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

Microbiological organisms and their antimicrobial sensitivity causing ventilator associated pneumonia [VAP]

Objective: To determine the frequency of different causative bacteriological organisms and their antibiotic sensitivity from Endotracheal Aspirate [EA] of patients suffering from Ventilator Associated Pneumonia [VAP]. Study Design: Prospective cross sectional study. Place and Duration of Study: Intensive Care Unit [ICU], Combined Military Hospital [CMH] Lahore, from May 2013 to Nov 2013

Material and Methods: A total of 180 cases of VAP, fulfilling the ?nclusion criteria and admitted in the ICU, were included in the study using the non-probability consective sampling technique. A written informed consent was obtained from the family. All these patients underwent endotracheal aspirate for microscopy and culture. Antibiotic sensitivity was determined using standard antibiotics regimens

Results: Out of 180 patients, 165 [91.7%] were culture positive while 15 [8.3%] were culture negative. Gramnegativebacilli accounted for about 70% of all isolates. The most common organism isolated was Pseudomonas aeruginosa 25% [n=45] followed by MRSA 18.9% [n=34], Klebsiella 15.6% [n=28], Actinobacter spp 13.3% [n=24], E.coli 11.7% [n=21] and Citrobacter spp 4.4% [n=8]. Carbapenem was the most sensitive drug that was seen in our setup but still 43.9% of the isolates showed resistance against it and resistance was noted still higher with Actinobacter spp, where 83% isolates were resistant. Quinolones showed resistance in 100% of the isolates of Actinobacter, MRSA and Citrobacter. While more than 50% strains of Pseudomonas, E.coli and Klebsiella were also resistant to quinolones. Cephalosporins showed excellent sensitivity towards gram negative bacteria which included Citrobacter [100% sensitive] and E.coli [80% sensitive]. Polymxins showed more than 50% sensitivity to Pseudomonas aeruginosa, Actinobacter, E. coli and Klebsiella

Conclusion: VAP remains a very important hospital-acquired infection. The most prevalent etiological organism in our study was Pseudomonas aeruginosa and the most effective antibiotics were carbapenems

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

Comparative analysis of cerebrospinal fluid Ada levels in Tuberculous and Non-Tuberculous Meningitis

Objective: To find out the association of Cerebrospinal Fluid [CSF] adenosine deaminase [ADA] Levels with tuberculosis meningitis

Study Design: Case control study

Place and Duration of Study: This study was conducted in the department of Medicine, Pak Emirates Military Hospital, Rawalpindi over a period of six months from May to Oct 2015

Material and Methods: One hundred and ten participants i.e. 55 cases and 55 controls were included in the study. Lumbar puncture were done and 2cc CSF was obtained. CSF for routine examination and ADA levels were sent to a single lab and pathologist verified report. Based on CSF report, patients were classified as tuberculous meningitis [TBM] and Non- tuberculous meningitis and comparative analysis of ADA level were done in both groups

Results: Mean age of the patients was 51.33 +/- 21.60 and 41.76 +/- 18.66 in tuberculosis meningitis and non-tuberculosis meningitis participants. In Tuberculous Meningitis patients, 33 [60.0 percent] were males while in non Tuberculous Meningitis participants, 35 [63.6 percent] were males. Mean ADA level in CSF [13.71 +/- 4.25 vs. 4.76 +/- 3.49, p<0.001], cerebrospinal fluid [CSF] protein level [144.71 +/- 99.15 vs 58.27 +/- 15.62, p<0.001] and mean cell count [185.00 +/- 97.29 vs. 73.71 +/- 111.38, p<0.001] were significantly higher in Tuberculous meningitis patients as compared to non Tuberculous Meningitis participants. However, mean glucose was significantly [p<0.001] lower 29.42 +/- 8.63 in Tuberculous Meningitis patients in comparison to 57.38 +/- 9.13 non-tuberculous meningitis participants

Conclusion: In conclusion, the estimation of CSF-ADA level is a speedy and simple method, which can be confidently used for diagnosis of tuberculous etiology in TBM patients and differentiating it from non- tuberculous etiology

Frequency of headache with stress in adolescent and young adults

Objective of this study was to establish a link between stress as a cause of headache in young adults. Cross sectional study. Department of Neurology Military Hospital [MH] Rawalpindi from September 2009 to March 2010. Thirty young patients, referred for the complaints of headache to the Neurology out patient department, were included in this study. A detailed especially designed, pre tested headache questionnaire was devised which was filled for every patient individually included in the study. Twenty One [70%] of the patients in the study group did have the feeling of stress preceding the headache which sometimes persisted during the episode. Nine [30%] did not report any such feeling of stress before or during the episode. Out of the patients reporting stress 71% [15] were female patients and 29% [6] were males. These key findings suggest that stress and headaches may be related for adolescents and young adults and that this relationship may be reinforced over time. Moreover female patients were far more susceptible to this stressful stimulus as compared to the males

Intracranial hypertension: a three year experience at military hospital, Rawalpindi

Idiopathic intracranial hypertension is a syndrome associated with multiple clinical conditions and is an important mimicker of cerebral venous thrombosis. Given the difference in prognosis of these two conditions they should be differentiated. This study was carried out in indoor and outdoor patients from 1998 to 2000 in Military hospital Rawalpindi. All patients who presented with headache and papilloedema were evaluated further as per protocol after informed consent. Out of 40 registered patients, 12 [30%] were male and 28 [70%] female. The age range was 18 to 45 years, mean was 27.28 + 6.64 years. On neuroimaging 16 [40%] patients found to be suffering from dural sinus thrombosis and all patients had a normal CT scan. Among 16 patients with dural sinus thrombosis 1 [6.3%] patient had protein C deficiency, 2 [12.5%] had pregnancy, 1 [6.3%] had postpartum haemoohage, 1 [6.3%] had puerperal sepsis, 5 [31.3%] were evaluated from high altitude, 1 [6.3%] had ear infection, 1 [6.3%] had factor V Leiden, 1 [6.3%] had antiphospholipid antibody syndrome and in the remaining 3 [18.75%] no etiology was found. In patients with isolated raised intracranial pressure a high index of suspicion should be kept for cerebral venous thrombosis as an underlying etiology especially when it occurs with the background of a hypercoaguable state