Symptomatic Cavum Septum Pellucidum Cyst: A Rare Presentation.

A cavum septum pellucidum is a cerebrospinal fluid (CSF) filled cavity situated between the lateral ventricles and is considered as a normal anatomic variant sporadically seen on neuroimaging. While a cavum septum pellucidum is a relatively uncommon incidental neuroimaging finding, symptomatic cysts of the cavum septum pellucidum are very rare, with only a few cases reported in the literature so far. They are defined as fluid-filled structures with lateral bowing of the walls and membranes separated by at least 10 mm or more. We present the case of a 25-year-old male patient with a rapidly expanding cyst of the septum pellucidum with headaches refractory to conventional pharmacological therapy. A 3T magnetic resonance imaging (MRI) of the brain with contrast was performed, which confirmed the diagnosis. Due to the failure of non-interventional treatment, he was treated with therapeutic endoscopic fenestration of the cyst. Postoperatively, he reported a complete resolution of the presenting symptoms.

Postpartum Ischemic Stroke: A Rare Case.

The risk of stroke is increased during pregnancy and the postpartum period. It can lead to significant maternal morbidity and mortality. The physiologically mediated hemodynamic changes in circulation and vascular tissue, and the increased coagulability account for this increased risk of stroke. Pregnancy-related strokes can be hemorrhagic or ischemic. We present a rare case of postpartum ischemic stroke. A 25-year-old female with no known comorbidities and a history of cesarean section 10 days back presented with a right-sided weakness and sensory loss for one day. An MRI of the head revealed a large area of restricted diffusion on diffusion-weighted 1 (DW1) image in the left parietal region with comparable low signals on apparent diffusion coefficient (ADC) map and a small area of blooming suggesting hemorrhage on susceptibility-weighted 1 (SW1) image. This area appeared hypointense on T1 and hyperintense on fluid-attenuated inversion recovery (FLAIR) and T2 images. These findings suggested acute ischemic infarction. She was started on antiplatelet therapy, and subsequently, her weakness improved. She was discharged upon improvement in her symptoms and was asked to follow up in the outpatient department. Numerous studies have shown an increased risk of ischemic stroke in the immediate postpartum period in women who undergo a cesarean section. Thus, we conclude that clinicians should be aware of this complication and high-risk patients should be identified and monitored more aggressively in their immediate postpartum period.

A Rare Case of Dengue Fever Presenting With Acute Disseminated Encephalomyelitis.

Dengue fever is a viral infection transmitted by mosquitoes with a clinical spectrum that ranges from asymptomatic infection to dengue shock syndrome. Neurologic manifestations are rare. We report a case of dengue fever presented with acute disseminated encephalomyelitis. An 18-year-old boy presented with high-grade fever, generalized headache for three days, intermittent altered sensorium, nausea, and vomiting for one day. Dengue-IgG and Dengue-IgM were positive. Magnetic resonance imaging (MRI) showed abnormal signal intensity areas in the bilateral deep white matter at centrum semiovale more on the right side, which seemed hypointense on T1 and hyperintense on T2 and fluid-attenuated inversion recovery (FLAIR) images, with open ring enhancement on contrast-enhanced T1 image, and peripheral diffusion restriction on diffusion-weighted 1 (DW1) image. These features were suggestive of acute disseminated encephalomyelitis. He improved within a week of taking IV methylprednisolone 1 g once daily for five days and supportive care. Follow up MRI after three weeks showed the resolution of all abnormalities. Thus we conclude that patients with acute disseminated encephalomyelitis should be checked for dengue fever, especially in areas of high prevalence, for early diagnosis and appropriate treatment and to prevent excessively aggressive surgery and/or treatment for such abnormal MRI findings.

Type II Myocardial Infarction: Predisposing Factors, Precipitating Elements, and Outcomes.

Introduction Myocardial infarction (MI) is a subset of the spectrum of the disease known as acute coronary syndrome (ACS), which comprises three distinct entities including unstable angina (UA) and MI with or without ST-segment elevation. However, many clinicians are unaware that MI itself is classified into five types, the most common being type I, followed by type II. Type II MI occurs due to coronary insufficiency not related to acute plaque change in the coronary vasculature. Data available on type II MI is still limited, particularly in the South Asian setting, despite documented poorer outcomes for the same compared to other types. Therefore, we conducted this study as an attempt to outline the predisposing factors, precipitating elements, and possible outcomes of type II MI. Materials and methods This prospective study was conducted at a tertiary care hospital in Kochi, Kerala for 12 months. A total of 59 patients of ages 10-99 years, with a final diagnosis of MI based on the levels of cardiac biomarkers and electrocardiography (ECG), no previous history of coronary angiography, thrombolysis, percutaneous coronary intervention (PCI), and non-ischemic conditions producing elevations in cardiac biomarkers were included in this study. Demographic features, cardiac biomarker levels, comorbidities, precipitating factors, foci of sepsis, and outcomes of type II MI were noted. The mean was calculated for age and cardiac biomarkers. The frequency and percentages were calculated for gender, comorbidities, precipitating factors, foci of sepsis, and the outcomes of type II MI. Results The mean age of the patients was 69.66 years; 38 (64.4%) patients were males and 21 (35.59%) were females. Mean elevation of creatine kinase myocardial band (CK-MB) was 47.457 IU/L and highly sensitive troponin I (Hs-Trop I) was 8.712 ng/mL. Diabetes mellitus [44 (74.57%)] and hypertension [41 (69.49%)] were the most common underlying patient comorbidities followed by dyslipidemia [38 (64.4%)]. Most of the patients had more than two comorbidities at a time; 33 (55.93%) patients had sepsis, 31 (52.4%) patients had anemia, 29 (49.1%) patients had electrolyte imbalance, 19 (32.2%) patients had respiratory failure, 16 (27.11%) patients had arrhythmia (tachyarrhythmia/bradyarrhythmia), and two (3.3%) patients had postoperative (non-cardiothoracic) stress. Sepsis was originating from the lower respiratory tract in 14 (42.42%) patients, blood in 11 (33.33%) patients, urinary tract in eight (24.24%) patients, and abdomen in six (18.18%) patients. Thirty-four (57.62%) patients had heart failure, 13 (22.03%) had arrhythmias, and 19 (32.20%) patients died. Conclusions Type II MI has a high mortality rate, mostly due to heart failure and arrhythmia. Patients with diabetes mellitus and hypertension are at increased risk of type II MI. Sepsis is the most common precipitating factor, primarily originating from the lower respiratory tract, followed by anemia and dyselectrolytemia. Treatment of precipitating factors is the primary way to manage type II MI.

Therapeutic Implications of Altered Energy Metabolism in Migraine: A State-of-the-Art Review.

Currently, the management strategies aimed at the resolution of migraine are pharmacological. Most of these therapies are known to alter the serotonin balance of the brain. Furthermore, therapies blocking the calcitonin gene-related peptide (CGRP) have also proven to be quite effective in their treatments. However, apart from being expensive, these therapies do not influence premonitory and aura symptoms. This suggests an incomplete approach and an inadequate understanding of the migraine pathophysiology. Recent metabolic studies have indicated that migraine should be considered as an adaptive response to the mismatch between the cerebral energy reserves and expenditure. Therefore, understanding the underlying metabolism helps derive possible novel therapeutic modalities for migraines. In this review, we highlight the underlying metabolic abnormalities found in migraine patients. This will form the basis of our evidence-based discussion on metabolic therapeutic options for migraines.

Paraphenylenediamine (Kala Pathar) Poisoning at the National Poison Control Center in Karachi: A Prospective Study.

Introduction Suicide by self-poisoning is a common cause of death, especially in the younger population. More specifically, hair-dye poisoning is being increasingly used for suicide. Paraphenylenediamine (PPD), also known as "Kala pathar", is a highly toxic ingredient present in hair-dye that can cause death. Therefore, this study is designed to assess the demographics, clinical features, laboratory findings, and outcomes of PPD poisoning in patients admitted to the National Poison Control Center in Karachi, Pakistan. Materials and methods We conducted a prospective study for a period of six months at the National Poison Control Center, Karachi, Pakistan. A total of eight patients with PPD poisoning with no cardiac, liver, or renal co-morbidities were included in this study. The demographic characteristics, clinical features, laboratory findings, mode of intoxication, and route of intoxication were noted in a proforma. Furthermore, hospitalization time, tracheostomy status, mechanical ventilation status, and mortality rates were also recorded. For continuous variables, the means and SDs were calculated. Whereas for categorical data, percentages were calculated. Results In our study, the mean age of the patients was estimated at 25.38 ± 3.77 years. It was deemed that the majority of poisoning cases were intentional in nature (75%). These suicide cases were more commonly observed in young females (75%) who belonged to a low socioeconomic class (87.5%). The preferred route of administration was oral (87.5%). In 87.5% of the patients, the characteristic clinical features such as cervicofacial edema, dysphagia, dysphonia, and stridor were noted. During the later clinical stages of poisoning, clinical features such as rhabdomyolysis (62.5%), chocolate-colored urine (87.5%), hepatitis (75%), and acute renal failure (12.5%) were noteworthy. The mean ± SD of total leukocyte count (TLC), creatine phosphokinase (CPK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum creatinine and serum potassium were, respectively, noted at 10,500 ± 3,854.4 cells/mm3, 32.87 ± 11.36 IU/L, 1,239.1 ± 1,106.2 IU/L, 776.8 ± 1,149.8 IU/L, 2.125 ± 2.275 mg/dL, and 4.9 ± 1.094 mmol/L. In our patients, the mean intensive care unit stay was 8.25 ± 3.99 days. Emergency tracheostomy was performed in 25% of patients. Mechanical ventilation was required for 50% of our patients. Overall, the mortality rate observed in our study stands at 25%. Conclusion PPD poisoning is associated with a high rate of morbidity and mortality. Therefore, it is imperative for physicians to be mindful of the clinical characteristics and treatment options in order to optimally manage such cases of poisoning. In addition, the use of hair-dyes composed of highly lethal PPD should also be banned.