Occipital seizures and persistent homonymous hemianopia with T2 hypointensity on MRI in nonketotic hyperglycemia.

INTRODUCTION: Nonketotic hyperglycemia (NKH) is known to cause focal motor or secondarily generalized seizures. Occipital seizures in NKH are seldom reported, especially with visual hallucinations and persistent homonymous hemianopia (HH) with characteristic radiological and electroencephalographic (EEG) findings. SUMMARY: Our patient was a middle-aged man who presented with a new onset, single episode of generalized tonic-clonic seizure and NKH. He complained of seeing intermittent colorful stripes in his right visual field. Examination revealed persistent complete right HH and he was observed to have complex partial seizures. Magnetic resonance imaging (MRI) showed subcortical T2 hypointensity within the left occipital lobe in T2W and FLAIR images. The EEG showed electrographic seizures originating from the left occipital region. Random blood glucose at presentation was 581 mg/dl with HbA1c of 11.4%. The seizure and visual field deficits were successfully terminated by the introduction of antiseizure medication and glycemic control. CONCLUSION: Occipital seizures with visual field deficits can occur in hyperglycemic states. These can be associated with specific MRI brain and EEG changes. The HH is reversible with apt treatment primarily including glycemic control with or without antiseizure medication.

Upper limb musculoskeletal abnormalities in type 2 diabetic patients in low socioeconomic strata in Pakistan.

BACKGROUND: Musculoskeletal manifestations of diabetes in the upper limb are well recognized. No data has been available in this regard from Pakistan. Our aim was to find out the frequency of upper limb musculoskeletal abnormalities in diabetic patients. METHODS: This was an observational study in which type 2 diabetes patients attending our diabetic clinic were enrolled along with age and gender matched controls. Data was analyzed on SPSS 16. RESULTS: In total, 210 Type 2 diabetics (male 34.3%, female 65.7%) and 203 controls (male 35%, female 65%) were recruited. The mean age was 50.7± 10.2 years in diabetic group as compared to 49.5±10.6 years in the control group. The frequencies of hand region abnormalities were significantly higher in the diabetic subjects as compared to the controls (20.4%, p-value <0.001). Limited joint mobility (9.5% vs 2.5%), carpal tunnel syndrome (9% vs 2%), trigger finger (3.8% vs 0.5%), and dupuytren's contracture (1% vs 0%) were found more frequent as compared to controls (all p-values <0.05). In the shoulder region of diabetic subjects, adhesive capsulitis and tendonitis was found in 10.9% and 9.5% respectively as compared to 2.5% and 2% in control group [p- value <0.001]. A weak but positive relationship was observed between age and duration of diabetes with these upper limb abnormalities. However, no correlation was found between the frequencies of these abnormalities with control of diabetes. CONCLUSION: A higher frequency of upper limb musculoskeletal abnormalities was observed in Type 2 diabetic patients as compared to control group.

Pulmonary tuberculosis with neuromyelitis optica: an uncommon association of a common disease.

Systemic tuberculosis has been reported with varying neurological manifestations like meningitis, tuberculomas, myositis and neuropathy. Neuromyelitis optica (NMO) is a well known neurological entity which has been described in association with several systemic disorders like systemic lupus erythematosis, diabetes mellitus, hypothyroidism, exposure to insecticides etc. However, only a few cases of NMO have been reported in association with Mycobacterium tuberculosis. Here, we report a case of pulmonary tuberculosis in association with NMO to highlight the under-reported association of NMO with pulmonary tuberculosis presenting in a peculiar anatomical fashion i.e. longitudinal myelitis with predominant posterior column involvement.

Frequency of newly diagnosed diabetes mellitus in acute ischaemic stroke patients.

OBJECTIVE: To determine the frequency of newly diagnosed diabetes mellitus in acute ischaemic stroke patients. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Jinnah Postgraduate Medical Centre, Karachi, from June 2007 - June 2008. METHODOLOGY: This study included adult patients (age > 30 years, both genders) with the diagnosis of acute ischaemic stroke. Patients who were known to have diabetes mellitus prior to stroke, had a non-lacunar stroke or were admitted to intensive care units for any reason were excluded. Detailed history and examination, fasting blood sugar, fasting lipid profile, a non-enhanced CT scan brain and electrocardiogram were done on every patient. Data were entered on a preformed proforma. The results were analyzed on SPSS version 10. Chi-square test was applied. P-value <0.05 was considered to be statistically significant. RESULTS: A total of 250 patients were enrolled. The male: female ratio was 1: 0.9. Mean age was observed as 60.9±10.1 years. In total, 50 new cases of diabetes mellitus were identified (20%). Average fasting blood sugar in diabetic subjects was 148±10 mg/dl. The most common risk factors in the newly diagnosed diabetic subjects were hypertension 26 (52%), smoking 18 (36%) and hyperlipidemia 14 (28%). Atrial fibrillation and myocardial infarction were seen in 12 subjects (24%) and 9 subjects (18%) respectively. CONCLUSION: Twenty percent patients with acute ischaemic stroke had un-diagnosed diabetes. Therefore, it is advisable to screen acute stroke patients for diabetes to reduce their long-term morbidity and mortality.

Clinical spectrum of post-stroke seizures.

OBJECTIVE: To determine the characteristics of post-stroke seizures and compare these in early vs. late post-stroke seizures. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Neurology, Liaquat National Hospital, Karachi, from March to September 2007. METHODOLOGY: All admitted patients aged over 25 years, with diagnosis of post-stroke seizures were included. Those with known epilepsy, sepsis and electrolyte imbalance were excluded. Age, co-morbid condition, details of seizures and radiological findings regarding type and location of stroke were collected and entered in a pre-formed proforma. Results were described as frequency and mean. Association of variables was determined through chi-square test with significance at p < 0.05. RESULTS: Out of the 50 patients, there were 28 (56%) males and 22 (44%) females with the mean age of 56.86 ± 15.26 years. Thirty-one (62%) patients had history of hypertension. Early seizures i.e. within 2 weeks were seen in 29 (58%) patients. Generalized seizures were seen more frequently i.e. in 37 (74%) patients. Thirty-one (62%) subjects experienced more than 2 seizures. Forty (80%) had an ischemic stroke including 36 (72%) arterial infarct and 3 (6%) venous infarcts. Intracerebral hematoma was seen in 10 (20%) of subjects. Comparison between early and late onset seizures revealed significant association between ischemic heart disease (IHD), old stroke, hypertension and late onset seizures (p < 0.05). CONCLUSION: Post-stroke seizures were more frequent in males, with history of hypertension, and with cortical ischemic strokes. Early seizures, multiple episodes and generalized seizure type were more common. Venous infarcts were chiefly associated with seizures at presentation. History of old stroke, ischemic heart disease, hypertension and hypercholesterolemia showed a strong relationship with the occurrence of late onset seizures.