Neurological consultations and diagnoses in a large, dedicated COVID-19 university hospital / Consultas neurológicas e diagnósticos em um grande hospital universitário dedicado a COVID-19

ABSTRACT Background: More than one-third of COVID-19 patients present neurological symptoms ranging from anosmia to stroke and encephalopathy. Furthermore, pre-existing neurological conditions may require special treatment and may be associated with worse outcomes. Notwithstanding, the role of neurologists in COVID-19 is probably underrecognized. Objective: The aim of this study was to report the reasons for requesting neurological consultations by internists and intensivists in a COVID-19-dedicated hospital. Methods: This retrospective study was carried out at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, a 900-bed COVID-19 dedicated center (including 300 intensive care unit beds). COVID-19 diagnosis was confirmed by SARS-CoV-2-RT-PCR in nasal swabs. All inpatient neurology consultations between March 23rd and May 23rd, 2020 were analyzed. Neurologists performed the neurological exam, assessed all available data to diagnose the neurological condition, and requested additional tests deemed necessary. Difficult diagnoses were established in consensus meetings. After diagnosis, neurologists were involved in the treatment. Results: Neurological consultations were requested for 89 out of 1,208 (7.4%) inpatient COVID admissions during that period. Main neurological diagnoses included: encephalopathy (44.4%), stroke (16.7%), previous neurological diseases (9.0%), seizures (9.0%), neuromuscular disorders (5.6%), other acute brain lesions (3.4%), and other mild nonspecific symptoms (11.2%). Conclusions: Most neurological consultations in a COVID-19-dedicated hospital were requested for severe conditions that could have an impact on the outcome. First-line doctors should be able to recognize neurological symptoms; neurologists are important members of the medical team in COVID-19 hospital care.

RESUMO Introdução: Mais de um terço dos pacientes com COVID-19 apresentam sintomas neurológicos que variam de anosmia a AVC e encefalopatia. Além disso, doenças neurológicas prévias podem exigir tratamento especial e estar associadas a piores desfechos. Não obstante, o papel dos neurologistas na COVID-19 é provavelmente pouco reconhecido. Objetivo: O objetivo deste estudo foi relatar os motivos para solicitar consultas neurológicas por clínicos e intensivistas em um hospital dedicado à COVID-19. Métodos: Estudo retrospectivo realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brasil, um centro dedicado à COVID-19 com 900 leitos (incluindo 300 leitos para unidades de terapia intensiva). O diagnóstico de COVID-19 foi confirmado por SARS-CoV-2-RT-PCR em swabs nasais. Todas as interconsultas de neurologia hospitalar entre 23 de março e 23 de maio de 2020 foram analisadas. Os neurologistas realizaram o exame neurológico, avaliaram todos os dados disponíveis para diagnosticar a patologia neurológica e solicitaram exames adicionais conforme necessidade. Diagnósticos difíceis foram estabelecidos em reuniões de consenso. Após o diagnóstico, os neurologistas participaram da condução dos casos. Resultados: Foram solicitadas consultas neurológicas para 89 de 1.208 (7,4%) em pacientes internados por COVID-19 durante o período. Os principais diagnósticos neurológicos incluíram: encefalopatia (44,4%), acidente vascular cerebral (16,7%), doenças neurológicas prévias (9,0%), crises epilépticas (9,0%), transtornos neuromusculares (5,6%), outras lesões encefálicas agudas (3,4%) e outros sintomas leves inespecíficos (11,2%). Conclusões: A maioria das consultas neurológicas em um hospital dedicado à COVID-19 foi solicitada para condições graves que poderiam afetar o desfecho clínico. Os médicos na linha de frente devem ser capazes de reconhecer sintomas neurológicos. Os neurologistas são membros importantes da equipe médica no atendimento hospitalar à COVID-19.

A study of etiological profile of acute confusional state

Background: ACS (Acute confusional states) are on the rise taking the shape of an epidemic. These states are common among the elderly, but young individuals are also not spared. Prompt diagnosis and management of these states can decrease the associated morbidity and mortality.Methods: In this prospective observational study, etiological profile of ACS was evaluated in a total 100 patients, selected over a period of one year, after they fulfilled the CAM (Confusion Assessment Method) criteria.Results: Among 100 patients of ACS, mean age was 54.77�.50 years, males were 66% and 34% were females. The most common diagnosis provisionally made on the basis of history and clinical examination was metabolic encephalopathy in 37% patients, meningoencephalitis (24%), CVA (Cerebrovascular accident) (18%), seizures (9%), sepsis (6%), poisoning (6%). Whereas the final diagnosis made after subjecting the patients to relevant investigations, was metabolic encephalopathy in 37% of patients, meningoencephalitis (20%), CVA (18%), sepsis (12%), unprovoked seizures (6%), poisoning (6%) and undetermined in 1%. The final diagnosis matched the provisional diagnosis in most of the patients except sepsis as a provisional diagnosis was underdiagnosed. The mean duration of hospital stay was 7.6�67days and the hospital stay was most commonly complicated by aspiration pneumonia and acute kidney injury.Conclusions: This study emphasizes that the ACS is an emergency medical situation, where prompt identification, workup and treatment should be done parallelly and urgently to prevent the morbidity and mortality.

Metronidazole-induced encephalopathy in a patient with Crohn's disease

Metronidazole is a widely used antibiotic for the treatment of anaerobic bacterial infections. Metronidazole-induced encephalopathy (MIEP) is a rare but potentially reversible disease. The mechanism of MIEP remains unclear, and differences in the neurotoxic effects of oral versus intravenous (IV) metronidazole administration have not yet been determined. We report the case of a Crohn's disease (CD) patient who experienced encephalopathy immediately after a single IV dose of metronidazole following long-term exposure to the oral form of the drug. The 64-year-old man with intractable CD experienced a sudden change in mental status, aphasia, and muscle weakness after IV administration of metronidazole. He had previously taken metronidazole orally for 13 years and received intermittent IV metronidazole treatments for CD exacerbation. Brain magnetic resonance imaging (MRI) showed high-intensity signals in the bilateral medial thalamus and the midbrain and pontine tegmentum on fluid-attenuated inversion recovery images. After discontinuation of metronidazole, the high-intensity brain MRI signals resolved and the patient's mental status dramatically improved; however, the patient exhibited mild cognitive dysfunction 2 months after the onset of encephalopathy.

Hypoglycemic Coma in a Patient with Metastatic Renal Cell Carcinoma Treated with Sunitinib / 대한내과학회지

We present a patient with type 2 diabetes mellitus and metastatic renal cell carcinoma who developed severe hypoglycemia and metabolic encephalopathy after sunitinib treatment. Sunitinib, a multi-target tyrosine kinase inhibitor, is used to treat metastatic renal cell carcinoma. Sunitinib-induced hypoglycemia has been reported and there are rare case reports of severe hypoglycemia due to sunitinib. Therefore, glycemic control should be monitored closely in diabetic patients treated with sunitinib.

A Case of Metabolic Encephalopathy Due to Bleeding after EPBD / 대한췌담도학회지

Endoscopic retrograde cholangiopancreatography is widely used for diagnosis and treatment of pancreatobiliary diseases and associated with a spectrum of complications such as pancreatitis, hemorrhage, and so on. Endoscopic papillary balloon dilatation (EPBD) has an advantage over endoscopic sphincterotomy in complication of bleeding. We report here on a 68-year-old woman who developed metabolic encephalopathy due to massive bleeding after EPBD. Massive bleeding was controlled after selective embolization and metabolic encephalopathy was improved after conservative management. Metabolic encephalopathy due to massive bleeding after EPBD has not been reported. We report on this unusual case along with a review of the related literatures.

Encefalopatía metabólica en acidemia isovalérica: Informe de caso / Metabolic encephalopathy in isovaleric academia: Case report

La acidemia isovalérica (AIV) es un trastorno congénito raro (prevalencia 1/105), herencia autosómica recesiva, en la vía metabólica de la leucina. Es causado por la deficiencia selectiva de la enzima mitocondrial isovaleril-CoA deshidrogenasa, la actividad reducida de esta enzima lleva a la acumulación tóxica del ácido isovalérico en el plasma y a un incremento en la concentración urinaria de isovalerilglicina. Han sido reportadas tres formas clínicas de presentación: aguda neonatal, crónica intermitente y una forma lentamente progresiva que puede ser asintomática. Caso clínico: Preescolar femenina de 3 años que ingresa a urgencias pediátricas por vómitos y somnolencia, sin déficit motor ni signos meníngeos; respiración profunda y rápida con olor particular. Historia negativa para trauma, infección o enfermedad metabólica definida. Citoquímica de líquido cefalorraquídeo normal; acidosis metabólica severa, hiperamonemia, disfunción hematológica y hepática motivaron el estudio metabólico, evidenciándose en orina Isovalerilglicina 38.290 mmol/mol creatinina, 3 OH Isovalérico, presente, 3 OH butírico 3.530 mmol/mol creatinina, orientando el diagnóstico a Acidemia Isovalérica. El diagnóstico de Acidemia Isovalérica debe considerarse ante la presencia de vómitos, deterioro neurológico progresivo y/o antecedentes familiares de muerte súbita neonatal. La posibilidad de evitar la mortalidad temprana y mejorar el resultado neurocognitivo por el diagnóstico y el tratamiento precoz favorece el diagnóstico preclínico y refuerza que la AIV sea incluida en el programa de cribado neonatal en Venezuela.

Isovaleric acidemia (IVA) is a rare autosomal recessive inborn error of leucine metabolism (prevalence 1/105) caused by a deficiency of the mitochondrial enzyme isovaleryl-CoA dehydrogenase resulting in the accumulation of derivatives of isovaleryl-CoA, the diminished activity of this enzyme leads to toxic accumulation of isovaleric acid in the plasma and an increase in urinary concentration of isovalerylglycine. There have been reported three clinical forms: acute neonatal form, a chronic intermittent form and a slowly progressive form which may be asymptomatic. Case report: We report the case of a 3 years old female with vomiting and drowsiness, sensorineural depression without motor deficit, no meningeal signs, CSF cytochemical normal, fast deep breathing and a "particular smell”, the presence of severe metabolic acidosis, hyperammonemia, hematologic and hepatic dysfunction motivated a metabolic study, showing in urine isovalerylglycine 38.290 mmol / molcreatinine, 3 OH isovaleric present, 3 OH butyric 3.530 mmol / molcreatinine, guiding the diagnosis to Isovaleric acidemia. The diagnosis of Isovaleric acidemia must be considered in the presence of vomiting, progressive neurological deterioration and / or family history of sudden infant death. The possibility of avoiding early mortality and improve neurocognitive outcome for diagnosis and early treatment promotes pre-symptomatic diagnosis and reinforces that IVA is included in the neonatal screening program in Venezuela.

Atypical Metronidazole-Induced Encephalopathy in Anaerobic Brain Abscess

Metronidazole-induced encephalopathy is a very rare complication of the long standing use of metronidazole. The encephalopathy is bilateral and symmetric in nature. We report on the magnetic resonance imaging (MRI) and clinical course of metronidazole-induced encephalopathy in a 60-year-old female with a persistent anaerobic brain abscess after draining of the abscess. After 3 months of metronidazole administration, the patient complained of dysarthria, tingling sense of all extremities, and left hemiparesis. MRI revealed symmetric hyperintensity lesions in medulla, pons, dentate nuclei of cerebellum, and splenium of corpus callosum, all of which represent typical findings of metronidazole-induced encephalopathy. In addition, asymmetric lesions in midbrain, thalamus, putamen and cerebral subcortical white matter were noted. The patient recovered after discontinuation of metronidazole and the remaining abscess was successfully treated with meropenem and levofloxacine.

Progress of hereditary metabolic encephalopathy in neonates / 国际儿科学杂志

Encephalopathy secondary to hereditary metabolic diseases leads to high mortality due to the difficulties in early diagnosis and timely treatment.Survivors are often left with severe sequelaes of the nervous system. A considerable number of hereditary metabolic diseases are not thoroughly understood, but pre-clinical or early-clinical diagnosis and treatment can be attempted with MRI which can generally optimize the outcome.

Clinical Features and Brain MRI Findings in Liver Cirrhosis-related Acute Metabolic Encephalopathy

BACKGROUND: Chronic liver disease is a common cause of metabolic neurologic deterioration. We analyzed the clinical features and MRI findings of patients with liver cirrhosis who showed rapidly progressing cerebral dysfunction. METHODS: From August 2001 to July 2003, we had 9 liver cirrhosis patients hospitalized due to acutely developed and rapidly progressed neurologic symptoms that were caused not by other metabolic disturbances. Blood tests and liver ultrasonography were performed to assess the severity of liver cirrhosis. A brain MRI study was done in all patients. RESULTS: The causes of liver cirrhosis were viral hepatitis (n=6), chronic alcoholism (n=2), and autoimmune disease (n=1). Serum ammonia and electrolyte levels were within the normal range. Truncal or limbs ataxia and dysarthria were the most common symptoms. The corpus callosum and dentate nucleus of the cerebellum were commonly involved on diffusion- and T2-weighted MRI. In spite of intensive investigation and treatment, all patients had a rapidly deteriorating course with the appearance of uncontrolled abnormal movements and a decreased consciousness level. Their deaths occured within 1 month of the onset of symptoms. CONCLUSIONS: We present nine liver cirrhosis patients with characteristic clinical features and diffusion- and T2-weighted MRI findings for the first time. It is assumed that some neurologic circuit plays a role in pathogenesis.

Comparison of MR Findings and Clinical Features according to Underlying Disease in Metabolic Encephalopathy

PURPOSE: Metabolic encephalopathy is not an infrequent condition. However it is very difficult to diagnose and treat because of its various causes and clinical manifestations. Our purpose was to clarify the cause of metabolic encephalopathy by evaluation of MR findings and clinical features. METHODS: We reviewed MR images and clinical features for 25 patients with metabolic encephalopathy who showed abnormal signal changes on the MR images with neurologic deterioration. RESULTS: The 25 patients had underlying diseases such as chronic liver disease (n=16) or renal failure (n=9). The MR findings showed significant differences in the involved sites according to the underlying disease. In 10 of the 16 patients with liver disease, corpus callosal involvement was observed. Red nucleus involvement was seen in 6 patients, dentate nucleus involvement in 5 patients. These lesions were seen to have a high signal intensity on the diffusion weighted image. Contrary to liver disease, encephalopathy with renal disease showed typical central pontine myelinolysis in 6 of the 9 patients and a relatively benign clinical course. CONCLUSION: Our results showed that the typically involved site and clinical manifestations depended on the underlying disease. We think that involvement of the corpus callosum, the red nucleus, and the dentate nucleus is a typical pattern of injury in metabolic encephalopathy with chronic liver disease and that these findings will be helpful for diagnosing and treating metabolic encephalopathy.