COVID-19 Associated Stroke-A Single Centre Experience.

BACKGROUND AND PURPOSE: Various neurological complications have been reported in association with COVID-19. We report our experience of COVID-19 with stroke at a single center over a period of eight months spanning 1 March to 31 October 2020. METHODS: We recruited all patients admitted to Internal Medicine with an acute stroke, who also tested positive for COVID-19 on RTPCR. We included all stroke cases in our analysis for prediction of in-hospital mortality, and separately analyzed arterial infarcts for vascular territory of ischemic strokes. RESULTS: There were 62 stroke cases among 3923 COVID-19 admissions (incidence 1.6%). Data was available for 58 patients {mean age 52.6 years; age range 17-91; F/M=20/38; 24% (14/58) aged ≤40; 51% (30/58) hypertensive; 36% (21/58) diabetic; 41% (24/58) with O2 saturation <95% at admission; 32/58 (55.17 %) in-hospital mortality}. Among 58 strokes, there were 44 arterial infarcts, seven bleeds, three arterial infarcts with associated cerebral venous sinus thrombosis, two combined infarct and bleed, and two of indeterminate type. Among the total 49 infarcts, Carotid territory was the commonest affected (36/49; 73.5%), followed by vertebrobasilar (7/49; 14.3%) and both (6/49; 12.2%). Concordant arterial block was seen in 61% (19 of 31 infarcts with angiography done). 'Early stroke' (within 48 hours of respiratory symptoms) was seen in 82.7% (48/58) patients. Patients with poor saturation at admission were older (58 vs 49 years) and had more comorbidities and higher mortality (79% vs 38%). Mortality was similar in young strokes and older patients, although the latter required more intense respiratory support. Logistic regression analysis showed that low Glasgow coma score (GCS) and requirement for increasing intensity of respiratory support predicted in-hospital mortality. CONCLUSIONS: We had a 1.6% incidence of COVID-19 related stroke of which the majority were carotid territory infarcts. In-hospital mortality was 55.17%, predicted by low GCS at admission.

Sudden mono-ocular blindness with recurrent transient diplopia and ptosis in a middle-aged woman.

Sudden painless loss of vision is an ophthalmologic and a medical emergency resulting from various causes such as occlusion of retinal artery or vein, macular or vitreous haemorrhages, retinal detachment, and anterior and posterior ischaemic optic neuropathy. We report a 48-year-old woman presenting with right monocular blindness due to branch retinal artery occlusion whose vision recovered due to timely paracentesis coupled with treatment with adequate antiplatelet agents and anticoagulants. The patient had transient diplopia and ptosis despite adequate antiplatelet agents and anticoagulants. Thorough search for aetiology revealed the underlying cause to be aortoarteritis. Aortoarteritis is a rare disease, and ocular involvement occurs late in the disease. We review ophthalmologic manifestation of aortoarteritis and diagnostic utilities of various modalities for aortoarteritis.

Tocilizumab in refractory adult-onset Still's disease with aseptic meningitis--efficacy of interleukin-6 blockade and review of the literature.

Adult-onset Still's disease is a multisystem inflammatory disorder of unknown etiology characterized by typical spiking fever, evanescent rash, arthralgia, and leucocytosis. Neurologic manifestations are infrequent, seen in 7 to 12% of cases. We present the case of a young male admitted with aseptic meningitis that satisfied the diagnostic criteria of Adult-onset Still's disease. Refractoriness to therapy with corticosteroids and cyclosporine A led to the use of humanized monoclonal anti-interleukin-6 receptor antibody "tocilizumab" with dramatic response. The case is reported for the rarity of presentation and the need to consider the diagnosis in related clinical scenarios. Also, current literature on the use of tocilizumab in intractable disease is reviewed.

Intractable seizures and metabolic bone disease secondary to celiac disease.

Celiac disease (CD) is Gluten sensitive enteropathy with a wide spectrum of severity and protean clinical manifestations. Patients with atypical (non-diarrhoeal) presentations are missed as the diagnosis of Celiac Disease is not considered. We present three young girls (ages 18, 19, 23 at presentation) who were admitted to our hospital as intractable seizures. All had low serum calcium, features of rickets/osteomalacia and anaemia. This prompted us to consider malabsorption due to CD. The diagnosis of CD was confirmed by serologic tests (IgA transglutaminase and IgG antigliadin antibodies) and biopsy of the duodenum. In all patients gluten free diet not only provided drug free control of seizures but also helped correct other features of malabsorption like hypocalcaemia and anaemia as the primary pathology behind these symptoms was corrected. We wish to highlight that hypocalcaemia of CD which may present as intractable seizures can be treated only by treating CD with gluten free diet and not by oral vitamin D and Calcium alone.

Isoniazid toxicity presenting as status epilepticus and severe metabolic acidosis.

Isoniazid (INH) is an integral component of treatment of tuberculosis. An acute overdose is potentially fatal and is characterized by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. The diagnosis of INH overdose should be considered in any patient who presents to emergency medical services (EMS) with the triad. We report a patient presenting with multiple generalised tonic clonic (GTC) convulsions with severe metabolic acidosis as a manifestation of INH toxicity.