Acute Transient Hemiparesis - An Unusual Pseudo Exacerbation of Multiple Sclerosis

Multiple sclerosis is a chronic demyelinating disease characterised by inflammation and plaque formation. Multiple sclerosis has many variants. It presents as four clinical forms, Relapsing Remitting Multiple Sclerosis (RRMS), Primary Progressive Multiple Sclerosis (PPMS), and Secondary Progressive Multiple Sclerosis (SPMS) and Primary Relapsing Multiple Sclerosis (PRMS). RRMS can present as acute attacks. They should be differentiated from pseudo-exacerbations. True exacerbation is when a new lesion appears in the brain or spinal cord, with a neurological episode lasting for more than 24 hours, with a period of clinical stability over the last 30 days.1 Any flaring up of symptoms of multiple sclerosis due to external factors such as fever, heat or infection is called pseudo-exacerbations. Pseudo-exacerbation episodes do not last for more than 24 hours and should resolve with treatment of the underlying fever or infection.2

Methotrexate (MTX) Induced Pancytopenia - A Rare Serious Adverse Effect

A 65-year-old woman presented to us with complaints of fatigability and appearance of red spots on extremities since 6 days. She was a known case of rheumatoid arthritis since 5 years and was on tablet prednisolone 5 mg OD and tablet hydroxychloroquine 200 mg bid orally. Two months back she had exaggerated symptoms in the form of increased joint pains for which tablet methotrexate 7.5 mg was started weekly once and was increased to 7.5 mg bid (15 mg) per week 2 weeks back along with folic acid 5 mg per day.Methotrexate (MTX) is a folate antagonist used to treat various malignancies, and autoimmune disorders including rheumatoid arthritis. It enters cell by an active cellular uptake and inhibits dihydrofolate reductase (DHFR) enzyme that converts dihydrofolate (DHF) to tetrahydrofolate (THF) affecting purine and ultimately DNA synthesis. Cell with capability of polyglutamylation like myeloblasts and lymphoblasts are most susceptible to the effects of MTX because polyglutamylation prolongs its intracellular presence.1,2

Bilateral Orbital Cellulitis with Pan Sinusitis in a Female without Cavernous Sinus Thrombosis- A Rare Presentation

Inflammation of the ocular structures behind the orbital septum is called orbital cellulitis. Etiological agents are usually bacteria and fungi. It affects persons of all ages but has greater prevalence in younger males. Rarely it affects both eyes. We report a middle aged female who presented with uniocular swelling and was later on diagnosed as pansinusitis with bilateral orbital cellulitis. Aggressive therapy with antibiotics and surgical drainage saved the patient.Inflammation of ocular tissues behind or posterior to the orbital septum is called orbital cellulitis. Orbital cellulitis differs from preseptal cellulitis by causing inflammation of the tissues proximal to the orbital septum. The clinical features of orbital cellulitis include, proptosis, generalized malaise, conjunctival chemosis, ocular pain, blurred vision, headaches, fever, lid swelling and ophthalmoplegia. [1] The inflammation can cross to the other orbit through cavernous sinus. The condition can cause loss of ocular function and death. Therefore, it should be considered an emergency. Approximately 11% of cases of orbital cellulitis result in visual loss.[1,2]