Cerebrospinal fl uid analyses in Thai multiple sclerosis patients

Objective: To evaluate cerebrospinal fl uid (CSF) patterns in Thai multiple sclerosis (MS) patients particularly oligoclonal bands compared with Western MS. Methods: Retrospective review of 72 patients from the MS Clinic, Siriraj Hospital, between January 1997 and June 2004. All were diagnosed MS using the Poser’ s criteria. Results: Seventy-six patients were evaluated. There were 62 female (86.1%),10 male (13.9%) with a female:male ratio of 6.2:1. The mean age at onset was 33.11±11.76 years. The mean duration of disease was 6.62 ± 5.9 years. Among the 56 MS patients, 52 patients (72.2%) had relapsing-remitting course, 3 (4.2%) had progressive relapsing course, 1(1.4%) had secondary progressive course, none had primary progressive course. Eleven patients (15.3%) had possible MS and the remaining 5 patients had Devic’s syndrome. Approximately 46% had CSF white blood cell (WBC) less than 5 cells/μL. Only 1 (2.3%) had CSF WBC count more than 50 cells/μL. However, both opticospinal form and classic form of MS similarly showed mononuclear cell predominant in differential CSF WBC count. Presence of CSF oligoclonal bands in defi nite MS patients was low in prevalence of only 27.3%. Conclusion: The CSF of Thai MS patients have lower incidence of oligoclonal bands compared with the reports from western countries.

MRI of multiple sclerosis in Thai patients.

OBJECTIVE: Evaluate the MRI findings of multiple sclerosis (MS) in Thai patients and compare these with the McDonald criteria for dissemination in space. MATERIAL AND METHOD: A retrospective study was performed by reviewing clinical and MRI records of patients attending MS clinic at Siriraj Hospital. Only patients with complete clinical and MRI data were included in the present study. RESULTS: There were 25 patients included in the study. Twenty-four patients were females and 1 was male. The mean age was 35.24 years old (range 16-50). The disease duration was 1 month to 17 years after the onset. Twenty-three patients were diagnosed as relapsing-remitting MS, one as possible MS and one as clinical isolated syndrome. Analysis for CSF oligoclonal bands was performed in 22 cases with positive results in 6 cases (27.3%). The sites of involvement were optic neuritis (16 cases), spinal cord (14 cases), and brain (9 cases). Seventeen cases had MRI study at the early presentations, and 8 cases during subsequent relapses. In the 9 cases with brain symptoms, all had positive brain MRI. Ten cases (58.8%) had infratentorial lesions mostly found at the medulla. Most T2 lesions were found at juxtacortical and periventricular regions. Five in 9 cases (55.6%) with periventricular lesions had lesions not less than 3 mm and at least 3 lesions were found. There were 6 cases (35.3%) with, at least, nine T2 lesions. Most of the T2 lesions were oval shaped. Seven cases (41.2%) had black hole lesions. Three cases (17.6%) had gadolinium enhanced lesions. Thirteen of 15 available spinal MRI were abnormal. The locations of the lesions were cervical (6), thoracic (4) and cervicothoracic (3) levels. The number of T2 lesions was one in 8 cases and more than one in 5 cases. The length of each lesion varied: less than 1 vertebral segment (5 cases) and 2 or more vertebral segments (8 cases). Swelling of the cord was found in 3 cases and atrophy in 7 cases. The lesions occupied the whole cross-sectional cord in 6 cases and center of the cord in 7 cases. The gadolinium enhancement was found in 6 cases with a patchy pattern in 5 cases and mixed ring and patchy patterns in 1 case. There were totally 6 cases (24%) that fulfilled the McDonald MRI criteria for dissemination in space. CONCLUSION: The MRI findings in Thai MS have distinct features from the Western reports. Re-evaluation of McDonald criteria for the Eastern countries is needed.

Evaluation of in-house optimized semi-nested PCR and EIA for direct detection of mycobacterial DNA in CSF.

A rapid and correct diagnosis of mycobacterial infections is important for effective patient treatment. Semi-nested-PCR with Fl-16 SOL, 16SOR and 16SNSR primers based on the 16S rRNA gene, under optimized conditions, can detect 499 bp amplified products from all tested mycobacteria. The assay could detect as little as 100 fg of mycobacterial DNA except for rapid growing mycobacteria, whose detection limits ranged from 1 ng to 10 pg. The specificities of the capture probes were assessed with 96 mycobacterial strains (22 species) and 33 nonmycobacterial strains (30 species). The specificities of pAll1, pTbc1 and pMar1 were 94%, 93% and 82%, respectively, and that of pAvi1, pInt1, pChe1 and pFor1 were 100%. The pTbc1 and pAvi1 were tested with DNA from 108 CSF samples, and the sensitivity and specificity of the detection method were 56% and 84% compared to culture and patient histories. The assay should be used for rapid detection and concurrent identification of slow growing mycobacteria without parallel conventional culture verification.

The accuracy of magnetic resonance venography for diagnosis of dural sinus thrombosis.

A retrospective study of 24 patients who underwent magnetic resonance venography (MRV) was performed. The MRV was using a 3D-PC technique and thick-slab multiplanar reconstruction. Four patients underwent conventional angiography. There were 4 males and 20 females with an age range of 8-71 years. The MRV was considered as positive for dural sinus thrombosis (DST) in 8 patients and negative in 16 patients. There were 2 false positive in the MRV.The sensitivity of MRV is 100%,specificity 88%,positive predictive value 75% and negative predictive value 100%.We concluded that MRV is a valuable screening method for DST. One pitfall concerning the use of MRV is that a false positive interpretation may occur due to hypoplasia of the transverse sinus which is a normal variant.

Siriraj acute stroke unit: The experience of 614 patients.

Background : Stroke is a leading cause of mortality and morbidity worldwide. Establishing a stroke unit is one of the most recent advance in an acute stroke management. A number of trials have shown the benefit of stroke unit. In Thailand, the Siriraj Acute Stroke Unit ( SASU) is the first and only unit in the country. It has been established since May 1997. Methods : We analysed the data from the acute stroke patients admitted to the SASU from May 1997 to January 2001. The main criteria for admission to the SASU were stroke patients of either sex, aged over 13 years, with a Glasgow Coma Scale over 11/ 15 , and those who did not require ventilation. Results : The total number of patients admitted to the SASU was 614. There were 310 males (50.49 per cent) and 304 females (49.51 per cent). The mean age of all patients was 63.79 years (range19-94 yrs ). CT or MRI brain scans were done on 580 patients (94.46%). Stroke subtypes were classified as cerebral infarction in 488 patients (79.40% ) and cerebral haemorrhage in 102 patients (16.61% ). Fifteen patients (3.07% ) were diagnosed with a transient ischaemic attack .Seven patients (1.14% ) initially diagnosed as having a stroke were found to have a brain tumour ( 4 primary and, 3 metastatic tumours). Risk factors for stroke were as follows :- hypertension (57.32% ), diabetes mellitus (30.94%), hyperlipidaemia ( 30.13% ), heart disease ( 24.08% ), and smoking ( 23.28% ). The mortality rate of acute stroke patients in SASU was 1.95 percent (12 patients) mainly due to brain herniation ( 6 patients ). The mean total hospital stay of stroke patients at the SASU was15.64 days ( ranging from 1-120 days ). Conclusion : The mortality rate of acute stroke patients in SASU was very low. The main cause of death was brain herniation. The hospital stay in the SASU is reduced by half in comparision with a general medical ward. An acute stroke patient admitted to the SASU has a better chance of survival as well as a shorter length of stay.

Hemifacial spasm treated with botulinum toxin injection: A ten-year experience at Siriraj Hospital.

Background : Hemifacial spasm is a common movement disorder in Thailand. Botulinum toxin has been introduced as an advanced treatment for this condition recently. Objective: To evaluate the efficacy and complication of botulinum toxin in the treatment of hemifacial spasm. Methods: We reviewed all files of patients with hemifacial spasm in the Movement Disorders Clinic at Siriraj Hospital, Mahidol University, who were treated with botulinum toxin injection from January, 1989 until September, 1999. Sex, age, duration of treatment, times of injection, treatment outcome, and complications were analysed. Results: There were 913 patients of which 38 patients were excluded because they were loss to follow up. 875 patients were analysed, (269 males, 606 females sex ratio 1:2.25). The mean age of all patients was 50.86+12.53 years with a range of 18 to 81 years. The follow up period ranged from 1-130 months (mean = 32.5+35.05 months). The outcome were classified as excellent (improvement >50%) in 58.9%, good (improvement >25%) in 37.3%, fair (improvement <25%) in 3.1%, and no improvement in 0.8%. Thus the efficacy of this treatment (improvement >25%) was 96.2 percent. There were complications of mild facial paresis in 80 patients (9.1%), ptosis in 39 patients (4.5%), excessive lacrimation in 7 patients (0.8%), and others (including pain and itching at the injection sites and double vision) in 7 patients (0.8%). All of the complications ere transient. ? Conclusion: Botulinum toxin A injection is a safe and effective way with no long term systemic complications (of treating patients with hemifacial spasm).

Neurosarcoidosis: First reported case in Thailand.

Sarcoidosis is a chronic multisystem granulomatous disease of unknown aetiology, which has a propensity to affect the lungs and rarely the nervous system; neurosarcoidosis may be an enigmatic diagnosis which is often entertained but rarely made with conviction. Prevalence rates for intrathoracic sarcoidosis vary from greater than 50 per 100, 000 e.g. in New York African-Americans, to under 10 per 100,0002. Much higher prevalence rates were obtained when consecutive postmortems were performed on approximately 60% of all deaths in an area of Sweden, of known to have sarcoidosis during life, yielding a prevalence of 641 per 100,0003. Previous data from large series of patients with sarcoidosis have estimated that approximately 5% of such patients will have clinical involvement of the nervous system4-7, although post-mortem studies suggest that ante-mortem diagnosis is only made in 50% with nervous system involvement. Therefore one can estimate that about 5 to 10 patients per million population will have clinical neurosarcoidosis. In Thailand there has been no previous report of neurosarcoidosis, thus our patient is the first documented case in the Kingdom.

Do physicians recognise dementia.

Background : Recognition and diagnosis of dementia is frequently overlooked by attending physicians both in the community and hospital settings. Objective : To determine the ability of attending physicians to recognise dementia. Methods : A cross-sectional survey of cognitive impairment in 150 medical inpatients at Siriraj Hospital, Bangkok, Thailand was done from May to November 1999. Inclusion criteria were patients aged over 50 year-old with Glasgow coma score over 12/15, no delirium and no active medical problems. Cognitive assessment was done before the discharge date by means of clinical evaluation, neurological examination and mental state examination. Dementia was diagnosed by DSM-IV criteria. The severity of dementia was classified by using the degree of dependency. Diagnosis of dementia in the medical records was categorised as whether dementia was recognised by the attending physicians. Results : Forty nine patients out of a total of 150 patients (32.67 per cent) were demented of which thirty three patients had mild dementia, thirteen patients had moderate dementia and three patients had severe dementia. The attending physicians recognised two patients out of forty nine dementia patients (4%). However, both of them had previously been diagnosed as having dementia before the admission. Conclusion : Delayed diagnosis of dementia is frequently due to attending physicians not recognising this condition. Early recognition of dementia usually leads to its proper management, thus internists should be more alert for this condition.

Comparison of dementia in stroke survivors and patients with parkinson’s disease in Thai subjects.

Comparison of dementia in stroke survivors and patients with Parkinson’s disease was done at Siriraj Hospital during 1990-1994. Two hundred and twelve Thai stroke survivors and 132 patients with Parkinson’s disease were enrolled in this study. The mean age of the study groups were 62.78 (SD 11.12) years for stroke survival group and 67.72 (SD 9.12) years for Parkinson’s diseases group. The mean duration of stroke suffering was 2.09 (SD 2.74) years whereas the mean duration of suffering from Parkinson’s disease was 3.5 (SD 3.53) years. All patients of both groups were screened for depression by using Thai Geriatric Depression Scale and patients with Alzheimer’s disease were excluded from the study. Thai Mental State Examination (TMSE) is a standard test used in this study to identify dementia. Seventy stroke patients (33.02%) scored below 23 points (cut-off point for dementia) and 34 patients (25.76%) of Parkinson’s disease scored below 23 points which they were classified as definite dementia. Anyone who scored below 20 points was classified as severe dementia which there were 40 patients (18.88%) in stroke group and 24 patients (18.18%) in Parkinson’s disease group. Patient who scored between 20-22 points was classified as mild to moderate dementia which there were 30 patients (14.15%) in stroke group and 12 patients (9.09%) in Parkinson’s disease group. Fifty-eight patients (27.36%) in stroke group and 37 patients (28.03%) in Parkinson’s disease group scored between 23-25 points and they were classified as borderline dementia. Comparison of the subset of demenyia yesting in TMSE between stroke group and Parkinson's disease group revented no statistically significant difference in any degree of dementia. Subset tests of orientation, language and abstract thinking, and recall seemed to be more affected in Parkinson's disease group whereas subset test of registration was equally impaired in both groups. There were no difference in subset tests of dementia in mild to moderate dementia group of both patients with stroke and Parkinson's disease. In conclusion we could not differentiate pattern of dementia between stroke survivors and patients with Parkinson's disease even they were severely demented.

The comparative study of CSF findings in AIDS and non-AIDS patients with cryptococcal meningitis.

The ceredrospinal fluid of patients with AIDS and Cryptococcus neoformans infection (n = 62) and those of non-AIDS with Cryptococcus neoformans infection (n = 31) were analysed for white cell count, protein and CSF sugar/blood sugar levels. The mean value of white cell count (39.43/cumm VS 160.83/cumm) and protein (77.91 mg/dl Vs 118.2 mg/dl) in patient with AIDS and cryptococcal infection were statistically significant lower than non-AIDS patients with cryptococcal infection (p < 0.005 and p < 0.01), whereas there were no difference in CSF sugar/levels. Two-thirds of the patients with AIDS and cryptococcal infection had the white cell count less than 10 cell/cumm. These data shows that AIDS aptients have lower immune response to cryptococcus neoformans than non-AIDS patients. Thus it is advisable that Indian ink preparation of CSF is always necessary for AIDS patients in spite of normal white cell count in the CSF.

Parkinson plus syndromes.

Parkinson plus syndrome was first described in 1997 and it is accounted for 10 per cant of parkisonian patients. In Thailand there was no such case documented. We thus reported th first three patients with Parkinson plus syndrome in Thailand. Two patients (60 years old man and 51 years old woman) presented with classical parkinsonism which few years later developed cerebellar and brainstem signs (dysarthria, nystagmus, dysdiadocholinesia and progressivedysphagia).Computed brain scanning showed marked atrophy of brainstem and cerebellum. They were both diagnosed as olivopontocerebellar atrophy variety of Parkinson plus syndrome. The first patient was deteriorated in the neurological deficits that needed to be confined in bed six years later but his intellectual function was still preserved. The third patient, a 51 years old man presented with parkinsonism that was not responsed to levodopa therapy, then 2 years later he developed myoclonus of the left arm, progressive dysarthria, gait difficulty and deterioration of his intellectual function. Magnetic resonance imaging of the brain showed marked atrophy of brainstem, cerebellum, basal ganglia and cerebral cortex. Single photon emission tomography showed bilateral decreased perfusion of both parietal lobes and basal ganglia. Multiple system atrophy category of Parkinson plus syndrome was diagnosed. He was still survived at his fifth years of illness but in a dependent state at home. Patient with Parkinson plus syndrome must be diagnosed from parkinsonism because it has differ natural history treatment and prognosis.

Neuroleptic malignant syndrome: A case report and review of the literature .

A case report of neuroleptic malignant syndrome was documented. A 54 year old woman had 2 week history of neuroleptic drug (haloperidol) therapy for her recent psychiatric symptoms. She developed high fever, stupor and muscle rigidity with leucocytosis and raised serum creatine phosphokinase. Investigations revealed no source of systemic infection and lumbar puncture showed no definite evidence of infection. She was successfully treated with bromocriptine and supportive procedure. She gained her consciousness four days later in spite of complication with pneumonia. She was discharged home after 5 weeks of admission with normal sensorium. Literature review for this syndrome was doe extensively.

Hemiparesis in herpes ophthalmicus: Report of a rare occurrence.

Report of a case of a 25 year-old Thai man who developed acute behavioural change and right hemiparesis one month after herpes zoster ophthalmicus (HZO) of the left trigeminal nerve. Neurological examination revealed disorientation and memory deficit with mild right central facial palsy and hemiparesis. CSF examination revealed 100 wbc with 97% lymphocyte. CT scan showed hypodensity over the left parietal region with gyral enhancement after contrast injection. Carotid angiogram revealed arteritis of left anterior and middle cerebral arteries, confirming the diagnosis of herpes zoster ophthalmicus associated cerebral angiitis. The patient recovered eventually on symptomatic treatment.