Cerebral vasospasm due to Fusarium solani meningitis: A complication from medical tourism. Case report and literature review.

OBJECTIVES: Medical tourism is expanding globally, with patients seeking cosmetic procedures abroad. To date, little information is known regarding the risks and outcomes of cosmetic tourism, especially potential stroke complications. Here, we present a case of fungal meningitis in the setting of medical tourism leading to ischemic strokes and vasospasm. MATERIAL AND METHODS: We describe an immunocompetent 29-year-old female patient who initially presented with intractable headaches and an abnormal cerebrospinal fluid (CSF) profile who was eventually diagnosed with Fusarium solani meningitis as a part of a common source outbreak in Matamoros, Mexico. These patients were part of a cohort who underwent cosmetic procedures requiring spinal anesthesia. This report also highlights the unusual clinical course leading to poor outcomes in such conditions. RESULTS: The patient initially presented with headaches, papilledema, elevated opening pressure on the spinal tap, abnormal CSF studies, and eventually developed ischemic strokes and hydrocephalus. CSF showed positive beta D-Glucan with repeated negative CSF fungal cultures. A cerebral angiogram revealed extensive basilar artery vasospasm that led to ischemic strokes. Continued clinical worsening and lack of response to antifungal treatment prompted further imaging that revealed significant non-obstructive hydrocephalus subsequently complicated by spontaneous intracranial hemorrhage. CSF PCR for Fusarium solani species was positive days after her passing. CONCLUSION: This novel case highlights fungal meningitis caused by Fusarium solani complicated by bilateral ischemic strokes stemming from basilar artery vasospasm. Complications from medical tourism impact not only individual patients but also the health systems of both countries. Professional and regulatory entities for cosmetic surgeries must highlight and educate patients on the risks and complications of cosmetic surgeries happening abroad. Physicians should be aware of ongoing outbreaks and possible complications of these procedures.

Postmortem Brain Imaging in Alzheimer's Disease and Related Dementias: The South Texas Alzheimer's Disease Research Center Repository.

BACKGROUND: Neuroimaging bears the promise of providing new biomarkers that could refine the diagnosis of dementia. Still, obtaining the pathology data required to validate the relationship between neuroimaging markers and neurological changes is challenging. Existing data repositories are focused on a single pathology, are too small, or do not precisely match neuroimaging and pathology findings. OBJECTIVE: The new data repository introduced in this work, the South Texas Alzheimer's Disease research center repository, was designed to address these limitations. Our repository covers a broad diversity of dementias, spans a wide age range, and was specifically designed to draw exact correspondences between neuroimaging and pathology data. METHODS: Using four different MRI sequences, we are reaching a sample size that allows for validating multimodal neuroimaging biomarkers and studying comorbid conditions. Our imaging protocol was designed to capture markers of cerebrovascular disease and related lesions. Quantification of these lesions is currently underway with MRI-guided histopathological examination. RESULTS: A total of 139 postmortem brains (70 females) with mean age of 77.9 years were collected, with 71 brains fully analyzed. Of these, only 3% showed evidence of AD-only pathology and 76% had high prevalence of multiple pathologies contributing to clinical diagnosis. CONCLUSION: This repository has a significant (and increasing) sample size consisting of a wide range of neurodegenerative disorders and employs advanced imaging protocols and MRI-guided histopathological analysis to help disentangle the effects of comorbid disorders to refine diagnosis, prognosis and better understand neurodegenerative disorders.

Recurrent cryptogenic strokes in a young female as a novel presentation of Parry Romberg syndrome: a case report and review.

INTRODUCTION: Parry Romberg Syndrome (PRS) is a less common genetic condition presenting with progressive hemifacial atrophy involving skin, underlying connective tissue, muscle and facial bone. Neurological manifestations include seizures, headaches, deafness and trigeminal neuralgia refractory to medications, while stroke is a less common presentation. MATERIALS AND METHODS: A 43-year-old right-handed female with previous history of Lower Motor Neuron (LMN) type facial palsy, seizure disorder and linear scleroderma, presented to our clinic with recurrent cryptogenic strokes. She developed progressive hemifacial atrophy on the left side and left eye ectropion and was eventually diagnosed with rare Parry Romberg Syndrome. RESULTS: Patient underwent extensive work up for stroke to rule out etiologies like hyperlipidemia, diabetes, lupus and vasculitis. Peripheral labs for inflammatory markers and Cerebrospinal fluid (CSF) studies were unremarkable. Brain imaging at different points in time showed progressive atrophy of brain parenchyma, overlying bone, connective tissue and facial muscles on the left side. Central Nervous System (CNS) vessel imaging and diagnostic cerebral angiogram was unremarkable. CONCLUSION: This novel case underscores the potential CNS involvement in PRS, which is a rare disease entity. Neurological manifestations are not uncommon, including stroke. Further research is needed to understand the mechanisms of stroke in this rare disease process, that could help develop potential therapeutic targets.

Motor Band Sign in Primary Lateral Sclerosis: A Case Report Proposing the Need for an Imaging Biomarker.

Motor neuron disease is a degenerative condition involving both upper motor neurons (UMN) and lower motor neurons (LMN). While amyotrophic lateral sclerosis (ALS) is an overlap of upper and lower motor neuron involvement, primary lateral sclerosis (PLS) is predominantly an upper motor neuron involvement with lower motor involvement seen in the later stages of illness. Diagnostic criteria rely on clinical features and electrodiagnostic tests such as electromyography (EMG). EMG predominantly helps in determining lower motor neuron involvement. No definitive objective measures are currently available to determine upper motor neuron involvement. We describe a patient diagnosed with PLS based on consensus diagnostic criteria. The patient had absent LMN features both clinically and on EMG. Magnetic resonance imaging (MRI) was significant for hypointense signals in the bilateral motor strip area on susceptibility weighted sequence, suggesting a surrogate marker of degeneration involving motor neurons in the brain. Early recognition of this MRI pattern called motor band sign (MBS) can help determine the earlier diagnosis of this neurodegenerative condition, potentially translating to better treatment and outcome measures.

Neuromodulation in Intractable Epilepsy Through Responsive Vagal Nerve Stimulation: A Three-Year Retrospective Study at the University of Texas Medical Branch, Galveston.

BACKGROUND: Vagus nerve stimulation (VNS) functions through neuromodulatory mechanisms to provide quality of life improvements to those with drug-resistant epilepsy. Responsive VNS (rVNS) generators are designed to further reduce seizure burden by detecting ictal tachycardia and aborting seizures soon after their onset.  Methods: Electronic medical records were accessed from January 2015 to December 2018 to identify patients with epilepsy managed with rVNS generators. Data were collected on seizure burden before and after rVNS implantation. Seizure burden was compared using t-tests, and monthly seizure reductions were gauged with the McHugh scale. Twenty-seven individuals met inclusion criteria; 10 were eliminated due to prior VNS implantation or undocumented seizure frequencies. RESULTS: The average seizure burden prior to rVNS implantation was 24.78 seizures/month. Following generator placement, the mean seizure frequencies at three months, six months, 12 months, and 18 months were 6.81, 16.57, 5.65, and 5.78 seizures/month, respectively. However, despite documented reductions in the average monthly seizure frequency, we found no statistically significant differences in seizure frequency relative to baseline. CONCLUSION: While many participants showed individual reductions in seizure burden, this study was unable to definitively conclude that rVNS therapy leads to statistically significant reduction in seizure burden.

Social cognitive deficits in schizophrenia and their neurocognitive correlates across the different phases of illness.

AIM: This study aimed to assess the relationship between neurocognition (NC) and social cognition (SC) in patients with schizophrenia during the symptomatic phase and the phase of clinical remission. METHODOLOGY: Thirty-two patients were assessed on Color trail test (CTT), Hopkins verbal learning test (HVLT), Controlled oral word association (COWA) test, Wisconsin card sorting test (WCST), Ravens standard progressive matrices (SPM) and Social cognition rating tool in Indian setting (SOCRATIS) during symptomatic and remission phases of illness at least 3 months apart. RESULTS: Compared to baseline assessment, even after controlling for PANSS scores except for social perception index all other domains of SC showed significant improvement at the time of remission. Although there was significant improvement in a few subtests of verbal learning, IQ and number of correct responses of COWA, colour trail test, no significant difference was seen in performance on WCST. Although second order theory of mind task had some association with IQ at the baseline assessment, no association was seen between SC and NC in the remission phase. CONCLUSIONS: To conclude, present study suggests that impairments in all the domains of SC (except for social perception index) and NC (except for WCST) improve in the remission phase.

Nationwide Trends in Cardiovascular and Cerebrovascular Diseases and Outcomes Among Young Adults (18-39 years) Hospitalized With Comorbid Depression.

Background Modern-day studies that assess temporal trends in cardiovascular and cerebrovascular events (CCE) and outcomes among the young population in the United States (US) with depression remain limited. Methods We compared baseline demographics, comorbidities, all-cause mortality, acute myocardial infarction (AMI), percutaneous coronary interventions (PCI), arrhythmia, stroke, and venous thromboembolism (VTE) among hospitalized young adults (18-39 years) with vs. without depression using the National Inpatient Sample (NIS) from 2007 to 2014. Results A total of 3,575,275 patients out of 63,020,008 hospitalized young adults had comorbid depression (5.7%; median 31 years, 71.3% females). The depressed cohort more often comprised of older, white, male, and non-electively admitted patients. Higher rates of comorbidities, all-cause mortality, PCI, arrhythmia, VTE, and stroke were observed among the depressed cohort. The rising trend in all-cause mortality was observed among the depressed against a stable trend in the non-depressed. The prevalence of AMI remained stable among depressed with consistent upsurges in arrhythmia and stroke. Those with depression had extended hospital stay, higher hospitalization charges, and were more often transferred to other facilities or discharged against advice. Conclusions Rising trends of inpatient mortality, CCE, and higher resource utilization among young adults with depression are concerning and warrants a multidisciplinary approach to improve quality of life and outcomes.

Social cognition of patients with schizophrenia across the phases of illness - A longitudinal study.

AIM: This longitudinal study aimed to evaluate social cognition of patients with schizophrenia at two points, i.e., during the symptomatic phase and clinical remission phase. Additional aim was to evaluate the relationship of social cognition with psychopathology and functional outcome. METHODOLOGY: Fifty-one patients (N=51) were evaluated on Social Cognition Rating Tools in Indian Setting (SOCRATIS), Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF), Socio-occupational functioning scale (SOFS) and Indian Disability Evaluation and Assessment Scale (IDEAS) during the symptomatic phase of illness. These patients were followed-up longitudinally for achieving clinical remission. Out of the 51 patients, 32 patients underwent second assessment after a mean duration of 143 (SD 34.9) days, while in clinical remission. Data of 111 healthy controls was used for comparison. RESULTS: Social cognitive deficits were present in both the phases of illness. However, when the baseline and follow-up data was compared, it was evident that the severity of social cognition deficits is lower during the clinical remission phase. Higher levels of social cognitive deficits in both phases of illness are associated with higher socio-occupational dysfunction and higher disability. CONCLUSION: Present study suggests that impairment in social cognition in patients with schizophrenia is present both in symptomatic and remission phase, with higher level of deficits during the symptomatic phase. Social cognition impairments are associated with poor social and occupational functioning and higher level of disability.

Venlafaxine induced akathisia: a case report.

Venlafaxine is a serotonin-norepinephrine reuptake inhibitor used for the management of depression and anxiety disorders. The drug has been rarely reported to be associated with the development of akathisia. A review of the literature revealed only three such case reports. In this report we present the case of a middle-aged female, who developed akathisia while receiving venlafaxine (225 mg/day). The patient was suffering from recurrent depressive disorder and Crohn's disease. She was earlier treated with Cap venlafaxine up to 75 mg/day, but had a relapse of depressive symptoms when an attempt was made to taper off venlafaxine. When she presented to us, her depressive symptoms amounted to severe depression without psychotic symptoms. In view of the past response to venlafaxine, she was restarted on venlafaxine, but did not achieve remission of symptoms with the earlier dose and hence, venlafaxine was increased up to 225 mg/day. Within 48 h of increasing venlafaxine to 225 mg/day, she developed akathisia, which subsided after stopping venlafaxine.