C-reactive protein levels in patients with amyotrophic lateral sclerosis: A systematic review

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease affecting cortical and spinal motor neurons. There is a lack of optimal biomarkers to diagnose and prognosticate the ALS patients. C-reactive protein (CRP), an inflammatory marker, has shown promising results in ALS patients.

MATERIALS AND METHODS

PubMed, Embase, and Google Scholar databases were searched from 2000 to June 1, 2021 for suitable studies showing the relationship between CRP and ALS. The concentration of CRP levels was assessed between ALS patients and controls. Further, end outcomes like ALS functional rating scale (ALSFRS-R), survival status, and mortality risks were assessed in relation to CRP levels.

RESULTS

Eleven studies including five case-control, five cohorts, and one randomized control study were assessed. There were 2785 ALS patients and 3446 healthy controls. A significant increment in CRP levels among ALS patients in comparison with healthy controls were seen in most of the studies. ALSFRS-R and disease progression were found to be significantly correlated with CRP levels. Overall accuracy of CRP in CSF was 62% described in a single study.

CONCLUSION

Although CRP has shown promise as a prognostic biomarker, extensive cohort studies are required to assess its prognostic value and accuracy in diagnosing ALS taking into account the confounding factors.

Clinical spectrum and management of dystonia in patients with Japanese encephalitis: A systematic review

BACKGROUND

Japanese encephalitis (JE) is a potentially fatal viral infection with a wide range of manifestations and can also present with a variety of movement disorders (MD) including dystonia. Dystonic features in JE are uncommon. Here, we have tried to summarize the clinical features and management of dystonia among JE patients with a comprehensive literature search.

METHODS

Various databases, including PubMed, Embase, and Google Scholar, were searched against the predefined criteria using suitable keywords combination and boolean operations. Relevant information from observational and case studies was extracted according to the author, dystonic features, radiological changes in the brain scans, treatment options, and outcome wherever provided.

RESULT

We identified 19 studies with a total of 1547 JE patients, the diagnosis of which was confirmed by IgM detection in serum and/or cerebrospinal fluid in the majority of the patients (88.62%). 234 (15.13%) of JE patients had dystonia with several types of focal dystonia being present in 131 (55.98%) either alone or in combination. Neuroimaging showed predominant involvement of thalami, basal ganglia, and brainstem. Oral medications including anticholinergics, GABA agonists, and benzodiazepines followed by botulinum toxin were the most common treatment modalities.

CONCLUSION

Dystonia can be a disabling consequence of JE, and various available medical therapies can significantly improve the quality of life. Owing to insufficient studies on the assessment of dystonia associated with JE, longitudinal studies with a larger number of patients are warranted to further clarify the clinical course, treatment, and outcome of dystonia.

Safety and efficacy of Direct Oral Anticoagulants in cerebral venous thrombosis: A meta-analysis

Cerebral venous thrombosis (CVT) is caused by partial or complete occlusion of the major cerebral venous sinuses or the smaller feeding cortical veins which predispose to the risk of venous infarction and hemorrhage. Current guidelines recommend treating CVT with either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) followed by an oral vitamin K antagonist (VKA) for 3-12 months. Direct oral anticoagulants (DOACs) have already established benefit over warfarin as a long-term treatment of symptomatic venous thromboembolic disorder like deep vein thrombosis (DVT), and pulmonary embolism (PE) given its equal efficacy and better safety profile. The benefit of DOACs over warfarin as a long-term anticoagulation for CVT has likewise been extensively studied, yet it has not been approved as first-line therapy in the current practice. We therefore performed a systematic review and meta-analysis of relevant studies to generate robust evidence regarding the safety and efficacy of DOACs in CVT. This meta-analysis demonstrates that the use of DOACs in CVT has similar efficacy and safety compared to VKAs with better recanalization rate.

Occurrence of osmotic demyelination syndrome in diabetes mellitus: A case report and literature review of various etiologies for osmotic demyelination syndrome

Osmotic demyelination syndrome is a rare condition reported mainly in the case of rapid correction of hyponatremia, but it can occur even in the case of complicated diabetes mellitus either during rapid correction of hyperglycemia or anytime during the complicated diabetes mellitus. We report a case of complicated diabetes mellitus developing osmotic demyelination syndrome. The patient had presented with altered sensorium and seizure, which was initially diagnosed as hyperglycemia, but during his treatment, the magnetic resonance imaging of brain revealed central pontine myelinolysis. Our search on the causes of osmotic demyelination syndrome other than rapid correction of hyponatremia has revealed several other causes like autoimmune liver disease, Sjogren’s syndrome and non-Hodgkin’s lymphoma in addition to diabetes mellitus.

Delayed myelopathy after organophosphate intoxication: A case report

Organophosphate-induced delayed neuropathy, a central-distal axonopathy, passes through latent, progressive, static and improvement phases. During the improvement phase, the peripheral nerves regenerate unmasking the spinal cord lesion with myelopathic features. We report a case of a 16-year-old male who developed myelopathy 6 weeks following chlorpyrifos poisoning. He had a motor weakness of 4/5 in bilateral hips and 3/5 in bilateral knees and ankles. Spasticity and exaggerated reflexes with ankle clonus were present in the lower limbs. Sensory and the upper limb motor examinations were all normal. Pertinent blood, cerebrospinal fluid and nerve conduction tests were normal. Magnetic resonance imaging of the spine showed features of cord atrophy. Three months following physiotherapy, his power improved to 5/5 in bilateral knee and hip joints and 4/5 in bilateral ankles with spasticity. Organophosphate-induced delayed neuropathy can present as earlier as 6 weeks with myelopathy. Previous history of organophosphorous exposure is important in myelopathy or peripheral neuropathy.

Magnetic resonance imaging abnormalities in encephalomyelitis due to paralytic rabies: A case report

The diagnosis of rabies, a potentially fatal neuroinfectious disease, should be strongly considered in all patients who develop encephalitis following an infected animal bite even when they have received post-exposure prophylaxis. In the absence of confirmatory tests, typical magnetic resonance imaging findings help confirm the clinical diagnosis of rabies.

Clinical Manifestations, Neuroimaging Findings, and Treatment of Idiopathic Intracranial Hypertension in a Nepalese Tertiary Centre

Introduction: Idiopathic Intracranial Hypertension is characterized by headache, visual impairment, papilledema, and increased cerebrospinal fluid opening pressure. We aim to evaluate clinical manifestations, neuroimaging findings, and treatment of Idiopathic Intracranial Hypertension in a Nepalese tertiary center. Materials and Methods: We retrospectively included patients with the diagnosis of Idiopathic Intracranial Hypertension who were admitted to the Neurology department of Tribhuvan University Teaching Hospital from 2019 June to 2021 May and presented to the Neuro-ophthalmology outpatient clinic of the hospital for follow-up. Results: Out of 16 Idiopathic Intracranial Hypertension patients, 12(75%) patients had either headache or ocular pain.  Reduced visual acuity and progressive visual loss were found in 44% of patients. Normal CSF opening pressure was found in 19%, 44% had CSF opening pressure at a range of 20-30 cm H20 and > 30 cm H20 in 37.5%. 15 Idiopathic Intracranial Hypertension patients (93.7%) were subtyped as Typical and 1 patient was diagnosed as Fulminant Idiopathic Intracranial Hypertension. Acetazolamide was used for treatment in 15 patients and 1 patient needed ventriculoperitoneal shunting. 56% Seven patients (44%) had some abnormal findings: partial empty sella (44%), and tortuous optic nerve (31%), flattened posterior eyeball (31%), and hypoplastic transverse sinus (19%). Conclusions: Idiopathic Intracranial Hypertension is an uncommon diagnosis but should be suspected in patients with chronic headaches with visual impairment. In low-resource settings, proper history along with neurological and ophthalmological examinations can even detect the early features and timely referral can save the vision and disability of Idiopathic Intracranial Hypertension patients.

Safety and efficacy of interleukin-6-receptor inhibitors in the treatment of neuromyelitis optica spectrum disorders: a meta-analysis

BACKGROUND

Interleukin-6-receptor inhibitors like Tocilizumab and Satralizumab are showing promising results in the treatment of Neuromyelitis Optica spectrum disorder (NMOSD). We aimed to investigate the efficacy and safety of various Interleukin-6-receptor inhibitors in the management of NMO/NMOSD.

METHODS

PubMed, Embase, and The Cochrane Library were systematically searched for suitable studies. Change in Annualized Relapse Ratio (ARR), Change in Extended Disability Status Scale (EDSS) s, the proportion of relapse-free patients and proportion of patients with adverse events, including serious adverse events and mortality were the parameters considered for the meta-analysis for Tocilizumab. Mean difference (MD) with 95% CI was used to quantify the change in ARR and change in EDSS before and after treatment. A forest plot was prepared to indicate the efficacy and adverse effects outcomes. The results were compared with those of Satralizumab included in two trials.

RESULTS

A total of nine studies with 202 patients were included in our study. Tocilizumab found a good proportion (76.95% CI: 0.61-0.91; p < 0.001) of relapse free patients at follow up. It also significantly reduced mean ARR (mean difference: -2.6, 95% CI: - 2.71 to - 1.68; p < 0.001) and but did not show significant difference in change in EDSS score (mean difference = - 0.79, 95% CI: - 1.89 to - 0.31; p = 0.16). Also, the toxicity profile of Tocilizumab was acceptable considering the proportions of patients with adverse events 56% (95% C.I.;0.27-0.85, I2 = 88.95%, p < 0.001), proportions of patients with serious adverse events 11% (95% C.I.; 0.05 to 0.17, I2 = 0%, p < 0.001) and zero treatment related deaths. SAkura studies for Satralizumab showed similar relapse free patients (70% to 80%) and reduction of ARR and EDSS from baseline. Some studies of Tocilizumab have shown to reduce pain and fatigue while trials of Satralizumab had non-significant findings.

CONCLUSION

Interleukin-6-receptor inhibitors therapy showed a promising result with good efficacy and acceptable adverse events profile for treatment of NMOSD.

Extensive bilateral intracranial calcifications and seizure in iatrogenic hypoparathyroidism: A case report

Postoperative permanent hypoparathyroidism can exhibit extensive intracranial calcifications involving basal ganglia, thalamus, cerebellum, and cerebral cortex.

Cryptococcal meningitis in an immunocompetent individual: A case report

Cryptococcal meningitis (CM) is mostly seen in immune-compromised patients and rarely occurs in immune-competent individuals. Immunocompetent individuals with CM present with indolent neurological disease and have better clinical outcomes after treatment. However, misdiagnosis is common and these patients may suffer from serious complications with high mortality.

Cerebral venous sinus thrombosis with concomitant subdural hemorrhage and subarachnoid hemorrhages involving cerebral convexity and perimesenchephalic regions: A case report

We should suspect cerebral venous sinus thrombosis in patients with subacute onset progressive headaches with brain imaging evidence of localized cerebral edema with superimposed parenchymal, convexity subarachnoid as well as subdural hemorrhages.

Paraparetic Guillain-Barre syndrome: An uncommon diagnosis of acute flaccid paralysis of the lower limbs

Apart from the usual differentials of transverse myelitis and cord compression, paraparetic GBS should be considered when sudden, flaccid paralysis of the lower limbs occurs, as prompt diagnosis and management can minimize sequel and unnecessary procedures. We do report a case wherein we managed a similar situation without the use of an immunomodulatory therapy.

Safety and efficacy of Magnesium Sulfate in the management of Tetanus: A systematic review

Tetanus is a rare life-threatening condition often complicated by repetitive spasms, dysautonomia and neuromuscular respiratory failure contributing to high fatality rates in its severe form. Benzodiazepines used to treat muscle spasms pose a high risk of respiratory failure requiring mechanical ventilation, which is unaffordable and inaccessible for many. Magnesium sulfate, a cheap and widely available medication in all urban and rural health centres of LMICs for the treatment of eclampsia, can be used to control muscle spasms and dysautonomia. We thus conducted a systematic review of evidence to assess the safety and efficacy of magnesium sulfate in the treatment of tetanus. Any study published before April 15, 2021, discussing the efficacy and/or safety of MgSO4 infusion in the treatment of tetanus was systemically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Our systematic review included data from 13 studies, three were randomised, double-blind and controlled trials. The remaining ten studies were observational; six prospective and four retrospective studies. Our review showed no mortality benefit associated with the use of magnesium sulfate. However, magnesium sulfate was found to be effective in reducing spasms along with diazepam, leading to better control of dysautonomia, reduced need for mechanical ventilation and shorter hospital stay by 3-7 days. The incidence of magnesium toxicity was very low in the studies included.

Isolated extrapontine myelinolysis with neuropsychiatric manifestation: A case report from Nepal

A referred case of a 34-year-old woman was brought to the emergency room with features of mutism and whole-body rigidity following rapid correction of hyponatremia. On presentation, she was ill looking with tremors on her both hands and legs. She was unresponsive to command and developed involuntary outbursts of laughter and crying. Based on clinical features and neuroimaging, diagnosis of isolated extrapontine myelinolysis was made. She was treated with quetiapine, vitamin B₁ and B₁₂ supplements, trihexyphenidyl, levodopa-carbidopa and physiotherapy of limbs. Due to lack of clinical trials for adequate diagnosis and management of extrapontine myelinolysis, this case report highlights the importance of extrapontine myelinolysis with neuropsychiatric manifestation in research world.

Neurobrucellosis: A differential not to be missed in patients presenting with neuropsychiatric features

When a patient presents with undulating fever and neuropsychiatric features, neurobrucellosis should be considered as a differential diagnosis. If diagnosed early, neurobrucellosis is a treatable disease with a favorable outcome.

Neurological Manifestations of COVID-19 Associated Multi-system Inflammatory Syndrome in Children: A Systematic Review and Meta-analysis

BACKGROUND

Children comprise only 1-5% of COVID-19 cases. Recent studies have shown that COVID-19 associated multisystem inflammatory syndrome in children (MIS-C) can present with neurological signs and symptoms. In this systematic review and meta-analysis, we have reviewed neurological involvement in these patients.

METHODS

A comprehensive electronic literature search was done on PubMed, Google Scholar, Embase, Cochrane database, and SCOPUS for the published English language articles from December 1, 2019, to February 28, 2021. A meta-analysis of the proportion was expressed as a pooled proportion with a 95% confidence interval (CI). Representative forest plots showing individual studies and the combined effect size were generated to provide an overview of the results.

RESULTS

This systematic review and meta-analysis analyzed 15 published MIS-C studies with a total of 785 patients. Neurological manifestations in patients with MIS-C was found in 27.1%. We found that 27% developed headaches, 17.1% developed meningism/meningitis and 7.6 % developed encephalopathy. Other uncommon neurological manifestations of MIS-C includes anosmia, seizures, cerebellar ataxia, global proximal muscle weakness and bulbar palsy. In MIS-C patients with neurological feature, neuroimaging showed signal changes in the splenium of the corpus callosum. Electroencephalography showed slow wave pattern and nerve conduction studies and electromyography showed mild myopathic and neuropathic changes.

CONCLUSIONS

Our study revealed that neurological manifestations are not uncommon in patients with MIS-C. Further large prospective studies are needed to better explore the disease spectrum and to unravel the underlying pathophysiology.

Longitudinally Extensive Transverse Myelitis: A Retrospective Study Differentiating Neuromyelitis Optica Spectrum Disorder From Other Etiologies

Background Longitudinally extensive transverse myelitis (LETM) is characterized by contiguous immune-mediated inflammatory lesion of the spinal cord extending more than three vertebral segments. Neuromyelitis optica spectrum disorder (NMOSD) is the most common and important cause of LETM. This study aims to evaluate the demographic profile, clinical presentations, neuroimaging features, laboratory parameters, and etiologies of LETM and differentiates NMOSD from other etiologies of LETM. Methodology This retrospective cross-sectional study was conducted at the Department of Neurology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. After receiving clearance from the ethical committee, a retrospective chart review was conducted and records of all the inpatient LETM cases admitted from March 2018 to June 2020 were obtained. From the patient records, the following information was extracted: the demographic profile, clinical presentations, neuroimaging features, cerebrospinal fluid analysis, serum anti-aquaporin-4 (AQP4) immunoglobulin G status, hemogram, infectious disease profile, inflammatory markers, and auto-immune panels. Descriptive analysis of data was performed with SPSS statistics 23.0 version (IBM Corp, Armonk, NY, USA). Results In our study, the mean age of LETM patients was 36.58 years, and 12 out of 19 (63.15%) patients were young, with an age less than 40 years. A total of 13 (68.40%) patients were male, with a male-to-female ratio of 2.16. Seven (36.80%) patients had a clinical diagnosis of NMOSD with anti-AQP4 antibody-positive status, four (21.10%) had unknown etiology, three (15.8%) had post-infectious transverse myelitis, and three (15.80%) had a diagnosis of idiopathic transverse myelitis. There was a single case (5.30%) of cervical spondylotic myelopathy and leukemic transverse myelitis each. The common presenting symptoms of LETM were bladder dysfunction, paraparesis, quadriparesis, and visual impairment. Visual involvement, either unilateral or bilateral, was common in NMOSD and LETM of unknown etiology category. Similarly, brain lesion was common in patients with NMOSD and LETM of unknown etiology category. Conclusion LETM is a heterogeneous disorder with diverse etiologies and clinical presentations. NMOSD is an important cause of LETM that predominantly affects females. Optic neuritis can be seen in LETM of various etiologies, but it is more common in anti-AQP4-positive NMOSD patients. Brain lesions in LETM are common in anti-AQP4-positive NMOSD.

Sporadic Creutzfeldt-Jakob disease: A case report and review of literature

Creutzfeldt-Jakob Disease is a rare neurodegenerative disease and earlier diagnosis is usually difficult. Combining clinical features with electroencephalogram, laboratory parameters, and neuroimaging findings will facilitate the diagnosis.

Efficacy and safety of rituximab in autoimmune encephalitis: A meta-analysis

BACKGROUND

Autoimmune encephalitis (AE) is a rare but debilitating neurological disease where the body develops antibodies against neuronal cell surface/synaptic proteins. Rituximab is an anti-CD20 chimeric monoclonal antibody which shows promise in AE treatment observational studies. To our knowledge, there has been no previous meta-analysis providing robust evidence on the effectiveness and safety of rituximab as second-line therapy for the treatment for AE.

METHODS

This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) statement. Investigators independently searched PubMed, Web of Science, Google Scholar, WANFANG, CNKI, and J-STAGE for studies. Meta-analysis via representative forest plots was conducted for good functional outcome (mRS ≤ 2), proportion of relapse, and mRS score change pre- and post-treatment.

RESULTS

Good functional outcome at last follow-up following rituximab therapy occurred in 72.2% of patients (95% CI: 66.3%-77.4%). Mean mRS score decreased by 2.67 (95% CI: 2.04-3.3; P < .001). Relapses following the rituximab therapy occurred in only 14.2% of patients (95% CI: 9.5%-20.8%). Infusion related reactions, pneumonia, and severe sepsis were seen in 29 (15.7%), 11 (6.0%), and two patients (1.1%), respectively. The efficacy and side effect profile of rituximab are comparable to outcomes seen in rituximab use in other autoimmune and inflammatory CNS disease.

CONCLUSION

Our meta-analysis showed that rituximab is an effective second-line agent for AE with an acceptable toxicity profile.

The dangers of mass drug administration of albendazole in Nepal, a Neurocysticercosis-endemic region

The majority of cases of Neurocysticercosis (NCC) are asymptomatic. Injudicious use of antihelmintics like albendazole (ALB) can cause cyst degeneration and perilesional inflammation, thus rendering asymptomatic individuals symptomatic with seizures, headache, vascular events, or cerebral edema. Mass drug administration (MDA) using ALB is a very common practice in developing countries like Nepal to contain transmission of soil-transmitted helminths (STH) and lymphatic filariasis (LF). Although the benefits of ALB-based MDA in the general population cannot be undermined, there can be severe consequences in certain groups, especially those with latent NCC. In this commentary, we discuss the effect it may have on such patients, and suggest potential solutions.

Anti-LGI1, anti-GABABR, and Anti-CASPR2 encephalitides in Asia: A systematic review

AIM

We aim to review the literature to collate and describe features of encephalitides arising from autoantibodies against leucine-rich glioma-inactivated 1 (LGI1), gamma aminobutyric acid receptor (GABABR), and contactin-associated protein-like 2 (CASPR2) in Asian populations and compare them with findings of Western studies.

METHODS

Peer-reviewed articles published till 24 May 2020 were searched, and original, full-text studies from Asia with serum/CSF antibody-based diagnosis and at least 2 patients were selected. Twenty-four studies with 263 patients (139 anti-LGI1, 114 anti-GAGABR, and 10 anti-CASPR2) were included. Data were pooled to produce descriptive information on demographics, clinical characteristics, diagnostics, treatments, and outcome.

RESULTS

The mean age was 54.2 (anti-LGI1), 55.2 (anti-GABABR), and 47.7 years (anti-CASPR2), with an overall male predominance of 62.0%. Commonest clinical features across all types were seizures (87.5%), memory deficits (80.7%), psychiatric disturbances (75.9%), and altered consciousness (52.9%). Four anti-LGI1, 40 anti-GABABR, and 1 anti-CASPR2 patients had tumors. CSF, MRI, and EEG were abnormal in 33.3%, 54.1%, and 75% patients in anti-LGI1; 60.0%, 49.6%, and 85.7% in anti-GABABR; and 50%, 44.4%, and 100% in anti-CASPR2 patients, respectively. 95.6% patients received first-line therapy alone (steroids/IVIG/Plasma therapy), and 4.4% received second-line therapy (rituximab/cyclophosphamide). 91.7%, 63.6%, and 70% of patients had favorable outcomes (modified Rankin Score 0-2) with mortality rates at 2.5%, 23.2%, and 0% in the three types, respectively.

CONCLUSION

Our findings suggest that these disorders present in Asian patients at a relatively young age often with features of seizures, memory deficits, and psychiatric disturbances and usually demonstrate a favorable clinical outcome.