Status Epilepticus in Srinagarind Hospital

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. 

Cardiogenic Cerebral Embolism in Srinagarind Hospital

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.

Cavernous Sinus Syndrome : A clinical comparison between mucormycosis and Non-mucormycosis

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

Chrug-Strauss Syndrome; A Case Report and Review of Literature

 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 

POEM SYNDROME: A CASE REPORT

“POEMS Syndrome” associated with plasma cell dyscrasia, is an acronym that stands for uncommon syndrome involving multisystem.  The major features are chronic progressive sensorimotor polyneuropathy, organomegaly (mainly hepatomegaly and lymphadenopathy) endocrinopathy (especially gonadal failure and diabetes mellitus), monoclonal gammopathy and skin changes.  In typical case, papilledema, high CSF pressure and CSF potein, anasarca and clubbing of fingers are found. Most cases were reported from Japan, and rarely reported from United States, Europe and other parts of Asia. We report a Thai woman who initially presented with chronic diarrhea, edema and kin changes, then the other complete features of POEMS syndrome were revealed later.

Prevalence and Clinical Features of Myasthenia Gravis only and Myasthenia Gravis with hyperthyroidism

 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.

Adult Community-acquired Bacterial Meningitis in Srinagarind Hospital

 The total 19 cases of community-acquired bacterial meningitis who were admitted in Department of Medicine, Srinagarind Hospital during December 1983 to November 1988 were reviewed.  Age incidence was ranged from 16 years to 69 years, male to female ratio was 5.3:1.  The majority of them were farmer and lived in Khon Kaen and nearby provinces.  There was no seasonal variation.  The common presenting symptoms were headache (94.7%), fever (89.4%), alteration of consciousness (68.4%) and nausea/vomiting (57.8%).  Meningeal signs were found in 84.2%.  Complete blood count showed leukocytosis and shift to the left.  In almost all of them, cerebrospinal fluid revealed white blood cell more than 1,000 cells/cu.mm. with polymorphoneuclear cell predominated, high protein (100-500 mg./dl.) and low sugar profile.  Gram stain and culture of CSF were positive in 78.9% and 68.4% respectively.  The most common organism was Stretococus pneumoniae.  The symptoms improved after treatment within 1-4 days.  The mortality rate was 36.8%.

Cryptococcal meningitis in adults

 Retrospective studies of 22 cases with cryptococcal meaingitis who were admitted in Department of Medicine, Srinagarind Hospital during February 1984 to October 1988 were performed.  Age incidence was range from 23 years to 70 years, male to female retio was 1.75:1.  The majority of them were farmer and lived in the North-East of Thailand.  There was no seasonal variation.  Associated diseases were found in 27.2%. All of them had no history of closed contact with the pigeon.  The common presenting symptoms were headache (100%), fever (50.0%), nausea/vomiting (40.9%) and alteration of consciousness (40.9%).  Meningeal signs were found in 57.0%.  Abnormal finding of chest X-rays was 36.3%.  On admission, cerebrospinal fluid values revealed : high initial opening pressure 63.6%, white blood cell pleocytosis 91.0%, high protein 77.1% hypoglycorrhachia 86.2%, positive india ink stain 63.1%, positive culture 89.4% and positive cryptococcal antigen 85.7%.  After treatment, 59.0% of the patients were improved.  Relapsed rate was 15.3%.  Less than 20 leukocytes/cu.mm. in cerebrospinal fluid was the poor prognostic factor.

Cardiogenic Cerebral Embolism in Srinagarind Hospital

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