Posterior reversible encephalopathy syndrome due to COVID-19

Objective: During the late 2019, a group of patients had unexplained chest infections in Wuhan which turned out to be the new pandemic coronavirus disease 2019 (COVID-19). New neurological symptoms have been reported in COVID-19 patients. Posterior reversible encephalopathy syndrome (PRES) is a new neurological finding and is associated or caused by COVID-19. Case Presentation: A 32-year-old lady, with no medical background had COVID-19 infection and needed mechanical ventilation. After surviving the intensive care, she started to have multiple seizures that required general anesthesia to be aborted. The patient turned out to have PRES. Conclusion: PRES is a neurological syndrome causing seizures, headaches, and blurred vision. It is usually associated with high blood pressure, renal failure, and other risk factors. The patient in this case had nearly normal blood pressure, but still had a diagnosis of PRES. The new reported neurological symptoms associated with COVID-19 infection need further research and attention from the academic society to predict and prevent the morbidity and mortality of COVID-19 patients.

Isolated convergence-retraction nystagmus secondary to intralesional haemorrhage of a pineal cyst: an easily missed neurological finding with potentially life-threatening consequences

This case report describes a patient who presented to the emergency department with intermittent visual disturbance and was found to have convergence-retraction nystagmus. This occurred in the setting of supratherapeutic anticoagulation on warfarin for an aortic dissection graft repair. Urgent imaging demonstrated haemorrhagic transformation of a previously identified incidental pineal cyst. After close monitoring given the risk of secondary hydrocephalus, the patient was discharged in stable condition with symptom resolution and without any further significant complications. This case report highlights the importance of identifying subtle clinical findings and the risk of secondary haemorrhage of pineal cysts when on anticoagulation. While the risk of secondary hydrocephalus is a significant concern, clinically stable patients can be followed without need for neurosurgical intervention.

P.112 Permanent isolated micrographia from traumatic basal ganglia injury

Background: Micrographia is a rare neurological finding in isolation. Most cases of isolated micrographia have been found in association with focal ischemia of the left basal ganglia. Methods: We present a case of post-traumatic micrographia stemming from contusion to the left basal ganglia. We performed a detailed analysis of the patient’s writing at three-year follow-up. Results: A halthy 15 year old male was admitted following a BM accident. CT showed contusion to the left basall ganglia/external capsule. MRI was negative for underlying lesion. He had a short stay in the ICU and then was discharged. Two years later, he expressed concern regarding difficulty with sma, cramped writing at school. Writing analysis revealed micrographia with spontaneous printing as well as printing to dictation, but not with copied English nor Japanese writing. Conclusions: Isolated micrographia is a rare neurological finding. We present the incidence of this symptom folllowing gliding contusion to the et basal ganglia and external capsule.

Temporal changes in the documentation of neurological findings among patients with acute ischaemic stroke in a single centre in Japan: a retrospective cross-sectional study

ObjectiveTo evaluate temporal differences in the documentation of neurological findings by the same physicians in patients with ischaemic stroke while in hospital. We also investigated differences in the rate of documentation of neurological findings in patients with stroke between internists and neurosurgeons.DesignA retrospective medical chart review.ParticipantsHospitalised adult patients with acute ischaemic stroke who stayed 7 or more days in our hospital. Neurosurgeons (n=8) and internists (n=19) caring for these patients (including up to 10 patients per physician).Main outcome measuresThe documentation rate of any neurological finding in the patients on each day (from day 1 to 7 and on discharge). The documentation rates of eight neurological finding components (consciousness, mental status, cranial nerves, motor function, sensory function, coordination, reflexes and gait). We included only documentation by the same physician. Fisher’s exact test was used to evaluate differences in outcomes between neurosurgeons and internists.ResultsDuring the study period, we identified 172 patients with stroke who were cared for by 27 physicians. The documentation rates of any neurological findings were 94% (day 1), 58% (day 2), 35% (day 3), 40% (day 4), 32% (day 5), 30% (day 6) and 23% (day 7). On discharge, all eight neurological finding components were documented in less than 10% of all cases. The documentation rate was significantly higher by internists than that by neurosurgeons on each day but not on discharge.ConclusionsThe documentation rate of neurological findings by physicians during usual stroke care decreased to less than 50% after the third hospital day. Given the importance of temporal changes in the neurological symptoms of patients with stroke, further study is needed to determine whether this low documentation rate after the third hospital day was due to a lack of physician interest in neurological findings or other factors.

Isolated tubercular hypoglossal nerve paralysis

Hypoglossal nerve palsy is not an uncommon neurological finding but primary nasopharyngeal tuberculosis (TB) presenting as hypoglossal nerve palsy is very rare. A 31-year-old woman presented with headache and progressive tongue deviation towards the right side. Diagnostic nasal endoscopy revealed soft tissue mass lesion on the posterior wall of nasopharynx while MRI revealed isointense tumour in nasopharynx with normal hypoglossal nerve and brain. Histopathological examination found TB. We discuss the clinical challenges and possible pathogenesis of this rare clinical entity.

THE NEUROLOGICAL FACE OF CELIAC DISEASE

BackgroundSeveral neurological disorders have also been widely described in celiac disease patients.ObjectiveThe aim of this study was to determine the incidence of accompanying different neurologic manifestations in children with celiac disease at the time of diagnosis and to discuss these manifestations in the light of the recent literature.MethodsThis prospective cross sectional study included 297 children diagnosed with celiac disease. The medical records of all patients were reviewed.ResultsIn neurological evaluation, totally 40 (13. 5%) of the 297 celiac patients had a neurological finding including headache, epilepsy, migraine, mental retardation, breath holding spells, ataxia, cerebral palsy, attention deficit hyperactivity disorder, Down syndrome and Turner syndrome in order of frequency. There was not any significant difference between the laboratory data of the patients with and without neurological manifestations. However; type 3a biopsy was statistically significantly more common among patients without neurological manifestations, while type 3b biopsy was statistically significantly more common among patients with neurological manifestations.ConclusionIt is important to keep in mind that in clinical course of celiac disease different neurological manifestations may be reported.

The normative and epistemological status of pain experiences in modern health care

This article explores the concept of ‘pain’ and the relation between abstract, detached knowledge and patient experiences and ‘first person perspectives’. Pain can be handled as the correlate of a neurological finding (for example in a professional practice) and as an experience in a patient’s life. Sometimes patients articulate experiences impossible to link to an objective trace. In such situations it is often claimed that we are left with a choice between dealing with pain and suffering as abstract, detached public conceptions or as private inaccessible entities. In this paper I argue that this is an unappetizing choice, and that we can develop a better understanding of ‘first person perspectives’ if we look at them in the light of contexts, stories and practices regulated by public exemplars. Discourses for handling pain as a phenomenon in a person’s life exist, and it is an epistemological as well as a normative problem if such perspectives are not recognized. The argument is elaborated through a discussion of, amongst others, Martha Nussbaum, Marx Wartofsky, Amartya Sen, and Ludwig Wittgenstein.

Article Commentary: Dysfunction of Corticomotoneurons in Guillain-Barrέ Syndrome (GBS)?

Guillain-Barrέ syndrome (GBS) is characterized by acute and symmetric flaccid paraparesis and areflexia. Involvement of the central nervous system has been infrequently reported. In the current issue of Clinical Medicine: Case reports, an unusual case of GBS with asymmetric muscle weakness was reported. Corticomotoneuronal dysfunction was invoked as a possible cause for this neurological finding. Reversible blockade of voltage gated Na+ channels resulting in conduction failure may be a possible pathophysiological mechanism.

Man-in-the-barrel syndrome after thoracoilium fusion

The authors report a case of man-in-the-barrel (MIB) syndrome occurring after an extensive revision involving thoracoilium instrumentation and fusion for iatrogenic and degenerative scoliosis, progressive kyphosis, and sagittal imbalance. Isolated brachial diplegia is a rare neurological finding often attributed to cerebral ischemia. It has not been previously reported in patients undergoing complex spine surgery. This 70-year-old woman, who had previously undergone T11–S1 fusion for lumbar stenosis and scoliosis, presented with increased difficulty walking and with back pain. She had junctional kyphosis and L5–S1 pseudarthrosis and required revision fusion extending from T-3 to the ilium. In the early postoperative period, she experienced a 30-minute episode of substantial hypotension. She developed delirium and isolated brachial diplegia, consistent with MIB syndrome. Multiple studies were performed to assess the origin of this brachial diplegia. There was no definitive radiological evidence of any causative lesion. After a few days, her cognitive function returned to normal and she regained the ability to move her arms. After several weeks of rehabilitation, she recovered completely. Man-in-the-barrel syndrome is a rare neurological entity. It can result from various mechanisms but most commonly seems to be related to ischemia and is potentially reversible.