Delta brush on EEG: a characteristic EEG finding in autoimmune encephalitis.

A woman in her late 20s was admitted via the emergency department in the psychiatric ward with acute-onset behavioural changes and suicidal thoughts in the past 2 weeks. Workup revealed positive N-methyl-D-aspartate (NMDA) receptor antibodies in cerebrospinal fluid and electroencephalogram (EEG) showing a specific pattern of delta brush on bilateral frontal regions. Other investigations were unremarkable. The patient was started on intravenous methylprednisolone 1000 mg for 5 days with oral steroids. She responded on steroids. She has been recommended for workup for teratoma/mediastinal tumours with NMDA receptor encephalitis is an autoimmune disorder predominantly affecting women of childbearing age. Delta brush pattern on EEG is specific for NMDA receptor encephalitis hence can be used as a diagnostic tool. It is advisable to investigate any patient with the presentation of mental deterioration for pathological causes. However, treatment with immunotherapy increases the chance of survival and may prevent cognitive impairment.

Community-Associated Methicillin-Resistant Staphylococcus aureus: Case Report of Acute Sinusitis With Orbital Extension in a Pregnant Lady.

Methicillin-resistant Staphylococcus aureus (MRSA) infections pose a significant burden on healthcare. Acute sinusitis can be one of its deadliest presentations as it can quickly lead to orbitocranial extension with complications including blindness, brain abscess and death. Previously believed to affect immunocompromised individuals only, community-associated MRSA is now known to affect healthy individuals too. The seriousness of MRSA infection increases manifold when the infection occurs in pregnant women who are immune modulated. We present a case of a 34-year-old pregnant lady who presented with a severe headache for two days. She had acute sinusitis that involved right orbit in less than 24 hours. She was promptly managed with intravenous antibiotics and drainage of abscess that revealed MRSA. Fortunately, the patient made a complete recovery. The purpose of this case report is to emphasize on keeping a high index of suspicion of MRSA for all soft tissue infections. Early recognition, proper evaluation and timely and appropriate treatment can prove lifesaving.

Depression and the Use of Selective Serotonin Reuptake Inhibitors in Patients with Acute Intracerebral Hemorrhage.

Introduction Depression is a common psychiatric complication associated with stroke. However, while most studies focus on post-stroke depression (PSD) subsequent to ischemic strokes, fewer studies have specifically explored depressive symptoms and the use of selective serotonin reuptake inhibitors (SSRIs) in patients with acute intracerebral hemorrhage (ICH). The aim of our study was to identify the incidence and factors associated with depression in ICH patients and the use of SSRIs as therapy by physicians at a tertiary care hospital in Karachi, Pakistan. Materials and methods A retrospective chart review was conducted to identify patients with ICH through the International Classification of Diseases, Ninth Revision (ICD-9) coding system electronic medical records of Aga Khan University Hospital, Karachi, Pakistan. Patient records spanning a period of five years at the hospital were identified and analyzed by neurology residents. Patients' clinical, laboratory, radiological, and pharmacological data were recorded and analyzed using a structured proforma. Patients with a past history of depression or those who were taking SSRIs at the time of admission were excluded from the analysis. Depression was defined as the presence of five or more symptoms according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Results Out of the 458 patients we analyzed, 258 (56%) were men and 200 (44%) were women. The mean age was 59 years. Median National Institutes of Health Stroke Scale (NIHSS) score on admission was 13 (range: 0-42), and the median modified Rankin Scale (mRS) score was 4 (range: 0-6). On neuroimaging, sites of hemorrhage in patients were found to include the basal ganglia/thalamus in 279 (61%) patients, cerebral cortex in 105 (23%), cerebellum in 25 (5%), brain stem in 17 (4%), ventricles in 17 (4%), and multiple sites in eight (2%). We found that 48 (10%) patients had a ventricular extension, and 130 (28%) had midline shift, hydrocephalus, or both. Overall, 103 (22%) patients met the DSM-IV diagnostic criteria for depression. The most common depressive symptoms included tearfulness (67%), sadness (55%), and loss of interest or pleasure in life activities (53%). None of the patients reported suicidal ideation. Only seven patients (2%) were seen by a psychiatrist. The presence of depression was not significantly associated with hemorrhage sites [prabability value (p): 0.55] or the extent of disability (p: 0.09). Among the 103 depressed patients, only 25 (24%) received SSRIs during the hospital stay. A total of 57 (12%) received SSRIs during the hospital stay, of which only 25 had met the DSM-IV diagnostic criteria for depression. The mean duration between the diagnosis of ICH and the start of SSRIs was five days (range 3-25 days). None of the patients received any psychotherapeutic help for depression. At the time of discharge, only 13 (13%) of the 103 patients diagnosed with depression were discharged on SSRIs, while 23 that had not met the DSM-IV diagnostic criteria were discharged on SSRIs. Conclusion The present study demonstrates that depression is not uncommon in acute ICH patients, and it is both underdiagnosed and inadequately treated. Physicians should be trained to accurately identify and effectively treat depressive symptoms in ICH patients. Clear guidelines should be developed to aid the diagnosis and treatment of post-ICH depression in hospital settings.

Acute Onset of Quadriplegia Secondary to Hypoparathyroidism: Mimicker of AMAN Variant of GBS.

Acute onset of quadriplegia is a rare phenomenon seen with hypocalcemia due to hypoparathyroidism. We describe a 33-year gentleman who presented with weakness of all four limbs and areflexia. ECG showed QT abnormality. Nerve conduction study revealed normal sensory and significantly low motor CMAP amplitudes in both the upper and lower extremities. This nerve conduction study can be seen in acute motor neuropathy of various etiologies, among which GBS is the most worrisome. Our patient found to have low calcium and parathyroid hormone level. His symptoms improved after calcium replacement. Occurrence of quadriplegia in hypoparathyroidism, and its improvement after correction of calcium, suggests crucial role of calcium in neuromuscular transmission. One should suspect electrolyte imbalance, like hypocalcemia in patients presenting with nerve conduction features of AMAN variant of GBS.

Pattern of neurological diseases in adult outpatient neurology clinics in tertiary care hospital.

OBJECTIVES: The burden of neurological diseases in developing countries is rising although little is known about the epidemiology and clinical pattern of neurological disorders. The objective of this study was to understand the burden of disease faced by neurologists a in tertiary care setting. RESULTS: A prospective observational study was conducted of all presentations to neurology clinics at Aga Khan University Hospital Karachi over a period of 2 years. A total of 16,371 out-patients with neurological diseases were seen during the study period. The mean age of the study participants were 46.2 ± 18.3 years and 8508 (52%) were male. Headache disorders were present in 3058 (18.6%) of patients followed by vascular diseases 2842 (17.4%), nerve and root lesions 2311 (14.1%) and epilepsies 2055 (12.5%). Parkinson's disease was more prevalent in male participants 564 (70.8%) as compared to female 257 (62.1%) (p = 0.002). Migraines and vertigo disease were more diagnosed in females as compared to males. Epilepsies were seen more in younger age groups. Parkinson's disease was seen in 50.9% of participants between the ages of 45 and 65 years, and the frequency increased with age.

Ischaemic pituitary tumour apoplexy and concurrent meningitis: a diagnostic dilemma.

Pituitary tumour apoplexy is a rare but potentially life threatening clinical syndrome that mostly results from haemorrhage in the pre-existent tumour. Pure ischaemic subtype of apoplexy is even rarer. The presentation can be hard to differentiate clinically from bacterial meningitis. Moreover, the presence of one does not necessarily exclude the other and early diagnosis of both conditions is imperative for timely management. We report a case of ischaemic pituitary tumour apoplexy that may have precipitated in the setting of bacterial meningitis.