Neurological complications of HIV infection.

More than half of HIV - infected persons develop symptomatic neurological disease. The nervous system is extensively involved with no part of the neuraxis being immune from the virus. Beisdes the brain and spinal cord, the peripheral nerves and muscles may be affected. Neurological complications typically occur with advanced disease and profound immunosuppression, hence a knowledge of the CD4 lymphocyte count is of paramount importance. Since many of the conditions are amenable to treatment, a proper diagnosis and therapy may decrease morbidity in the already curtailed life span of the patient. Some opportunistic neurological infection is a result of latent/persistent infection requiring lifelong secondary prophylaxis e.g. toxoplasma encephalitis and cryptococcal meningitis. Neuroaids does not follow the law of parsimony i.e. a single entity may not be responsible for the entire constellation of signs and symptoms. HIV infection is the commonest cause of dementia in people under the age 50 in thedeveloped world. Cryptococcosis is the commonest infection affecting the nervous system in HIV positive patients. Tuberculosis has seen a resurgence following the out break of AIDS. CNS lymphoma is the commonest cause of raised ICP followed by tuberculoma, toxoplasmosis and brain abscess. Most patients with paraparesis have a typical HIV associated vacuolar myelopathy. A distal predominantly sensory neuropathy is the initial feature of insult to peripheral nerves. Muscle involvement may be due to polymyositis and HIV associated wasting syndrome but may also be aggravated by drugs (e.g. zidoudine).

Profile of status epilepticus : a prospective study.

Forty adult patients (age> 14 years) of generalised convulsive status epilepticus were studied prospectively. All the patients were subjected to detailed history, neurological examination and baseline investigations including haemogram and metabolicprofile. CT scan was carried out in 26 patients. All the patients were treated with intravenous diazepam and phenytoin. The age range of the patients was 14-71 years with a mean of 32.75 ? 15.78. There were 24 males and 16 females. Twenty six patients had generalised tonic clonic seizures while 14 had partial seizures with secondary generalisation. Symptomatic epilepsy was the commonest type of epilepsy and was seen in 25 patients. The diagnosis of cryptogenic and idiopathic epilepsies was made in 11 and 4 patients respectively. Drug withdrawl precipitated status epilepticus in 5 patients and systemic infection in one. The mean frequency of seizures was 4.70??1.83/hour, mean duration was 1.78???l.0l/minutes and cumulative convulsive time 25.27??21.50 minutes. Twelve patients had focal neurologic deficits. Papilloedema was seen in four cases only. CT scan was abnormal in 18 of 26 patients. All patients except one showed immediate response to therapy. Seven patients had recurrence of seizures after initial response to diazepam and phenytoin. Low serum level of the drug at 12 hours had a significant correlation with recurrence of seizures. Ataxia was the most common side effect of phenytoin therapy. Serious side effects e.g. hypotension and respiratory depression were seen in 4 and 2 patients respectively. Two patients expired during 48 hours follow up.

CT in nonvisualised vertebral levels caudal to the complete block on lumbar myelogram.

CT was performed in 51 patients at and caudal to the level of lumbar myelographic block due to disc herniation with or without lumbar canal stenosis. The causes of complete or almost complete myelographic block included disc herniation (27 patients)disc herniation with spinal stenosis (12 Patients), spinal canal stenosis (11 patients) and posterior osteophytes (1 patient). CT helped in detecting the non-visualised vertebral levels, demonstrated a surgically treatable lesion below the level of myelographic block and provided information for preoperative planning.

Clinical profile of Subacute scelerosing panencephalitis (SSPE).

Thirty nine confirmed cases of SSPE were analysed retrospectively to study the clinical profile and to look for any atypical presentations. There were 29 males and 10 females with the age ranging from 4-19 (mean 11.5 × 3.5) years. Sixteen patients (41.0 percent) had received measles vaccination. Definite history of measles was available in 33 (84.6 percent) cases. Onset of symptoms was after 10 years of age in 58.9 percent of cases. Majority (56.42 percent) had presented within six months of onset of symptoms but 5 patients (12.8 percent) had symptoms for more than 3 years prior to the presentation. Decreased scholastic performance (58.97 percent) and myoclonus (33.33 percent) were the common presenting symptoms. Generalized tonic clonic seizures (2 cases), visual deterioration (2 cases) and altered sensorium (1 case) were the unusual presenting features. Ophthalmological manifestations were seen in 6(15.4 percent) patients. One patient had diminution of hearing in earlier stages illness. Mean age of onset of symptoms was significantly different (p < 0.01) in vaccinated (13.10 × 2.84 years) and non-vaccinated (9.87 × 3.44 years) group. Oligoclonal bands in cerebrospinal fluid (CSF) revealed a positivity in 79.4 percent of cases. Antimeasles antibody titres in serum and CSF were significantly raised in 31 cases (79.5 percent). Electroencephalogram (EEG) revealed periodic complexes in 38 cases (97.4 percent).

Electrophysiological assessment of early hepatic encephalopathy in chronic liver disease.

Forty two patients of chronic liver disease (CLD) were studied to evaluate the diagnostic utility of brainstem auditory evoked potentials (BAEP) and visual evoked potentials (VEP) with respect to development of hepatic encephalopathy (HE). The evoked potential (EP) evaluation was coincided with electroencephalography (EEG). A sequential analysis of electrophysiologic modifications occurring in response to dietary protein challenge or large-volume paracentesis was planned by carrying out the study in two phases. The first phase patients did not undergo provocation procedures. They were divided into group 1 (28 patients) and group 2 (14 patients) on the basis of respective absence or presence of neuropsychologically recognizable HE. Phase II included 13 patients of which 10 were given high-protein diet and 3 underwent ascitic tap. A control group of matched healthy individuals was also studied with the 3 step paradigm of electophysiologic assessment comprising VEP, BAEP and EEG. The EEG abnormalities were detected in 10.7 percent of non-HE and 64.2 percent of HE patient groups, without a statistically significant difference between the P100 mean latency scores of both these groups. Evaluation of BAEP revealed abnormalities in 17.8 percent patients of group 1 and 42.8 percent of group 2 enrolled under phase I, and 30.76 percent patients of phase II. The chief abnormality in the non-HE group was significantly higher mean I-V interpeak latency (IPL) scores compared to controls. All the 3 interpeak latencies I-III, III-V and I-V were abnormally prolonged in the HE patients group. There was no significant prolongation of various mean latencies after the provocation procedures in phase II patients, despite an appreciable upward trend in the BAEP interpeak latencies. The mechanisms underlying EP abnormalities in CLD are discussed. It is concluded that BAEP is a useful neurophysiologic device to follow up patients with CLD at risk of lapsing into overt HE.

POEMS syndrome associated with solitary, osteolytic plasmacytoma : a case report.

POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, M protein and Skin changes) syndrome in a patient with solitary osteolytic plasmacytoma has been reported in this communication. He presented with a demyelinating polyneuropathy, lytic lesion in the left femur and hypogonadism. Serum protein electrophoresis, urine Bence-Jones protein and multiple bone marrow aspirations were negative for the presence of a myeloma. A biopsy from the lytic lesion confirmed the diagnosis of plasmacytoma.

Comparative cognitive effects of phenytoin and carbamazepine in adult epileptics.

Forty newly diagnosed, drug naive adult epileptic patients were evaluated for cognitive effects of phenytoin (DPH) and carbamazepine (CBZ). They were randomized into DPH and CBZ groups. Patients with space occupying lesions, progressive degenerative, metabolic and active central nervous system infections were excluded from the study. None of the patients had seizures during the study period. Both the groups were comparable for age, duration as well as type of epilepsy. Full cognitive assessment was carried out using a neuropsychological battery consisting of verbal and performance intelligence, memory, vasomotor function and dysfunction analysis tests before starting the anticonvulsant therapy. The same tests were repeated after 3 months. The mean serum levels of DPH and CBZ at the end of the study period were 19.42 × 4.20 ug/ml and 9.45 × 9.26 ug/ml respectively. The cognitive functions were compared between pre and post study periods in each group and between the two groups. The differences were correlated with serum drug levels. No significant difference in cognitive functioning was noticed in either of the study groups. There was no significant correlation with serum drug levels. It was concluded that both DPH and CBZ have no adverse effects on cognition in adult epileptics with normal therapeutic drug levels.

Churg-Strauss syndrome presenting as mononeuritis multiplex : a case report.

A 25 year old female presented with mononeuritis multiplex and pulmonary symptoms. Investigations revealed the presence of marked peripheral blood eosinophilia. Skin and nerve biopsies were consistent with a diagnosis of Churg Strauss Syndrome. These were characterized by vasculitis of the small arteries and veins and perivascular eosinophilic infiltrates. The patient showed good response to cyclophosphamide and steroids.

Reappraisal of palmomental reflex and its variants.

Palmomentalis reflex (PMR) is a superficial polysynaptic, primitive reflex seen in normal population with higher incidence at the extreme of ages. It is exaggerated in upper motor neuron lesions involving corticobulbar tracts. We describe palmolevator labii superioris reflex - new variant palmomentalis reflex. The mechanism, pathway and diagnostic applications of PMR are discussed on recent studies.

Polymyositis : a clinical profile.

Clinical data of 132 patients of polymyositis seen over a period of ten years was retrospectively analysed. Important features included a mean age of 32.31 years with a range of 8 years to 70 years. 40.62 percent patients were of primary idiopathic polymyositis while 53.13 percent presented with disease of more than six months duration. Pelvic girdle weakness was demonstrated in 31 cases (96.87 percent). Creatin phosphokinase (CPK) values were consistently elevated in 81.25 percent of these cases. Electromyography in majority showed mixed neurogenic and myopathic pattern. Muscle biopsy was performed in 23 patients and all revealed changes characteristic of polymyositis. Follow up was available in 18 cases.

Neurocryptococcosis in acquired immunodeficiency syndrome.

Two cases of Neurocryptococcosis in AIDS are described. The first patient presented with generalised lymphadenopathy, hepatosplenomegaly and raised intracranial tension. The clinical manifestations of second patient included prolonged fever and hepatosplenomegaly. Both the patients had evidence of disseminated cryptococcosis. The distinctive clinical manifestations, investigative abnormalities and modification of therapy of neurocryptococcosis manifestations in AIDS are discussed.