiganglioside antibodies was positive for IgG anti-GM3 and -GT1b, suggesting the association of these antibodies with isolated bulbar palsy.
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Background: Epilepsy is a common disease but to achieve successful seizure control in developing countries is still a challenge. This study aimed to investigate the epilepsy services in Thailand. Methods: This was a survey by questionnaires on epilepsy service sent to 1,033 public hospitals all over Thailand. Results: The response rate was 54.1%. The results show that most of physicians that provide care for persons with epilepsy were General Practitioners (91.5%). Epileptologists and Neurologists accounted for only 11.1% and 14.4%. There were only 52 EEG, 54 CT Scan, and 6 MRI instruments in the entire country of 65 million. Standard antiepileptic drugs (AEDs) were widely available, phenobarbital (99.9%), phenytoin (96.0%), carbamazepine (97.9%), and valproic acid (89%) of institutions. The availability of new AEDs were: gabapentin (77.6%), topiramate (63.9%), levetiracetam (46.0%), lamotrigine (45.3%), pregabalin (33.6%), were also available in 77.6%, 63.9%, 46.0%, 45.3%, 33.6%, vigabatrin (14.5%), and oxcarbazepine (14.3%) of institutions. Intravenous AEDs used for status epilepticus patients include phenytoin (54.2%), phenobarbital (33.9%), and sodium valproate (12.1%). Therapeutic drug monitoring could be done in 45.7% of the responding hospitals. Conclusion: There is limited human and material resources for the care of epilepsy in Thailand. There is a need to develop a model of epilepsy care that is appropriate with the limited resources in the country.
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Background: Oral topiramate is a broad-spectrum antiepileptic drug. There is limited documented data on its use in refractory convulsive and non-convulsive status epilepticus. Methods: A retrospective study of the clinical characteristics and responses of patients diagnosed as status epilepticus treated with topiramate at the Srinagarind Hospital, Khon Kaen University from 2001-2010. Results: There were 8 patients included in this study, 6 patients were convulsive status epilepticus and 2 patients were non-convulsive status epilepticus. The most common cause was stroke seen in 4 patients. Oral topiramate successfully controlled status epilepticus in 7 out of 8 patients with no serious adverse events. Of these 7 patients, status epilepticus was controlled after initial loading and re-loading of oral topiramate in 3 and 4 patients, respectively. In two patients with hepatitis, oral topiramate was successful after failure with benzodiazepine. The initial loading dose of topiramate in most cases was 400 mg with a maintenance dose of 100 mg/day. Conclusion: Oral topiramate has the potential to treat both convulsive and non-convulsive status epilepticus after failing the fi rst antiepileptic drug. Further study with larger number of patients is needed to confi rm this.
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Background : Status epilepticus (SE) is an emergency condition and contributes to high mortality rate if patients were misdiagnosed and improperly managedObjective: To describe characteristics and management of patients with SE in Srinagarind Hospital.Setting : Medical ward, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University.Patients: Patients diagnosed as SE, between 1990-1996.Design : Descriptive study.Results : Thirty cases were diagnosed as SE, 18 male, and 12 female. Types of seizures were generalized tonic – clonic sezure (GTC) in 25 cases and epilepsia partialis continua in 5 cases. Seven cases were diagnosed as having epilepsy in the past. Causes of SE (GTC) were CNS infection in 7 cases, antiepileptic drug withdrawal in 6 cases, post arrest in 3 cases, antiepileptic drug withdrawal in 6 cases, post arrest in 3 cases, hyperglycemia in 1 case, hypertensive encep-halopathy in 1 case and unknown in 4 cases. Eighteen GTC patients were improperly managed (72.00%) ,the common causes were too low phenytoin for loading dose and incorrect diagnosis. Mortality rate was 56.00% , cause of death were sepsis and brain herniationh.Conclusion : SE is an emergency condition, common causes were CNS infection and antiepileptic drug withdrawal and contributed to high mortality rate of 56.00%. Eighteen patients (72.00%) were improperly managed.
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Background : Rheumatic heart disease is the most common of valvular heart disease in Thailand and contributes to cerebrovascular disease.Objective : To study clinical features and recurrent rate of cardiogenic cerebral embolism in Srinagarind HospitalDesign : Descriptive studySetting : Srinagarind Hospital, Faculty of Medicine, Khon Kaen UniversityOne hundred and ten patients who were diagnosed cardiogenic cerebral embolism in department of internal Medicine service between 1983 and 1989.Measurement : Clinical features, history of previous stroke, underlying disease, atrial fibrillation, left atrial colt and recurrent rate by percentage.Results : There were 110 cases, 48 male and 62 cases were female. The patients’ mean age at diagnosis was 48.36 years (20-89 years). The main symptoms were hemi paresis (97.27%), aphasia (35.45%), alternation of conscious (32.73%), seizure (11.82%) and hemi anesthesia (10.00%). Underlying diseases were rheumatic heart disease (79.10%), non-valvular AF (11.82%), ischemic heart disease (4.55%), congenital heart disease (2.73%), prosthetic valve (0.90%) and endocarditic (0.90%). Sixty-five patients had echocardiogram, left atrial thrombus was found in 13 cases (20.00%). The most common abnormal valve was mitral valve. A trial fibrillation was found in 54 cases(62.00%). Three patients developed recurrent stroke within 2 weeks. Mortality rate was 15.45%, the most common cause of death was brain herniation (64.70%).Conclusion : Cardiogenic cerebral embolism was the most common cause of stroke in the young. The most common cause was mitral valve stenosis with atrial fibrillation. Recurrent rate within 2 weeks was 3.45%. The cause of death was brain herniation.
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Introduction : Cavernous sinus syndrome is a disorder characterized by paralysis of cranial nerve 3, 4 6, and 5. Causes of this syndrome are infectious and non – infectious source, such as mucormycosis, bacteria and malignancy. Delay in diagnosis and improper management contributed to high mortality rate. We report cavernous sinus syndrome patients at Srinagarind hospital for recognition and clinical comparison between mucormycosis and non – mucormycosis. Patient and Method : Review of patient charts from 1985 to 1994 at Srinagarind Hospital, Department of medicine, Faculty of Medicine, Khon Kaen university with sinus thrombosis.Result : There were 25 patients, 9 male, 16 female, male to female ratio was 1:1.7, age range form 30-79 years, mean was 55.08 years. Common presenting symptoms were headache 96%, eye pain 76%, visual impairment 56% ptosis 52% . Physical examination showed paralysis of CN 3,4,6 100%, visual impairment 90%, chemosis 72%, proptosis 64%, black crust 28% weakness 20% and associated with sinusiis 80% . Underlying diseases were diabetes mellitus 48% and chronic renal failure 20%. Mortality rate was 54% . The common causes of cavernous sinus syndrome were mucormycosis 60% , bacteria 36% and lymphoma 4%. Clinical comparison between mucormycosis and non-mucormycosis, visual impairment, weakness, black crust were more common in mucormycosis group, high level of BS, BUN and CSF sugar to BS ratio were more common in mucormycosis group too, but fever was more common in non-mucormycosis group (P
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Churg-Strauss syndrome (CSS) is a rare syndrome, but steroid responsive systemic vasculitis. The major presentation compose of asthma, cutaneous vasculitis, abdominal pain and mononeuritis multiplex. We reported a case of Churg-Strauss Syndrome and review related iterature. A 41 year-old married Thai male patient had history of asthma 8 months ago. Two months later, he had recurrent asthmatic attack with hemoptysis, abdominal pain, diarrhea and generalized purpura. Five months after that he had progressive paresthesia and weakness all extremities and unable to walk by himself. The physical examination showed atrophy of both intrinsic hand muscles, muscle powers were grade 4/5. Deep tendon reflexes were decreased and there was asymmetrical impairment of sensation of both hands and feet. The results of investigation revealed eosinophilia, high ESR. Nerve biopsy showed acute demyelinating and axonopathy. He improved after steroid treatment. CSS is more common in male than female. All patients have asthma, systemic vaculitis and eosinophilia. CSS has the multisystem involvement, monoeuritis multiplex, abdominal pain cutaneous vasculitis. heart failure and arthritis. Diagnosis base on criteria four of six; asthma, eosinophilia\> 10%, neuropathy, nonfixed pulmonarty infiltration, paranasal sinus abnormality and extra vascular eosinophils. CSS usually respond to steroid treatment. We report a case of CSS and review related literature
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Objective : To study prevalence and clinical features of myasthenia gravis (MG) and myasthenia gravis with hyperthyroidism (MGHT) Design : Case review study Setting : Srinagarind hospital, Faculty of Medicine, Khon Kaen University Patienes : One hundred and four patients who were diagnosed as MG and MGHT in Department of Internal Medicine service between Januay 1891 and May 1992. Measurement : Prevalence of MGHT, history of fatigability, fluctuation, staging, symptoms and signs, prostigmine test and treatment by thymectomy in MG and MGHT by percentage and Z – test ( P = 0.05) Results : One hundred and four records were available for review, there were 85 cases of MG and 19 cases of MGHT that made the prevalence of MGHT of 18.3%. Regarding the staging of disease, in MG group of patients only 8.2% were in stage I compared to 31.6% in MGHT group( P = 0.003). Ninty four percent of MGHT patients seeked medical attention within 1 year after having MG, but there were only 77.2% in MG patients ( P = 0.048). Concerning thymectomy, in the patients who had stage IIA and above, 58 / 78 (74.4%) were thymectized in MG group. There were only 5/13 (38.5%) in MGHT group went for thymectomy (p = 0.048). The other clinlical features were comparable. The pathological findings of 50 patients in MG group were thymic hyperplasia 34 cases (68%) , htymoma 2 cases, malignant thymoma 1 case atrophic change 5 cases and normal 8 cases. In MGHT goup were thymic hyperplasia 4 cases and involuted 1 case. Concludions : The prevalence of myasthenia gravis with hyperthyroidism in our study is 18.3%, which probably is the highest among all series. There were differences in some clinical features between MG and MGHT. MGHT patients were in stage 1 more frequent, seeked medical aedical altention earlier and MGHT patients went for thymectomy less frequent.
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Introduction : Epilepsy is a common disease, some patients have only symptoms during sleep. The patient thinks this condition is sudden unexplained nocturnal death syndrome (SUNDS)Objective : To study characteristics of patients with nocturnal epilepsy (NE), and compared clinical features between NE and Sunds.Patients : Patients were diagnosed as NE.Setting : Department of Medicine,Srinagarind Hospital, Faculty of Medicine, Khon Kaen University.Design : Descriptive study.Results : Five cases were diagnosed of NE, 3 male and 2 female. Mean age was 38 years old. All patients denied family history of epilepsy. Duration of symptoms before diagnosis was 19.8 months. Types of seizures were generalized seizure in 4 cases and complex partial seizure in 1 cases. CT-scan brain was done in 4 cases and the results were normal. Electroencephalography was done in 3 cases and the results showed epileptic activity at right frontoparietal in only one case. All patients had clinically improved with antiepileptic drugs.Conclusion : NE was found in both sex and all age groups. The patient denied family history of epilepsy. NE had no cyanosis during attack. These characteristics were different from SUNDS.
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Background: Rheumatic heart disease is the most common valvular heart disease in Thailand and contributes to cerebrovascular disease.Objective:To study underlying diseases , recurrent rate and complication of anticoagulant therapy of cardiogenic cerebral embolism in Srinagarind Hospital.Design: Descriptive studySetting: Srinagarind Hospital, Faculty of Medicine, Khon Kaen University.Subjects: One hundred and eighty four patients who were diagnosed cardiogenic cerebral embolism in department of internal medicine service between 1985 and 1996.Measurement: Underlying diseases, atrial fibrillation, long term follow up, recurrent rate and complication of anticoagulant therapy by percentage.Results: There were 184 cases, 81 males and 103 females. The patients’ mean age at diagnosis was 47.50 years (15-89 years). Underlying diseases were rheumatic heart disease (70.10%), non-valvular AF (9.23%), dilated cardiomyopathy (6.20%), bacterial endocarditis (3.80%) , ischemic heart disease (3.26%) , mitral valve prolapse ( 2.10%) , hyperthyroidism ( 2.10%) , prosthetic valve ( 1.63%) , hypertrophic cardiomyopathy ( 1.05%) and ventricular septal defect with pulmonic stenosis ( 0.53%). Atrial fibrillation was found in 124 cases ( 67.39%). Thirty nine patients (30.24%) were rheumatic heart disease without atrial fibrillation. Recurrent rate within first year was 19.04%. Intracerebral hemorrhage caused by anticoagulant therapy was 4.34%.Conclusion: Cardiogenic cerebral embolism was the most common cause of stroke in the young. Although the most common cause was rheumatic heart disease with atrial fibrillation but there were about 30% of rheumatic heart disease patients that still have normal sinus rhythm. Recurrent rate within one year was 19.04% while intracerebral hemorrhage caused by anticoagulant therapy was only 4.34%.Key words : Cardiogenic cerebral embolism, rheumatic heart disease, atrial fibrillation
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Introduction : Cerebral infarction in the young adult is uncommon. However, this condition is important. Because stroke in the young adult could be prevented and treatment if there is a definite cause. These patients are let to have nearest normal life style. This can be achieved by find out and modification risk factors. Certainly, modification of risk factor is benefit for treatment and prevention of recurrence.Objective : To study risk factors, clinical signs and prognosis of cerebral infarction in the young patientsPopulation: Fourty-six patients with cerebral infarction of age between 15 to 45 years old, who was treated in Medical department, Srinagarind Hopsiptal, during August 1996 to December 1998.Methodology : Descriptive studyResult : There are 46 patients, 23 were male and 23 were female. The common underlying diseases were DM, HT and valvular heart diseases (VHD). There were smoker 17.39 percents, mean of pack-year was 2.66. On physical examination, 8 patients had HT, 11 patients had VHD and 5 patients had artial fibrillation (AF). All of the patients had done CT or MRI brain and tranesophageal echocardiogram (TEE), 37 patients had abnormal brain imaging finding. The most abnormal area was basal ganglia (11 of 37). Twenty-two patients had abnormal TEE findings, 3 patients had LA clot, 9 patients had mitral value stenosis (MS), 7 patients had patent foramen ovale (PFO), 5 patients had other VHD and 1 patient had cardiomyopathy. Causes of cerebral Infarction were atheroscierosis 14/46 (30.43%), cardiogenic cerebral embolism 12/46 (6.1%) and unknown cause 20/46 (43.48%). Risk factors were DM, HT, smoking and dyslipidemia. The most complications were urinary tract infection. Two patients (4.3%) had recurrent stroke in 2 weeks, 1 patients within 2 year Duration of follow up more than 1 year was 54.3% (14 to 48 months, mean was 46 months). There was no any death during the follow up time.Conclusion : The most common causes of stroke in the young adults was unknown cause, atherosclerosis and cardiogenie cerebral emboli respectively. Risk factors for atherosclerotic were DM, HT, smoking and dysispidemia. Rheumatic MS was the most common cause of cardiogenic cerebral embolism. There is no relation between PFO and stroke in the young.