Fatal dengue encephalitis in a recruit: lessons learnt

Dengue infections may present within a widely variable spectrum of clinical manifestations. However, neurologic complications in general are rare and unusual. A 19 yrs old healthy male army recruit was brought to a service hospital in South India in a state of unresponsiveness, following 12 km route march. Despite aggressive and prompt management, his condition progressively deteriorated and he finally passed away about 10 hrs after reporting to the hospital. The final cause of death was acute dengue encephalitis with raised intracranial pressure. Epidemio-clinico-pathological correlation in this case led to the conclusion that vigorous exertion with a hyper-metabolic state of fever in a setting of encephalitis led to metabolic injury, multi-organ failure, cerebral edema and intracranial hemorrhage. Encephalitis following dengue virus (DENV) infection is a rare phenomenon with the incidence ranging from 0.5% to 6.2%. Neurological features associated with DENV were first reported by Sanguansermsri et al in 1976. The rare neurologic presentations reported with DENV infection are transverse myelitis, acute encephalomyelitis, myositis, and gullain barre syndrome. As encephalitis caused by DENV mimics that caused by other pathogens it should always be kept in mind while managing encephalitis of unknown origin. Medical officers should maintain a high index of suspicion of DENV encephalitis. Training of medical officers; therefore, needs to be undertaken with regular refresher cadres, besides equipping of all peripheral facilities with rapid diagnostic kits for dengue. The same will ensure prompt detection of cases and timely referral to higher medical centres in chain. The instant case reflects an important, potentially fatal, complication of dengue. Pathophysiology of DENV encephalitis needs to be elucidated on priority through research involving all stakeholders.

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Abdominal apoplexy during pregnancy

BMJ Case Reports ◽

10.1136/bcr-2020-235946 ◽

2020 ◽

Vol 13 (10) ◽

pp. e235946

Author(s):

Jasmeet Kumari ◽

Rosemary Harkin

Keyword(s):

Iliac Fossa ◽

Unknown Origin ◽

Breech Presentation ◽

Sudden Onset ◽

Left Iliac Fossa ◽

Safe Delivery ◽

Uterine Contractions ◽

Early Labour ◽

Increased Risk ◽

High Index Of Suspicion

We report a case of idiopathic spontaneous intraperitoneal haemorrhage (ISIH) in a 31-year-old patient at 37 weeks gestation in her second pregnancy. The patient presented to the labour ward with abdominal pain and uterine contractions. The initial complain was of sudden onset, severe sharp pain in left iliac fossa. She started having uterine contractions within 30 min of her presentation. Examination confirmed early labour with a footling breech presentation. Urgent caesarean section was performed that confirmed peritoneal bleeding of unknown origin with safe delivery of the baby. Mother and baby were safely discharged on day 5. ‘Abdominal apoplexy’ (ISIH), is a rare obstetric emergency with increased risk of fetal and maternal morbidity and mortality. With various clinical presentations as a possibility, diagnosis is challenging. High index of suspicion with prompt management of suspected cases can be pivotal life saving measure for the fetus and mother.

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Deep Cerebral Venous Thrombosis—A Clinicoradiological Study

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0041-1730109 ◽

2021 ◽

Author(s):

Sujana Gogineni ◽

Dhananjay Gupta ◽

R. Pradeep ◽

Anish Mehta ◽

Mahendra Javali ◽

...

Keyword(s):

Venous Thrombosis ◽

Care Center ◽

Tertiary Care ◽

Clinical Manifestations ◽

Arterial Occlusion ◽

Venous System ◽

Common Risk Factor ◽

Imaging Characteristics ◽

Deep Cerebral Venous Thrombosis ◽

High Index Of Suspicion

AbstractStroke is a common neurological emergency. Almost 80% of strokes are due to arterial occlusion. Venous thrombosis comprises less than 1–2% of all strokes. Involvement of the deep cerebral venous system is still rare and accounts for about 10.9% of all cerebral venous thromboses (CVT). CVT diagnosis is often delayed or missed, because of its variable clinical manifestations. We retrospectively (2015–18) and prospectively (2018–20) reviewed all the cases of CVT in a tertiary care center in south India. Out of a total of 52 CVT cases, 12 were due to the involvement of deep cerebral venous system. Their clinical presentation, imaging characteristics, and outcomes were assessed. The most frequent presentation was headache followed by seizures. Hyperhomocysteinemia was the most common risk factor noted. Imaging characteristics were variable, and a high index of suspicion was required for early diagnosis. All patients had favorable outcome in our study, and except one, all were treated conservatively.

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Gasperini Syndrome: A Case Report and Systematic Review and Proposing a New Definition

Case Reports in Neurology ◽

10.1159/000510845 ◽

2020 ◽

Vol 12 (3) ◽

pp. 433-439

Author(s):

Riwaj Bhagat ◽

Siddharth Narayanan ◽

Marwa Elnazeir ◽

Thong Diep Pham ◽

Robert Paul Friedland ◽

...

Keyword(s):

Systematic Review ◽

Brain Mri ◽

Cranial Nerves ◽

Clinical Manifestations ◽

The Other ◽

Neurological Deficits ◽

Brainstem Stroke ◽

Neurological Features ◽

The Right ◽

Core Features

Gasperini syndrome (GS), a rare brainstem syndrome, is featured by ipsilateral cranial nerves (CN) V–VIII dysfunction with contralateral hemibody hypoesthesia. While there have been 18 reported cases, the GS definition remains ambiguous. We report a new case and reviewed the clinical features of this syndrome from all published reports to propose a new definition. A 57-year-old man with acute brainstem stroke had right CN V–VIII and XII palsies, left body hypoesthesia and ataxia. Brain MRI showed an acute stroke in the right caudal pons and bilateral cerebellum. After a systematic review, we classified the clinical manifestations into core and associate features based on the frequencies of occurring neurological deficits. We propose that a definitive GS requires the presence of ipsilateral CN VI and VII palsies, plus one or more of the other three core features (ipsilateral CN V, VIII palsies and contralateral hemibody hemihypalgesia). Additionally, GS, similar to Wallenberg’s syndrome, represents a spectrum that can have other associated neurological features. The revised definition presented in this study may enlighten physicians with the immediate recognition of the syndrome and help improve clinical localization of the lesions and its management.

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Mycobacteria Infection in Incomplete Transverse Myelitis Is Refractory to Steroids: A Pilot Study

Clinical and Developmental Immunology ◽

10.1155/2011/501369 ◽

2011 ◽

Vol 2011 ◽

pp. 1-8 ◽

Cited By ~ 3

Author(s):

Yanqing Feng ◽

Ning Guo ◽

Junxiu Liu ◽

Xi Chen ◽

Qiaosong Sun ◽

...

Keyword(s):

Spinal Injury ◽

Transverse Myelitis ◽

Unknown Origin ◽

Resonance Imaging ◽

Open Label ◽

Open Label Study ◽

Antituberculous Treatment ◽

Methylprednisolone Treatment ◽

Magnetic Resonance Imaging Mri ◽

Over Time

Incomplete transverse myelitis (ITM) of unknown origin is associated with high rates of morbidity and mortality. This prospective, open-label study was undertaken to determine whether antituberculous treatment (ATT) might help patients with ITM whose condition continues to deteriorate despite receiving IV methylprednisolone treatment. The study consisted of 67 patients with steroid-refractory ITM in whomMycobacterium tuberculosis(MTB) was suspected clinically and in whom other known causes of myelopathy were excluded. The study occurred from January 2003 to June 2010. Patients underwent trial chemotherapy with ATT. Efficacy was assessed by the American Spinal Injury Association (ASIA) scoring system, the Barthel Index (BI) and the Hauser Ambulation Index (AI) at baseline, 12 months, and 24 months, using magnetic resonance imaging (MRI). Of the 67 patients enrolled, 51 were assessed and 16 withdrew. At 24 months, 49 patients experienced benefits as indicated by significantly increased ASIA and BI scores. The Hauser AI index also improved with markedly decreased abnormal signals in spinal cord MRI over time. The results from this prospective study provide beneficial clinical and MRI data on the efficacy of ATT in ITM patients and suggests mycobacteria may be an important and neglected cause of myelitis.

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Abstract 212: Acute Myocardial Infarction in the Acute Phase in Kawasaki Disease in Mexican Children.

Circulation ◽

10.1161/circ.131.suppl_2.212 ◽

2015 ◽

Vol 131 (suppl_2) ◽

Author(s):

William Sarmiento-Robles ◽

Luis M Garrido-Garcia

Keyword(s):

Myocardial Infarction ◽

Kawasaki Disease ◽

Acute Phase ◽

Delayed Diagnosis ◽

Clinical Manifestations ◽

Unknown Origin ◽

Z Score ◽

Laboratory Parameters ◽

Small Series ◽

Coronary Aneurysms

Background: Kawasaki disease (KD) is an acute febrile vasculitis of unknown origin. Despite treatment with intravenous immunoglobulin during the acute phase of the disease, up to 5% of those affected will develop coronary aneurysms predisposing them to thrombotic complications that could result in myocardial infarction (AMI). In Mexico there are few reports of ischemic complications secondary to KD. Objective: To describe the clinical features, the laboratory parameters, treatment used and the outcome of children who presented with myocardial infarction during the acute phase of KD in a third level facility in Mexico City Methods: From our Institutional Database of KD we search for children who presented AMI in the acute phase of the disease from August 1995 to August 2014. We analyzed gender, age, clinical manifestations, time from the onset of the symptoms to diagnosis, laboratory parameters, treatment used, and outcome in the acute phase of the disease. Results: Eight infants were diagnosed with AMI during the study period. The median age at diagnosis was 8 months (range 2 to 53 months). Seven patients were male (87.5%). The median from the onset of the clinical manifestations to diagnosis of KD was 22 days (range 4 to 26 days). All patients developed giant coronary aneurysms (median Z-score 18.98, with a range of Z-score from 11.58 - 27.70). An abnormal EKG and abnormal perfusion tests demonstrated the myocardial infarction in all cases. Two patients died in the acute phase of cardiogenic shock, one more patient died of dilated cardiomyopathy 12 months after coronary bypass surgery with an overall mortality of 62.5% of this group. Conclusions: AMI is a fatal complication of KD. In our small series it was associated with a delayed diagnosis of the disease and therefore the development of giant coronary aneurysms. Treatment of AMI in children after KD is a medical challenge with a poor prognosis in children.

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A young lady with inflammation of unknown origin

Hong Kong Bulletin on Rheumatic Diseases ◽

10.2478/hkbrd-2018-0008 ◽

2018 ◽

Vol 18 (2) ◽

pp. 67-71

Author(s):

Chiu Sum Chu ◽

Chi Hung To ◽

Chi Chiu Mok

Keyword(s):

Young Women ◽

Systemic Vasculitis ◽

Unknown Origin ◽

Young Lady ◽

Imaging Studies ◽

Biochemical Tests ◽

Vascular Stenosis ◽

High Index Of Suspicion ◽

Anemia Of Chronic Inflammation ◽

Delay In Treatment

Abstract Takayasu’s arteritis (TAK) is a systemic vasculitis mainly affecting the aorta and its first branches. The initial presentation can be very non-specific while its sequelae can be debilitating and fatal. Apart from clinical and biochemical tests, imaging studies remain pivotal for the diagnosis of this rare disease. Delay in treatment may result in vascular stenosis, leading to morbidity and mortality. We report a case of a young woman who presented with anemia with no obvious causes. Subsequently she developed ischemic symptoms and the diagnosis of TAK was established with magnetic resonance angiography (MRA). Our case illustrates the importance of recognition of the possibility of TAK in young women who presented with non-specific systemic upset and anemia of chronic inflammation. A high index of suspicion is needed and imaging studies should be considered early. The treatment of TAK will also be briefly reviewed.

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Five - Year Analysis of Rickettsial Fevers in Children in South India: Clinical Manifestations and Complications

Pediatric Oncall ◽

10.7199/ped.oncall.2013.18s ◽

2013 ◽

Vol 10 (3) ◽

Author(s):

Rwituja Thomas ◽

Preethi Puranik ◽

Bhuvanesh Kalal ◽

Carl Britto ◽

Savitha Kamlesh ◽

...

Keyword(s):

South India ◽

Clinical Manifestations

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Neurological manifestations of antiphospholipid antibody syndrome

Lupus ◽

10.1177/096120339800700216 ◽

1998 ◽

Vol 7 (2_suppl) ◽

pp. 67-74 ◽

Cited By ~ 78

Author(s):

R.L. Brey ◽

A Escalante

Keyword(s):

Cerebral Ischemia ◽

Clinical Manifestations ◽

Fetal Loss ◽

Transverse Myelitis ◽

Symptomatic Treatment ◽

Antiphospholipid Antibody ◽

Antiphospholipid Antibody Syndrome ◽

Neurological Manifestations ◽

Immunosuppressant Therapy ◽

Plausible Mechanism

Thrombosis, thrombocytopenia, recurrent fetal loss and a variety of non-thrombotic neurological disorders have all been associated with antiphospholipid antibodies (aPL). Cerebral ischemia associated with aPL is the most common arterial thrombotic manifestation. Depression, cognitive dysfunction, depression and psychosis have all been associated with aPL. The presumed pathophysiologic mechanism underlying these manifestations is thought to be a result of cerebral ischemia in some, but not all cases. Seizures, chorea and transverse myelitis all appear to be associated with aPL. An interaction between aPL and central nervous system cellular elements rather than aPL-associated thrombosis seems to be a more plausible mechanism for these clinical manifestations. Migraine on the other hand, does not appear to be associated with aPL in either lupus or non-lupus populations. Neuroimaging studies show an increased frequency of brain abnormalities in patients with aPL, but none appear to be specific. The best treatment strategy for preventing neurological manifestations of aPL is not fully defined. For thrombotic manifestations, both antiplatelet and anticoagulant therapies have been suggested. In some patients, immunosuppressant therapy has been used. For non-thrombotic manifestations, some combination of immunosuppressant therapy and symptomatic treatment may be warranted.

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Neuromyelitis Optica Spectrum Disorder and Anti-MOG Syndromes

Biomedicines ◽

10.3390/biomedicines7020042 ◽

2019 ◽

Vol 7 (2) ◽

pp. 42 ◽

Cited By ~ 18

Author(s):

Marco A. Lana-Peixoto ◽

Natália Talim

Keyword(s):

Optic Neuritis ◽

Neuromyelitis Optica ◽

Area Postrema ◽

Water Channel ◽

Clinical Manifestations ◽

Transverse Myelitis ◽

Myelin Oligodendrocyte Glycoprotein ◽

Immunosuppressive Drugs ◽

Spectrum Disorder ◽

Neuromyelitis Optica Spectrum Disorder

Neuromyelitis optica spectrum disorder (NMOSD) and anti-myelin oligodendrocyte glycoprotein (anti-MOG) syndromes are immune-mediated inflammatory conditions of the central nervous system that frequently involve the optic nerves and the spinal cord. Because of their similar clinical manifestations and habitual relapsing course they are frequently confounded with multiple sclerosis (MS). Early and accurate diagnosis of these distinct conditions is relevant as they have different treatments. Some agents used for MS treatment may be deleterious to NMOSD. NMOSD is frequently associated with antibodies which target aquaporin-4 (AQP4), the most abundant water channel in the CNS, located in the astrocytic processes at the blood-brain barrier (BBB). On the other hand, anti-MOG syndromes result from damage to myelin oligodendrocyte glycoprotein (MOG), expressed on surfaces of oligodendrocytes and myelin sheaths. Acute transverse myelitis with longitudinally extensive lesion on spinal MRI is the most frequent inaugural manifestation of NMOSD, usually followed by optic neuritis. Other core clinical characteristics include area postrema syndrome, brainstem, diencephalic and cerebral symptoms that may be associated with typical MRI abnormalities. Acute disseminated encephalomyelitis and bilateral or recurrent optic neuritis are the most frequent anti-MOG syndromes in children and adults, respectively. Attacks are usually treated with steroids, and relapses prevention with immunosuppressive drugs. Promising emerging therapies for NMOSD include monoclonal antibodies and tolerization.

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Leukocytosis of Unknown Origin: Gangrenous Cholecystitis

Case Reports in Medicine ◽

10.1155/2013/418014 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Amara Jyothi Nidimusili ◽

M. Chadi Alraies ◽

Naseem Eisa ◽

Abdul Hamid Alraiyes ◽

Khaldoon Shaheen

Keyword(s):

Acute Cholecystitis ◽

Surgical Intervention ◽

Imaging Modality ◽

Case Reports ◽

Unknown Origin ◽

First Line ◽

Current Case ◽

Gangrenous Cholecystitis ◽

Line Imaging ◽

High Index Of Suspicion

There have been case reports where patients admitted with acute cholecystitis, who were managed conservatively, had subsequently developed GC (gangrenous cholecystitis). The current case is unique, since our patient denied any prior episodes of abdominal pain and the only tip off was leukocytosis. A high index of suspicion is essential for the early diagnosis and treatment of GC. GC has a mortality rate of up to 22% and a complication rate of 16–25%. Complications associated with GC include perforation, which has been reported to occur in as many as 10% of cases of acute cholecystitis. The radiological investigations may not be conclusive. Ultrasonography usually serves as the first-line imaging modality for the evaluation of patients with clinically suspected acute cholecystitis. However, CT can play an important role in the evaluation of these patients if sonography is inconclusive. There is a need for an early (if not urgent) surgical intervention in acute cholecystitis (whether laparoscopic or open surgery) in order to decrease the time elapsed from the start of symptoms to admission and treatment.

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