BERTOLOTTI SYNDROME: AN UNDER RECOGNIZED CAUSE OF INFLAMMATORY BACK PAIN?

BackgroundBertolotti syndrome describes a lumbosacral transitional vertebra (LSTV) which causes symptoms, usually low back pain. LATV is a congenital anomaly where the L5 vertebra has an unusual morphology. Bertolotti syndrome is an under-recognised condition by clinicians.ObjectivesTo clarify the presentation of Bertolotti syndrome, whether there are features of inflammatory back pain (IBP) and the effect on quality of life.MethodsIn this pilot study, 62 patients with LSTV were identified on imaging (plain x-ray). Imaging was performed for a variety of indications, predominently for back pain. In total, 34 patients agreed to take part, with 18 returning questionnaires. Questionnaires were selected for face vailidity and included: Calin IBP Questionnaire, EQ-5D Questionnaire, Visual analogue pain scale (VAS-P). In view of Covid restrictions all contact was by phone and questionnaires were completed online or returned via post.Plain X-rays visualising the lumbar spine were assessed for radiological features of LSTV.ResultsSeventeen (94%) of the participants (n=18) recorded a VAS-P score >3, indicating a clinically significant level of pain. The mean VAS-P score was 6 (range of 2-9). 89% of respondents scored at least 3/5 in the Calin questionnaire. Of the 5 features of inflammatory back pain in the Calin questionnaire, 4 out of the 5 were reported by most respondents. The exception was ‘improvement on exercise', which was only reported by 18% of respondents. Quality of life was impaired-EQ-5D (mean: 0.503, range -0.074 to 0.796).The commonest radiological abnormality was enlarged transverse process (100%) followed by pseudoarticulation with the sacrum (83%) and scoliosis (33%). Presence of sclerosis and/or osteoarthritis at the pseudoarticulation was associated with worse pain scores. Female respondents reported worse pain.ConclusionThese results suggest Bertolotti syndrome is associated with pain in the majority of patients and affects quality of life,. The character and site of the pain suggests that Bertollotti syndrome should be considered in the differential diagnosis of spondyloarthritis.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsSimon Stebbings Consultant of: Abbvie.Janssen, Ciara White: None declared, Terence Doyle: None declared.

THE RELATIONSHIP BETWEEN THE FUNCTIONALITY OF CHILDREN WITH DISABILITIES AND ITS EFFECTS ON PARENTS DURING THE COVID-19 PANDEMIC PROCESS.

Purpose: The aim of this study was to investigate the relationship between the functionality of disabled children and its effects on parents during the Covid-19 pandemic. Method(s): A total of 168 people, including 84 disabled children and 84 mothers, were included in the study. The Pediatric Disability Assessment Inventory (PEDI) and Gross Motor Function Classification System (GMFCS) were used for children with disabilities. The Zarit Burden Scale (ZBS), Fatigue Severity Scale (FSS) and The Nordic Musculoskeletal Questionnaire (NMQ) were applied to the mothers to question musculoskeletal disorders. Result(s): There was no correlation between care burden score and PEDI, total score, self-care and mobility scores (p>0.05). A moderately negative (r=-0.306;p<0.01) significant linear relationship was found between care burden score and social function score. There was no significant linear relationship between the fatigue severity score and PEDI total score, self-care, mobility and social function scores (p>0.05). No correlation was found between care burden score and fatigue severity score (p>0.05). For the last 12 months, only the pain in the lumbar region of the parents prevented them from doing their usual work. It was determined that the most aching body parts of the parents who complained of musculoskeletal pain during the last 12 months were in the waist, neck, shoulder, back, and knee regions. Conclusion(s): As a result, no relationship was found between the functionality of disabled children and their parents' influences during the Covid-19 pandemic.Copyright © 2022 Turkish Physiotherapy Association. All rights reserved.

ID: 219407 The Cardiac Patient and Neuromodulation, When Anticoagulation Dictates the Intervention

Introduction: Patients with cardiac comorbidities present unique challenges for undergoing interventional pain procedures. Consensus guidelines on safe anticoagulation management are categorized by procedure, patient specific bleeding risk factors, and class of anticoagulation (Table 1, Table 2).1 Specifically, some procedures occur in close proximity to the spinal cord, require large gauge needles and styletted leads, while others are in compressible locations with minimal tissue disruption. Further, pain-induced hypercoagulation increases the risk of thrombo-vascular events.1 This accentuates the importance of interdisciplinary perioperative coordination with the prescribing cardiologist. Case: A 71-year-old male with past-medical-history of CABG, bilateral femoral-popliteal bypass, atrial fibrillation on apixaban and ticagrelor, and multiple cardiac stents presented with intermittent shooting axial back pain radiating to right buttock, lateral thigh, and calf, worsened with activity. MRI demonstrated thoracic myelomalacia, multi-level lumbar disc herniation, and moderate central canal stenosis. An initial multi-model treatment approach utilizing pharmacologic agents, physical therapy, ESI's, and RFA failed to alleviate symptoms. After extensive discussion with his cardiologist, he was scheduled for a three-day SCS trial. Ticagrelor and apixaban were held throughout the 3-day trial and for 5 and 3 days prior, respectively, while ASA was maintained. Successful trial with tip placement at T6 significantly improved function and pain scores (Figure 1). Upon planned percutaneous implant, the cardiologist recommended against surgical implantation and holding anticoagulation. Alternatively, the patient underwent bilateral lumbar medial branch PNS implant with sustained improvement in lower back symptoms. However, he contracted COVID, resulting in delayed lead explanation (>60 days) without complication. Conclusion(s): Interventional pain practice advisories are well established for anticoagulation use in the perioperative period.1,2 However, there is limited high-quality research on the appropriate length to hold anticoagulation prior to surgery for high thrombotic risk patients. Collegial decision making with the cardiologist was required to avoid deleterious procedural complications. However, they may be unfamiliar with the nuances between interventions or between trial and implant. Prospective studies have shown that low risk procedures, such as the PNS, may not require holding anticoagulants.3 Other case data has demonstrated post-SCS epidural hematoma with ASA use after being held for 1-week prior to surgery. Our patient was unable to undergo SCS implant and instead elected for a lower risk procedure with excellent efficacy. 4 However, delayed PNS lead extraction due to COVID19 hospitalization presented further risk of infection and lead fracture.5 PNS may prove to be an appropriate treatment option for patients who are anticoagulated and are not SCS candidates. Disclosure: Elliot Klein, MD,MPH: None, Clarence Kong, MD: None, Shawn Sidharthan, MD: None, Peter Lascarides, DO: None, Yili Huang, DO: NoneCopyright © 2023

A baby girl with TBX1 haploinsufficiency who died after elective cardiac repair surgery due to suspected enteroviral meningitis

Introduction: TBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case Presentation: A 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient's irreversible neurological status. The patient was disconnected from ECMO and expired. Discussion(s): Though we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.Copyright © 2023 Elsevier Inc.

Coronavirus in patient with positive PCR test in cerebrospinal fluid led to generalized tonic-clonic seizure without brain lesion: a case report

SARS-CoV-2 which first was observed in Wuhan region, China in December 2019 is affected many organs, such as central nervous system. We describe a case of a 57-year-old male patient, in hospital with the loss of consciousness, in the form of lack of verbal and visual communication. He got a seizure attack for about 3 minutes in the form of generalized tonic-clonic seizure (GTS) and admitted to the neurological department and was intubated. Since, the patient was not aware, awake, did not obey, corneal reflexes test was positive and his pupils were isochoric and reactive therefore, the primary diagnosis was cerebrovascular accident (CVA). On the second day after admission, although the brain computed tomography (CT) did not show brain lesion, but chest X-ray (CXR) revealed lung involvement. In addition, on third day the RT-PCR test for coronavirus RNA in and the cerebrospinal fluid and nasopharyngeal swap done and the result was positive for both of them. Therefore, treatment for the covid-19 was started. Result(s): Since, the treatment for the covid-19 was started with Atazanavir, Clindamycin and ceftriaxone, ten days after hospitalization, the lung involvement and general condition of patient got better and after two weeks he was released from the hospital. Conclusion(s): GTS should be considered as a neurological outcome of COVID-19 and medications against the coronavirus, such as Atazanavir, Clindamycin and ceftriaxone can recover the neurological deficits in these patients.Copyright© 2020, TMU Press.

Agreement of Skeletal Muscle Area and Muscle Quality Between Two Different Image Analysis Software Tools

Background: Both clinicians and researchers have a growing interest in assessment of muscle mass utilizing diagnostic abdominal computed tomography (CT) scans. Different imaging analysis software tools exist for the assessment of muscle mass;however, minimal information is available to describe the agreement between tools. The objective of this project was to determine the agreement, reliability, and strength of the relationship between skeletal muscle cross-sectional area (CSA) and muscle quality at the third lumbar region (L3) between two different image analysis software tools (3D Slicer vs SliceOmatic) using a convenient sample of individuals who have undergone diagnostic abdominal CT scan imaging. Method(s): A retrospective sample of individuals who had undergone a diagnostic abdominal CT scan was utilized. For both image analysis software tools, L3 skeletal muscle CSA was identified using a Hounsfield Unit (HU) range of -30 to +150 and muscle quality was defined as the mean HU. For each patient, L3 skeletal muscle CSA (cm2) and mean HU was calculated using 3D Slicer (version 5.0.3) and SliceOmatic (version 4.3, TomoVision, Quebec, Canada). Lin's correlation coefficient (LCC), intraclass correlation coefficient (ICC), and Spearman correlation coefficient (SCC) were used to examine the agreement, reliability, and strength of the relationship with both L3 skeletal muscle CSA and muscle quality using3D Slicer versus SliceOmatic. Bland Altman plots were created to depict the agreement of L3 CSA and muscle quality between the two tools. Result(s): A total of 504 patients were included;the sample included 128 healthy adults and 376 patients who had the following diagnoses: breast cancer (n = 175), colorectal cancer (n = 127), sepsis (n = 37) and COVID-19 (n = 37). The mean L3 skeletal muscle CSA measured using SliceOmatic was 140.6 +/- 36.0 cm2 and using 3D Slicer was 137.6 +/- 36.1 cm2. When examining the agreement, reliability, and strength of the relationship of L3 skeletal muscle CSA between SliceOmatic and 3D Slicer, LCC was 0.934 (p < 0.001), ICC was 0.968 (p < 0.001), and SCC was 0.930 (p < 0.001). The mean muscle quality measured using SliceOmatic was 35.1 +/- 10.8 HU and using 3D Slicer was 34.6 +/- 11.0 HU;LCC was 0.928 (p < 0.001), ICC was 0.964 (p < 0.001), and SCC was 0.957 (p < 0.001). Both the Bland Altman plots for L3 skeletal muscle CSA and muscle quality using SliceOmatic and 3D Slicer displayed overall strong agreement (Figures 1 and 2). However, 27 outliers were identified when visualizing the agreement L3 skeletal muscle CSA;further investigation of these outliers revealed that most of these measurements were conducted in critically ill patients (sepsis and COVID-19). Examining L3 skeletal muscle CSA between SliceOmatic and 3D Slicer among a subgroup of patients with sepsis and COVID revealed lower overall agreement (LCC: 0.679, p < 0.0001), reliability (ICC: 0.811, p < 0.001), and strength (SCC: 0.642, p < 0.001). Similar findings were observed with muscle quality between SliceOmatic and 3D Slicer among a subgroup of patients with sepsis and COVID (LCC: 0.585, p < 0.0001;ICC: 0.741, p < 0.001;SCC: 0.592, p < 0.001). Conclusion(s): Overall, both the SliceOmatic and 3D Slicer imaging analysis software tools had strong agreement, reliability, and strength when examining muscle mass and muscle quality. However, the agreement, reliability, and strength between muscle mass and muscle quality was lower between the two tools among critically ill patients compared to healthy controls and patients with cancer. Further research is needed to describe the etiology of this lower agreement in critically ill patients. (Table Presented).

Larva currens secondary to corticotherapy. Case report.

The infection by the new coronavirus (SARS-CoV-2) had in its beginnings a debated treatment, due to the unknown about its pathogenesis, which with the passage of time was clarified evidencing an inflammatory component. Corticosteroid therapy showed as a therapeutic option. In patients with corticosteroids it is essential to know the possible side reactions due to their immunosuppressive effect. We present the case of a 48-year-old male from Ecuador, who after infection by SARSCoV- 2 treated with corticosteroids, suffering as a complication the appearance of a serpiginous rash in the lumbar region. Due to its migratory history, serology for Strongyloides stercoralis, the diagnosis of currens larva was confirmed.Copyright © 2023 Sociedad Madrinela de Neumologia y Cirugia Toracica. All rights reserved.

Severe Headache as an Early Manifestation of Brain Involvement in a Patient with Covid-19 Infection

Purpose of study COVID-19 primarily affects the respiratory system from flu-like syndrome to acute hypoxic respiratory failure. Neurological manifestations are uncommon and can result in serious complications. We report a unique case of sudden onset of rapidly progressive encephalopathy in the setting of COVID-19. Methods used Reviewed the manifestations, clinical course, and outcome for a patient presenting with altered mental status secondary to COVID-19. Summary of results A 48-year-old with no significant past medical history presented to the emergency department complaining of severe headache for four days. His vital signs on presentation showed a blood pressure of 154/90, pulse of 114 bpm, temperature of 99.6 degreeF, and oxygen saturation of 97% on room air. Physical exam was unremarkable. Lab work showed elevated D-dimer 8,500 ng/L, Elevated ESR:42, LDH:340 and Ferritin:692. White blood count: 7.59 uL, Platelets 50 x 103 uL. Computer tomography angiography (CTA) of the chest showed bilateral multifocal pneumonia. CT Head was performed and was negative for an acute hemorrhage, hydrocephalus or territorial infarcts. Patient spiked a fever shortly after admission 103degreeF. Patient was started on Ceftriaxone and Azithromycin. Blood and urine cultures were positive for Klebsiella pneumonia. Patient was re-evaluated in the morning and was found altered with associated neck stiffness. Antibiotics were switched to cover for suspected meningitis. Neurology was consulted and recommended lumbar puncture. Within a few hours, the patient's mental status deteriorated and was found to be hypertensive with a blood pressure of 220/110. Repeat CT Head was negative. The patient was tested and found to be positive for COVID-19. Patient further decompensated within a few hours and became unresponsive, pulseless. ACLS was performed and the patient was transferred to the intensive care unit. Conclusions This case report highlights the heterogenous presentation in patients with COVID-19 and the importance of recognizing a new onset, severe headache as the only initial presentation. Headaches in some cases may precede the respiratory symptoms or may be the only manifestations in COVID-19 patients and it is crucial to be aware of the neurological complications and the rapid decompensation these patients may undergo if not recognized early.

Spinal Versus General Anesthesia for Spine Surgery During the COVID-19 Pandemic: A Case Series

Background: Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neuro-surgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objective(s): To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Method(s): We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Result(s): Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 +/- 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients;63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusion(s): Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.Copyright © 2023, Author(s).

West Nile Meningoencephalitis in a Patient with Leiomyosarcoma Presenting with Neutropenic Fever

Case Report: West Nile Virus (WNV) was first isolated from the West Nile district of Northern Uganda in 1937, but was first detected in the United States well over half a century later in 1999. The arthropod-borne virus has since persisted, with 2,401 cases reported to the CDC on average annually. The infection typically causes a nonspecific acute systemic febrile illness with occasional gastrointestinal and skin manifestations;however, in less than 1% of infected patients, it can cause severe and potentially fatal neuroinvasive disease, presenting as meningitis, encephalitis or acute flaccid paralysis. Immunosuppression is one of the risk factors associated with the development of neuroinvasive disease, and chemotherapy thus places patients at risk. Uterine leiomyosarcoma is a rare gynecological malignancy. Palliative chemotherapy is common in late stage disease, but may predispose patients to conditions that present as neutropenic fever, leading to a diagnostic conundrum. This is the first case report where patient with neutropenic fever was found to have West Nile neuroinvasive disease, so it is important to include West Nile disease in the differential diagnosis. Case Description: This is a case of a 45-year-old female with history of diabetes, hypothyroidism and recently diagnosed uterine leiomyosarcoma status post tumor debulking with metastasis on palliative chemotherapy with gemcitabine that presented to the Emergency Room for a fever of 103.8 degrees Fahrenheit. Given the history of advanced leiomyosarcoma, the patient was admitted for neutropenic fever with an absolute neutrophil count of 1000. During the hospitalization, the patient became acutely altered and confused. CT head without contrast and lumbar puncture were performed. Due to clinical suspicion of meningitis, she was started on broad spectrum antibiotics. Lumbar puncture revealed leukocytosis of 168 with lymphocytic predominance and elevated protein level in the cerebrospinal fluid, therefore acyclovir was started due to high suspicion of viral meningoencephalitis. An EEG showed severe diffuse encephalopathy as the patient was persistently altered. A broad workup of infectious etiology was considered including HIV, syphilis, hepatitis A, B, C, COVID-19, adenovirus, pertussis, influenza, WNV, HHV6, coccidiomycosis, aspergillus, and tuberculosis. Patient was ultimately found to have elevated IgM and IgG titers for West Nile Virus. Discussion(s): It is important to consider a broad spectrum of diagnosis in patients with metastatic carcinoma presenting with new-onset fever and acute encephalopathy. This includes working up for other causes of altered mental status including cardiac, neurologic, psychiatric, endocrine, metabolic, electrolyte, drug, and infectious etiology. While uncommon in the healthy population, WNV encephalitis should be on the radar for any patient who is immunocompromised or on immunosuppressive therapy, especially those who present with a neutropenic fever.

Guillian-Barre Syndrome Post Covid-19 Vaccination

Case Report: This is a 50-year-old man that presented to the ED complaining of generalized weakness and acute loss of ability to ambulate which has been progressing for a month. Patient began having left arm and leg weakness, which started in his fingertips of his left upper extremity and soon moved proximally to upper left arm. Symptoms then progressed to right upper and lower arms. Symptoms further continued to progress making the patient bedridden. On presentation, CT head showed a C1/C2 subluxation possibly chronic without significant focal soft tissue swelling. CT cervical spine showed C1-C2 subluxation, possibly chronic. MRI of brain was unremarkable pre and postcontrast without focal findings or abnormal enhancement and showed redemonstration of the C1-C2 subluxation as described on CT scan. MRI of cervical spine showed at the level of C1 there is spinal canal stenosis. However, there is no direct pressure upon the cord/medulla. Upon evaluation, patient had significant motor weakness and required maximal assistance for movement. Patient was moreover noted to have flaccidity of muscles associated with weakness with no bulbar weakness. Patient had no difficulty in breathing or with speech. A lumbar tap was performed which showed elevated protein, WBC, and glucose. Upon further investigation, patient stated that he received his (3rd dose) of the Moderna Vaccine for Covid-19 about a month before the onset of symptoms and felt fine. Two weeks later, he began experiencing subjective fevers, diarrhea, abdominal pain, and fatigue that lasted for a week and then self-resolved. Approximately another two weeks later is when patient began noticing his neurological symptoms. Possible Guillain-Barre Syndrome post Campylobacter Jejuni (C. Jejuni) infection vs. post Covid-19 vaccine induced GBS was suspected at this point and patient was started on Intravenous Immunoglobulin (IVIG). Stool cultures were collected for C.Jejuni which came back negative. Gastrointestinal Pathogen Panel PCR Feces also came back negative. Patient was discharged to a rehab center and planned to receive another round of IVIG for 5 days. Conclusion(s): Guillain Barre Syndrome (GBS) is a rare immune-mediated neurological disorder affecting peripheral nerves and nerve roots, that presents as acute sensorimotor neuropathy starting with distal paresthesia that progresses to weakness of legs and arms, noteably, flaccid paralysis. GBS has several triggers namely infections such as C. jejuni, cytomegalovirus, M. pneumoniae, Epstien-Barr virus and Zika virus. There has also been several case reports and studies that have shown increased incidence of GBS vaccines such as influenza vaccine. Furthermore, there has been several studies that have linked GBS to COVID-19 vaccine. With COVID-19 cases continuing to persist, and increasing advocacy for vaccination against the disease, GBS should be considered as very rare but possible side effect of the vaccine.

Which vertebral level should be used to calculate sarcopenia in covid-19 patients? A systematic review and meta-analysis.

BACKGROUND & AIMS: Evidence shows that CT-derived sarcopenia can predict adverse outcomes in COVID-19 patients. However, discrepancies exist as to which vertebral level can be used to calculate sarcopenia which can effectively serve as a prognostic tool. Thus, we aim to investigate the difference in sarcopenia calculated at the Thoracic and Lumbar vertebral levels. METHODS: An online literature search was conducted on Electronic databases such as PubMed, Cochrane CENTRAL, and Google scholar. Meta-analysis was performed by using Revman 5.3 software. RESULTS: A total of 14 articles were selected for meta-analysis. The prevalence of sarcopenia calculated at the Thoracic level was 31% (95%CI 24%-37%; p < 0.00001; I2 = 86%), while sarcopenia calculated at the Lumbar vertebral level was 63% (95%CI 51%-75%; p < 0.00001; I2 = 88%). Meanwhile, sarcopenia calculated at the Upper thoracic level was a significant predictor of mortality OR 3.47 (95%CI 1.74-6.91; p = 0.0004; I2 = 56%)as compared to sarcopenia calculated at the lower thoracic OR 1.74 (95%Cl 0.91-3.33; p = 0.10; I2 = 60%)or lumbar level OR 2.49 (95%CI 0.45-13.72; p = 0.30; I2 = 57%). In addition to this sarcopenia calculated at the Upper thoracic level was also a significant predictor of severe illness OR 3.92 (95%CI 2.33-6.58; p < 0.00001; I2 = 0%) as compared to lower thoracic OR 1.40 (95%CI 0.78-2.53; p = 0.26; I2 = 67%) or lumbar level OR 1.64 (95%CI 0.26-10.50; p = 0.60; I2 = 81%) CONCLUSIONS: Sarcopenia calculated at the thoracic vertebrae and lumber level has different prognostic values. Sarcopenia is prevalent at the lumbar level. Sarcopenia at the thoracic level has a higher mortality and severity rate.

Bilateral longitudinally extensive optic perineuritis post-COVID-19 presenting as "idiopathic" intracranial hypertension: A case report

Background: Severe acute respiratory syndrome coronavirus 2 (SARSCoV2) has been associated with several neuro-ophthalmic manifestations. We report a case of bilateral longitudinally extensive optic perineuritis suspected due to SARSCoV2. Case Presentation: A 32-year-old woman developed headaches, photophobia, pulsatile tinnitus, and blurred vision 8 d after having a positive SARS-CoV-2 qualitative polymerase chain reaction (PCR) testing for coronavirus disease 2019 (COVID-19). She was diagnosed with and treated for idiopathic intracranial hypertension (IIH) elsewhere. Repeat evaluation at our institution showed a poor visual acuity in both eyes with Frisen grade II papilledema and cotton wool spots on fundoscopic examination. Orbital magnetic resonance imaging (MRI) showed bilateral longitudinally extensive optic nerve sheath enhancement. Repeat lumbar puncture revealed an elevated cerebrospinal fluid (CSF) opening pressure and protein, a finding that is incompatible with the diagnosis of IIH. Myelin oligodendrocyte glycoprotein, aquaporin-4 (AQP4)-IgG antibodies, and other serological tests for optic neuritis were unremarkable. Her visual acuity partially improved after corticosteroids. With the growing association of demyelinating disorders and COVID-19, unremarkable serological workup, and temporal relation of the patient's symptoms to the infection, we believe that her diagnosis is SARS-CoV-2 associated bilateral optic neuritis. Conclusion(s): There is a growing association between demyelinating disorders and COVID-19 and COVID-19 vaccination, and it is essential to recognize CSF abnormalities that are incompatible with a diagnosis of IIH, such as increased protein in our case, and may lead to an incorrect diagnosis.Copyright © 2023 The Authors. Clinical and Experimental Neuroimmunology published by John Wiley & Sons Australia, Ltd on behalf of Japanese Society for Neuroimmunology.

Bilateral optic neuritis and myocarditis after the first dose of COVID-19 vaccine

Since the introduction of COVID-19 vaccine, various adverse events have been reported including injection site pain, fatigue, headaches, and myocarditis. Cranial neuropathies and optic neuritis, have been also rarely reported, however, the significance of these autoimmune manifestations after the administration of COVID-19 vaccine remain controversial. In this report we present a case of myocarditis and bilateral optic neuritis that occurred in a young healthy male patient after the administration of first dose of mRNA-1273 vaccine (Moderna).Copyright © 2022 The Author(s)

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.

Lumbar fusion during the COVID-19 pandemic: greater rates of morbidity and longer procedures.

Background: The coronavirus disease 2019 (COVID-19) pandemic has altered the standard of care for spine surgery in many ways. However, there is a lack of literature evaluating the potential changes in surgical outcomes and perioperative factors for spine procedures performed during the pandemic. In particular, no large database study evaluating the impact of the COVID-19 pandemic on spine surgery outcomes has yet been published. Therefore, the aim of this study was to evaluate the impact of the COVID-19 pandemic on perioperative factors and postoperative outcomes of lumbar fusion procedures. Methods: This retrospective cohort study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, which was queried for all adult patients who underwent primary lumbar fusion in 2019 and 2020. Patients were grouped into cohorts based on 2019 (pre-pandemic) or 2020 (intra-pandemic) operation year. Differences in 30-day readmission, reoperation, and morbidity rates were evaluated using multivariate logistic regression. Differences in total relative value units (RVUs), RVUs per minute, and total operation time were evaluated using quantile (median) regression. Odds ratios (OR) for length of stay were estimated via negative binomial regression. Results: A total of 27,446 patients were included in the analysis (12,473 cases in 2020). Unadjusted comparisons of outcomes revealed that lumbar fusions performed in 2020 were associated with higher rates of morbidity, pneumonia, bleeding transfusions, deep venous thrombosis (DVT), and sepsis. 2020 operation year was also associated with longer length of hospital stay, less frequent non-home discharge, higher total RVUs, and higher RVUs per minute. After adjusting for baseline differences in regression analyses, the differences in bleeding transfusions, length of stay, and RVUs per minute were no longer statistically significant. However, operation year 2020 independently predicted morbidity, pneumonia, DVT, and sepsis. In terms of perioperative variables, operation year 2020 predicted greater operative time, non-home discharge, and total RVUs. Conclusions: Lumbar fusion procedures performed amidst the COVID-19 pandemic were associated with poorer outcomes, including higher rates of morbidity, pneumonia, DVT, and sepsis. In addition, surgeries performed in 2020 were associated with longer operative times and less frequent non-home discharge disposition.

The Incidence of Serious/Invasive Bacterial Diseases in Infants 90 Days Old or Younger at an Emergency Hospital in Japan.

Background The incidence of severe bacterial infections (SBIs) in infants aged ≤90 days is thought to have decreased because of widespread vaccination programs. However, relevant epidemiological data in Japan are scarce. Materials and methods This observational, single-center study investigated the epidemiology of fever in infants aged ≤90 days. SBI was defined as the presence of meningitis, urinary tract infections (UTIs), or bacteremia. Invasive bacterial infection (IBI) was defined as the presence of meningitis, bacteremic UTI, or bacteremia. We determined the incidence of UTIs, bacteremia, meningitis, SBIs, and IBIs in the following three age groups: 0-28, 29-60, and 61-90 days. We subsequently calculated the relative incidence for the groups aged 29-60 and 61-90 days, using the group aged 0-28 days as the reference group.  Results Herein, 58, 124, and 166 infants were included in the 0-28 days, 29-60 days, and 61-90 days age groups, respectively. Of the total number of patients, 15.5%, 8.9%, and 16.9% in the 0-28 days, 29-60 days, and 61-90 days age groups, respectively, were diagnosed with SBI. The relative incidences were 1 for the 0-28 days group (reference group), 0.67 for the 29-60 days group (95% confidence interval [CI], 0.39-1.15), and 1.08 for the 61-90 days group (95% CI, 0.58-2.00). Of the total number of patients, 10.3%, 3.2%, and 0.6% in the 0-28 days, 29-60 days, and 61-90 days age groups, respectively, were diagnosed with IBI. Relative incidences were 1 (reference group), 0.50 (95% CI, 0.29-0.88), and 0.28 (95% CI, 0.19-0.41) for the 0-28 days, 29-60 days, and 61-90 days age groups, respectively. All cases of IBI were caused by Group B streptococcus (GBS), except for two cases of bacteremia, which were caused by Haemophilus influenzae.  Conclusion The incidence of SBI was similar in the 0-28 days and 61-90 days age groups. However, the incidence of IBI decreased with increasing age. The incidence of UTIs was highest in the 61-90 days age group, and that of meningitis and bacteremia decreased with increasing age.

Meningoradiculitis post-COVID-19 mRNA vaccination: A case report

We present a rare case of meningoradiculitis occurring after mRNA COVID-19 vaccination. This patient, with a history of inflammatory arthritis following rubella vaccination, presented to the emergency department 4 days after her vaccination with both central and radicular nervous system symptoms. Symptoms included pain, sensory and motor deficits in L5 roots distribution, along with signs of central irritation, such as headache, difficulty concentrating and a Babinski sign. MRI showed bilateral L5 nerve roots enhancement. Lumbar puncture showed elevated protein and IgG, and relevant serologies excluded common causes. Prednisone and physical therapy helped the patient to achieve near complete recovery nine weeks after presentation. We concluded that this patient presented meningoradiculitis probably secondary to her vaccination in a context of possible overactive immune system. While such presentations might be rare, and do not constitute a general reason to abstain from vaccination, they must be well recognized and treated.Copyright © 2022

An unusually fulminant case of encephalomyelitis in an 80 year old

Background: There have been reports of demyelinating syndromes in association with COVID-19 and to a much lesser extent COVID 19 vaccines. The association between demyelination and vaccines, in general, remains controversial. We review a presentation of fulminant demyelination, and discuss antecedent COVID-19 vaccination, the formulation of a broader differential diagnosis and ultimately the pathologic diagnosis. Case presentation: An 80-year-old woman presented with seizure, encephalopathy, quadriparesis and ultimately expired. She received a SARS-CoV-2 vaccine one day prior. Imaging revealed contrast enhancing cerebral lesions, longitudinally extensive transverse myelitis. CSF was markedly inflammatory. Pathologic examination of the CNS lesions revealed demyelination and inflammation beyond white matter, not restricted to a perivenular distribution. Conclusion(s): This case depicts a seemingly fulminant course of a diffuse demyelinating syndrome characterized clinicopathologically as Marburg's variant of multiple sclerosis. There are several unique aspects of this case including the extremely rapid course, the unusual evolution of CSF abnormalities, with hypoglycorrhachia and markedly elevated protein. The proximity to vaccination is a pertinent association to document, though we cannot unequivocally prove causation.Copyright © 2022 The Authors