Isolated Self-Limited Right Oculomotor Nerve Palsy With Positive Asialo-GM1 Antibody After SARS-CoV-2 mRNA Vaccination.

mRNA vaccines have been a critical tool in combating the current coronavirus disease 2019 (COVID-19) pandemic and demonstrated a high safety profile. However, rare cases of isolated oculomotor nerve palsy following vaccination have been reported. These few reported cases can be divided into two groups based on symptom onset: immediate and delayed. While most reported cases involving Pfizer and Moderna vaccines occurred within the first few days of vaccination, a few cases with delayed onset have also been described. We present a unique case of a patient experiencing isolated, unilateral oculomotor nerve palsy 14 days after receiving a Moderna booster shot. Notably, our case and a previously reported case of 17-day onset case share the interesting finding of positive ganglioside antibodies. This not only highlights the potential for unusual occurrences following COVID-19 vaccination but also opens up avenues for exploring the underlying mechanisms behind these events.

SOX1 Antibody in a Patient With Serotonin Syndrome.

SOX1 antibody is an autoimmune antibody, usually associated with Lambert-Eaton myasthenic syndrome, paraneoplastic conditions, and encephalitis. This antibody has also been found among psychiatric patients. However, the role of SOX1 antibody in serotonin syndrome has not yet been defined, as a literature search yielded no results. Therefore, the treatment as such has unknown clinical significance. In this case study, we report a patient with SOX1 antibodies and altered mental status out of proportion to serotonin syndrome whose symptoms improved with simultaneous treatment of both conditions.

A Patient With Miller Fisher Syndrome With Positive GQ1b and Aquaporin-4 Antibodies: Will There Be an Aquaporin-4 Antibody Associated Disorder?

There have been many advancements in the field of neuromyelitis optica and neuromyelitis optica spectrum disorder since the discovery of aquaporin-4 (AQP4) and myelin oligodendrocyte glycoprotein antibodies. It is also recognized that the pathological features associated with myelin oligodendrocyte glycoprotein antibodies are beyond the domain of neuromyelitis optica spectrum disorder and there is a separate nomenclature, namely myelin oligodendrocyte glycoprotein antibody associated disease. Currently, there is no aquaporin-4 antibody associated disorder, even though aquaporin-4 antibodies are not as widely present in other disorders.  Miller Fisher syndrome (MFS) is a variant of Guillain Barré syndrome, in which there are positive GQ1b antibodies with no evidence of myelitis or optic neuritis. MFS is not considered a component of neuromyelitis optica spectrum disorder. We report on a patient with MFS that was positive for GQ1b and aquaporin-4 antibodies but negative for myelin oligodendrocyte glycoprotein antibodies and is devoid of any features of neuromyelitis optica spectrum disorder. This finding may lead to investigations and reports of other pathologies that are associated with the aquaporin-4 antibody.

Three Patients With Chorea and Positive Voltage-Gated Potassium Channel Antibody: Is This the Link Between Hyperkinetic von Economo Disease and COVID-19?

Chorea, hemichorea, and other movement disorders have been reported after different pandemics since Constantin von Economo's time. In the current COVID-19 pandemic, numerous delayed neurological manifestations have been reported in the postinfectious or postvaccination periods. However, very few of these are movement disorders in nature; there are even fewer voltage-gated potassium channel (VGKC) antibody-related movement disorder cases in the literature. We encountered three patients with some COVID-19-related issues featuring both chorea and VGKC antibody. Modern medical science and technology may be able to further our understanding of the molecular basis of von Economo disease and reveal a possible link to COVID-19 along with the immunomodulation aspect of its treatment.

A Sharp Rise in Autoimmune Encephalitis in the COVID-19 Era: A Case Series.

BACKGROUND: Autoimmune encephalitis was very rare prior to the current pandemic. A sharp rise in cases has been observed from March to August of 2022 in Los Angeles. Such an increase, especially with certain types of antibodies, may point toward the possibility of post-infectious autoimmune encephalitis. While review articles on autoimmune encephalitis during this pandemic have been published, a sharp rise in one geographic area within a short period of time has not been documented yet. AIMS: To report an alarming increase in autoimmune encephalitis with mostly positive glutamic acid decarboxylase (GAD) and/or voltage-gated potassium channel (VGKC) antibodies over six months during 2022 in Downtown Los Angeles. MATERIAL AND METHODS: This is an observational case series from one neurocritical care practice in Downtown Los Angeles. Autoimmune encephalitis antibody panels were sent to patients with altered mental status or neurologic deficits of unclear etiology from March to August of 2022. RESULTS: Of the 29 patients tested, 12 reports came back positive. Ten had positive GAD and/or VGKC antibodies, one had a positive myelin oligodendrocyte glycoprotein antibody, and one had a positive leucine-rich glioma-inactivated 1 protein antibody; a 41% positive rate. CONCLUSIONS: This observation has important implications: (1) We may be entering an era of heightened autoimmune encephalitis. (2) These occurrences may be post-infectious in nature at this point of the pandemic. (3) Mostly GAD and VGKC antibodies have been identified (10 of them), which may point toward a new direction of research from a molecular mimicry standpoint. (4) To benefit patients, clinicians need to be aware of such disease manifestations and increase testing; resources must be increased to improve test availability and shorten turnaround time; and treatment, which is expansive, must be made widely available for these potentially reversible diseases.

Bilateral Diffuse Leukoencephalopathy in an Electrocuted Patient Where the Brain Was Not in the Pathway of Conduction.

Electrocution, damage caused by electric current passing through the body, is usually a serious event causing significant morbidity or even mortality. Graded damage is seldom encountered. According to Ohm's law, the current is directly proportional to the applied voltage and inversely proportional to the resistance of a circuit. Electric current is expected to travel through cells that have the least resistance. Therefore, cells that allow action potential to travel down their cell membrane are presumably the ones with the least resistance. Among these are neurons and cells within the cardiac conduction system. Within a neuron, the axon will conduct electricity better than the cell body. While there have been a few cerebral white matter lesions caused by electrocution described in the literature, the mechanism is not fully understood. We report a patient with bilateral symmetrical subcortical abnormality where the electric current entered one hand and exited through her legs without affecting the head directly. We reviewed the literature and we hope it will further our understanding of how electrocution affects the central nervous system and which groups and parts of neurons are more susceptible than others.

A Patient With Myelin Oligodendrocyte Glycoprotein Positive Encephalitis With Ring Enhancing Lesions on Magnetic Resonance Imaging (MRI) After COVID-19 Exposure.

Myelin oligodendrocyte glycoprotein (MOG) antibody has been associated with a wide range of neurological diseases, from neuromyelitis optica spectrum disorder to acute disseminated encephalomyelitis. However, MOG positivity with isolated encephalitis has been infrequently reported. MRI findings are usually of the demyelination type. In this case, we report on a patient with COVID-19 exposure who presented with altered mental status and multiple ring-enhancing lesions on MRI mimicking metastatic disease. Due to his unusual MRI findings and presentation, the correct diagnosis was not apparent until MOG antibody results came back positive.

A Case of Acute Ischemic Stroke Treated With Alteplase Immediately After Transcatheter Aortic Valve Implantation: Which Procedures or Surgeries are Considered Contraindications to Thrombolytics?

Undergoing a major surgery within 14 days is considered a contraindication for intravenous alteplase. However, there is no consensus as to what qualifies as major surgery or an invasive procedure. Occasionally, determining whether a procedure is "invasive" or too risky in the setting of emergency ischemic stroke thrombolytic management can be challenging. Stroke neurologists may not be able to make such a decision on their own. Guidance or clearance from the physicians who performed the procedure is essential. We report the case of a patient who received intravenous alteplase after developing a stroke immediately following transcatheter aortic valve implantation (TAVI).

Multiple Sclerosis in a Patient With Prior West Nile Encephalitis.

Multiple sclerosis is a neurodegenerative disease characterized by an inflammatory demyelination of the central nervous system. The degenerative disease has been linked to numerous viral infections, geographical locations, and genetic predisposition. One link that has not been fully established is the relationship between West Nile virus infection and its role in the initiation of multiple sclerosis. This case study provides further evidence that the proinflammatory neurological processes induced by the West Nile virus may lead to systemic demyelination of neuronal axons, ultimately causing multiple sclerosis.

Pantopaque: Does It Still Migrate With Gravity After 30 Years?

Pantopaque was an oil-based positive contrast media used in central nervous system imaging before the use of water-soluble contrast agents. It is no longer used due to side effects, including arachnoiditis. Prior studies have indicated that remnants of pantopaque can be seen in modern radiographic imaging, including CT and MRI. With its use obsolete, these remnants have been increasingly mislabeled from "tumor" to "shot gun pellets". An understanding of this historic modality will usually lead to the correct diagnosis.

Another Case of Bell's Palsy Recurrence After Pfizer-BioNTech COVID-19 Vaccination.

Twenty-seven months into the current pandemic and 18 months after vaccinations were made available, there are still relatively limited data on the incidence of recurrent Bell's Palsy after the administration of mRNA-based vaccines. The authors continue to believe that it is through rigorous reporting that the true incidence can be tabulated eventually.

Acute Vestibular Neuritis After Pfizer Booster in a Healthcare Worker.

Numerous reports of healthy individuals falling ill after COVID-19 vaccination or booster have surfaced. Isolated vestibular dysfunction is uncommon. Such occurrence within 24 hours of booster shot in a relatively healthy highly functional colleague suggests beyond a simple temporal relationship.

Cryptococcus Meningoencephalitis With Severe Localizing Neurological Deficits Mimicking a Large Right Middle Cerebral Artery Infarct in a HIV Patient.

Immunocompromised patients with Cryptococcal meningoencephalitis can develop focal neurological signs and symptoms. Stroke and abscess are usually the leading etiologies. Definitively localized non-fluctuating deficits mimicking a large middle cerebral artery (MCA) infarct without corresponding MRI findings is rare. Localized lobar cerebritis may be the underlying etiology. Despite having many different kinds of sequences, a significant pathological process can still evade MRI's detection. Diffusion-weighted imaging (DWI) abnormality has also been seen in pathology other than ischemic stroke.

Miller Fisher Syndrome in the COVID-19 Era - A Novel Target Antigen Calls for Novel Treatment.

Although Miller Fisher syndrome cases have been published in this coronavirus disease 2019 (COVID-19) pandemic, anti-GQ1b antibody has not been identified so far. A direct proof of association is not yet available since the exact pathophysiology is not known. Using a proof of contradiction argument, lack of GQ1b serves as the indirect proof that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is probably the infection preceding demyelination. A novel antigen has yet to be described.

Fatal Rhabdomyolysis in a COVID-19 Patient on Rosuvastatin.

It is well-established by now that COVID-19 can have a wide variety of neuromuscular manifestations, including rhabdomyolysis. Weakness and elevated creatinine kinase (CK) have been documented as the initial presentation of COVID-19. Myopathy from statin use has also been well-established since the introduction of this class of medication, and the common pathologic mechanism of both entities may have been mitochondrial dysfunction. We present here the case of a COVID-19 patient on rosuvastatin who developed rhabdomyolysis with CK above 1,000,000 units/L. The patient did not present with any respiratory difficulty and responded poorly to treatment, resulting in his untimely demise. COVID-19 may have accentuated an otherwise survivable condition by means of extra stress on mitochondrial homeostasis. Understanding the actual mechanism will be important in the development and utilization of medications in the fight against COVID-19.

Three Cases of West Nile Encephalitis over an Eight-Day Period at a Downtown Los Angeles Community Hospital.

Since its introduction in New York City in 1999, the virus has spread throughout the entire North American continent and continues to spread into Central and Latin America. Our report discusses the signs and symptoms, diagnostics, and treatment of West Nile disease. It is important to recognize the disease quickly and initiate appropriate treatment. We present three cases of West Nile encephalitis at White Memorial Medical Center in East Los Angeles that occurred over the span of eight days. All three patients live within four to six miles from the hospital and do not live or work in an environment favorable to mosquitoes including shallow bodies of standing water, abandoned tires, or mud ruts. All the patients were Hispanic. Physicians and other health care providers should consider West Nile infection in the differential diagnosis of causes of aseptic meningitis and encephalitis, obtain appropriate laboratory studies, and promptly report cases to public health authorities. State governments should establish abatement programs that will eliminate sources that allow for mosquito reproduction and harboring. The public needs to be given resources that educate them on what entails the disease caused by the West Nile virus, what the symptoms are, and, most importantly, what they can do to prevent themselves from becoming infected.