Case Presentation Competition, 5 Back to Basics

Serotonin syndrome associated with clozapine withdrawal and concurrent selective serotonin reuptake inhibitor (SSRI) use has previously been reported. A 56-year-old female with schizophrenia was admitted for pyrexia, rigidity, and altered mental state after her second dose of clozapine restart. She had discontinued her long-term clozapine 2 weeks prior. She developed ventilatory failure, reduced consciousness, eye deviation, and worsening rigidity, requiring ICU support. Examination showed a right upper motor neurone syndrome with absent ankle reflexes. She had raised inflammatory markers and creatine kinase. Serum neuropathy, encephalitis screen, and COVID PCR were negative. Respiratory investigations were unfruitful. MRI head and spine did not show brain or cord signal change to correlate to signs. Lumbar puncture showed a quiet CSF, negative culture, viral PCR, and encephalitis antibodies. EEG showed bihemispheric background slowing. Despite clinical improvement, repeat examination showed persistent signs. She was diagnosed with serotonin syndrome after developing a bilateral tremor. Treatment with cyproheptadine correlated with an improvement in her signs, cognitive state, and EEG. Serotonin syndrome can present with reversible neuromuscular signs. With clozapine withdrawal, it can require a prolonged time course of recovery in contrast with classical serotonin syndrome. Cyprohepta- dine can cause agranulocytosis and this delays clozapine restart.

Post Covid Guillain-Barre Syndrome and pulmonary embolism: A rare combination

We hereby report a case with rare combination of Guillain-Barre Syndrome (GBS), Deep Vein Thrombosis (DVT) and Pulmonary embolism (PE) during post-covid period. A 67-year-old male presented with acute breathlessness and calf pain for seven days. He suffered from COVID-19 four weeks prior. He recovered fully then but was not on prophylactic anticoagulants. His lower limb venous doppler confirmed DVT. CT Pulmonary Angiography (CTPA) confirmed PE. His neurological examination revealed bilateral diminished ankle jerks and Babinski flexion reflex, though he had no neurological complaints. Nerve conduction studies revealed acute motor sensory axonal neuropathy (AMSAN) variant of GBS. He was treated with enoxaparin followed by rivaroxaban for thromboembolism and with intravenous immunoglobulins for GBS, to which he responded well. Early diagnosis of GBS saved him from further morbidity. Post Covid GBS has been rarely reported from India. Concurrence of GBS with DVT and PE is further rare. Copyright © 2023 Ubiquity Press. All rights reserved.

Systemic Lupus Erythematous Flare Up Presenting as Myelitis

Objective: Present a case of lupus myelitis occurring in a patient already receiving immunosuppression. Background: Neurologic complications of systemic lupus erythematosus span the central and peripheral nervous systems. We present a case of lupus myelitis in a patient previously well controlled with immunosuppression. Design/Methods: N/A Results: A 24-year-old woman with history of systemic lupus erythematosus presented with acute onset inability to walk due to bilateral leg weakness and numbness, associated with constipation and urinary retention. A week before, she experienced runny nose, sore throat, headache and neck pain radiating down her shoulders. Her medication regimen prior to admission included mycophenolate mofetil 1500 mg BID, hydroxychloroquine 200 mg daily, and prednisone 2.5 mg daily. Examination revealed bilateral lower limb weakness, more pronounced on right, hyperesthesia in the right leg, decreased proprioception bilaterally. She had intact pinprick, light touch, and vibration sense. Ankle reflexes were absent bilaterally. Laboratory testing showed pancytopenia, elevated anti-DsDNA (107 IU/mL), ESR of 69 mm/h, low serum C3/C4 and proteinuria. COVID-19 testing was negative. CSF analysis showed WBC of 890/mm3 , neutrophil predominance (93%), decreased glucose (32 mg/dL) and elevated protein (129 g/L). CSF cultures were negative. Aquaporin-4 receptor antibodies testing is pending. MRI of thoracic spine revealed patchy FLAIR hyperintensities at the level of T2, T4 and T10- T11 with mild enhancement at the level of the lesion T10-11, following intravenous gadolinium. The patient was treated IV methylprednisolone followed by cyclophosphamide and maintenance daily oral steroids with significant improvement of motor symptoms. She had mild residual right dorsiflexion weakness. Urinary and bowel function normalized. Conclusions: Lupus myelitis is a rare and potentially devastating complication of systemic lupus erythematosus. The timely recognition is crucial for proper management. CSF picture resembles an infection and may be misleading. While aquaporin-4 receptor antibodies report is pending, her very good recovery with methylprednisolone and cyclophosphamide strongly suggests lupus myelitis.

Neurologic Sequela of COVID-19.Guillain Barré Syndrome Following Johnson and Johnson COVID-19 Vaccination;A Case report

Objective: Outbreak of novel coronavirus-19 (COVID-19) began in December 2019 in Wuhan, China and became global pandemic by March 2020. Federal Drug administration (FDA) has approved three vaccines for prevention of COVID-19 infection. Multiple neurological complications have been reported following vaccine administration. In July 2021 FDA issued warning about increased risk of Guillain Barre Syndrome (GBS) following Johnson and Johnson (J&J) vaccine and since then cases have been reported during clinical trials. Here we report a real life case of GBS after receiving single dose of J&J vaccine. Background: A 53 year old female presented to emergency department with progressive bilateral symmetric proximal more than distal upper and lower extremity weakness, with bilateral ascending paresthesia's, 14 days after receiving the J&J COVID-19 vaccination. Exam consistent with motor strength 4/5 in hip flexors/extensors bilaterally, 4/5 knee extensors/flexors, 4/5 plantar flexion, 4/5 dorsiflexion bilaterally, 4/5 shoulder abductors/adductors, 4/5 elbow extensor/flexors, 2+ patellar reflex, 1+ Achilles tendon reflex bilaterally and decrease sensation to light touch and pinprick in lower extremities till mid-thigh bilaterally. MRI of the Lumbar Spine with and without contrast revealed subtle enhancement of the cauda equina nerve roots suggestive of Acute Inflammatory Demyelinating Polyradiculoneuropathy. CSF analysis consistent with mildly elevated protein 48, nucleated cell count of 0, glucose of 52. Negative GM1 and Gq1b antibodies. Due to the high suspicion for Guillain-Barre syndrome the patient was started on IVIG. After 5 days of treatment the patient had significant improvement and was discharged to rehab facility. Design/Methods: NA Results: NA Conclusions: As we continue mass vaccinations for COVID-19 prevention, clinicians should be able to recognize potential complications and side effects associated with COVID-19 vaccination and must educate and reassure their patients regarding the safety and rationale of COVID-19 vaccination because the benefits of vaccination outweigh the risks of COVID-19 infection and associated morbidity and mortality.

Epochs Of Sternutation Induced By Coronavirus 19

Objective: To understand that COVID-19 can cause epochs of sneezing. Background: While Coronavirus 19 has been reported to inhibit sternutation (Mattu, 2021), Coronavirus-induced epochs of sternutation has not henceforth been described. Case Study: 38-year-old right-handed nasute woman, seven months prior to presentation, experienced an acute onset of loss of smell and taste, with a positive nasopharyngeal swab for SARS COV-2. Since then there has been no improvement in her chemosensory complaints and has developed periods of sternutation, whereby she sneezes 18 times in a row every morning. Results: Abnormalities of physical examination: Neurological Examination: Motor Examination: Drift testing: Left pronator drift with left abductor digiti minimi sign. Cerebellar examination: dysmetria in both upper extremities, left more than right. High frequency low amplitude tremor on extension of both upper extremities. Reflexes: 3+ biceps and brachioradialis and absent ankle jerks bilaterally. Bilateral Hoffman reflexes. Chemosensory testing: Alcohol Sniff Test: 0 (anosmia). Olfactory Retronasal Smell Test Index: 0 (anosmia). Gustatory testing: Propylthioruacil Disk Taste Test: 0 (ageusia). Conclusions: The neuroanatomy of the sneeze reflex suggests that it occurs through the afferent pathway from the trigeminal nerve to the rostral dorsolateral medullary sneezing center where the efferent discharge of the autonomic nervous system occurs through the nervous intermedius to the greater superficial petrosal nerve and to the sphenopalatine ganglion. In any of these afferent or efferent pathways or in the central nervous system itself, COVID may have acted to cause intermittent irritation and thus epochs of sneezing (Songu, 2009;Herman, 1983). The common experience of sneezing occurring in threes may be centrally mediated and this occurred with eighteen sneezes may just be a prolonged variant of such a chronobiological reflex. In those who present with COVID-19, query as to epochs of sternutation may be revealing.

Eosinophilic granulomatosis with polyangiitis: Diagnostic and therapeutic challenges during COVID-19 pandemic

Case report-IntroductionCOVID-19 pandemic affected medical practise significantly and caused difficulties in accessing necessary investigations at the appropriate time. As of March 2020, NHS England issued measures to redirect staffs and resources in preparation for the rising cases of coronavirus. As a result of this, non-urgent tests/treatments were put on hold. We present a new case of EGPA admitted to our district general hospital during the COVID-19 pandemic to highlight the challenges faced. The diagnosis was reached based on clinical judgment in the absence of some confirmatory tests as well as the decision of starting immunosuppressant treatment during the pandemic.Case report-Case descriptionA 41-years-old lady with a background of well-controlled asthma, presented with five days history of paraesthesia and swelling in both legs. She also reported mild pleuritic chest pain, which radiated to her left arm. Physical examination revealed left foot drop. She had reduced sensation on the L5-S1 dermatomal distribution with absent ankle reflex and reduced knee reflex of her left leg. Her left calf was swollen and tender. The rest of her examination was unremarkable.Baseline blood revealed raised WCC of 19.3 with significant eosinophilia (10). CRP and ESR were 135 mg/L and 48mm/hr, respectively. Electrocardiogram showed new T-wave inversion in the anterolateral leads with significantly raised troponin levels. There was ground glass appearance in both lungs, keeping with suspected COVID-19 and no evidence of pulmonary embolus was found on CTPA. MRI spine confirmed no evidence of cauda equina compression. Deep vein thrombosis was also excluded with US doppler.She was treated as myocarditis and pneumonia secondary to probable COVID-19 infection. Echocardiogram revealed severe LVSD (EF < 35%) with no LV hypertrophy. Three days later, she became acutely breathless and required high flow oxygen. New bilateral basal crackles were found on auscultation. Her antibiotic regimes were escalated to intravenous infusion.A revised CT report suggested the findings may correlate with eosinophilic pneumonia or EGPA. MRI of lower legs proved muscular oedema in bilaterally, which was suggestive of myositis with fasciitis. There was no significant change on the thigh musculature. CK level was slightly elevated (403 IU/L). Urinalysis was positive for blood (3+). Given the strong clinical suspicion of EPGA, a decision to start high dose steroid therapy was made, despite the pending immunology results. After the third dose of the methylprednisolone, pulsed cyclophosphamide was started along with high dose oral prednisolone. The patient was discharged home following significant clinical improvement.Case report-DiscussionThis patient has fulfilled 4 out of 6 criteria of ACR 1990 classification for EGPA, which are eosinophilia, bronchial asthma, mononeuritis multiplex and pulmonary infiltrates on radiological images. However, in the context of current pandemic, these changes on chest CT findings could also be suggestive of COVID-19 pneumonitis.At present, there is no reliable test for COVID-19. Even though RT-PCR testing has been the gold standard for diagnosing suspected cases, the clinical sensitivity and specificity of these tests are variable. A negative test may not rule out infection. In our case, the patient was tested twice at separate times to rule out the possibility of COVID-19 infection.During the pandemic, there is extremely limited access to some confirmatory tests. We were not able to perform nerve conduction studies on our patient as the service was suspended, instead, we sought neurologist's review to confirm the mononeuritis multiplex. We also sought advice from haematologist to rule out the possibility of hyper-eosinophilic syndrome as bone marrow biopsy was unavailable. The screen for atypical pneumonia, aspergillosis, viruses, and tuberculosis were negative. By excluding the alternative diagnoses related to eosinophilia, we concluded that this was likely to be a case of first presentation EGPA.Our next obstacle was intr ducing remission-induction regimens during COVID-19 pandemic. BSR does not recommend starting new treatment due to the increased risk of infection. We had to weigh out the benefits and risks of initiating immunosuppression. Our patient was made aware of the potential risks involved which include severe infection with COVID-19. She was also shifted to a side room with strict infection control precautions and PCP prophylaxis prescribed before starting pulsed methylprednisolone and cyclophosphamide. Fortunately, her neurological symptoms resolved after three days of steroid therapy. Eosinophils count dropped within 1 day to zero, after the first dose of IV methylprednisolone.Case report-Key learning pointsDespite the rising cases of COVID-19 infection, it is essential to keep an open mind and consider alternative diagnosis if a patient did not respond to conventional treatment. As EGPA and COVID-19 pneumonia share similar clinical and radiological presentation, clinical judgement is essential when making the diagnosis as the treatments for both conditions are vastly different. When EGPA is suspected, a multidisciplinary team should be involved in the evaluation of different organ involvements as well as ruling out other causes of eosinophilia. The role of specialists' inputs is extremely important in reaching the diagnosis, especially with limited access to the usual confirmatory tests due to reduced services during the pandemic.In addition, when there is an increased risk of infection such as during the COVID-19 pandemic, it is essential to weigh up the benefits and risks of commencing immunosuppressant treatment carefully. Patients need to be involved in the decision-making process as well as take precautions to minimise the risk of infection. The decision to start remission induction regimes should not be delayed if there is a presence of life or organ threatening disease manifestations in EGPA patients. Our patient has had a life-threatening disease because of multi-organ involvements (cardiac, pulmonary, and neurological systems).