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Biswas U, León-Ruiz M, Ghosh R, Joarder U, Islam KM, Bheeman R, Benito-León J. An Intriguing Case of Expanded Dengue Syndrome With Co-existing Encephalitis, Pancreatitis, and Hepatitis: The Classic Thalamic "Double-Doughnut" Sign Revisited. Neurohospitalist 2024; 14:316-321. [PMID: 38894998 PMCID: PMC11181972 DOI: 10.1177/19418744241230730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Background Dengue neuro-infection can present with symptoms ranging from mild to severe. Atypical presentations, such as expanded dengue syndrome, pose diagnostic and therapeutic challenges. Neuroimaging findings, particularly the "double-doughnut" sign on brain magnetic resonance imaging (MRI), have emerged as one of the most valuable aids in diagnosing complex cases of central nervous system infection by dengue virus. Case Presentation We report the case of a 35-year-old female from rural West Bengal, India, with expanded dengue syndrome. The patient presented with fever, headaches, body aches, and sudden disorientation over minutes, which progressed to a coma. Neurological examination revealed profound unconsciousness and nuchal rigidity. Laboratory findings were consistent with dengue infection, including altered liver and pancreatic enzyme levels. The diagnosis was facilitated by identifying the "double-doughnut" sign on the brain MRI, which suggested dengue encephalitis. This finding and clinical and serological evidence guided the treatment strategy. Discussion The "double-doughnut" sign, though not exclusive to dengue encephalitis, proved crucial in this case, aiding in differentiating from other causes of encephalitis. Recognition of this sign can be pivotal in diagnosing expanded dengue syndrome, facilitating timely and appropriate intervention, and improving patient outcomes. This case also underscores the importance of considering dengue in the differential diagnosis of encephalitis, especially in endemic areas. Also, this case's excellent outcome (both clinically and radiologically) was noteworthy.
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Affiliation(s)
- Uttam Biswas
- Department of General Medicine, Burdwan Medical College and Hospital, Gurap, India
| | - Moisés León-Ruiz
- Section of Clinical Neurophysiology, Department of Neurology, University Hospital “La Paz,” Madrid, Spain
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Gurap, India
| | - Utsab Joarder
- Department of General Medicine, Burdwan Medical College and Hospital, Gurap, India
| | | | - Raghul Bheeman
- Department of General Medicine, Burdwan Medical College and Hospital, Gurap, India
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Coslada, Spain
- Instituto de Investigación Sanitaria Hospital, 12 de Octubre (i+12), Madrid, Spain
- Centro de Investigación Biomédica en Red, Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain
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Grover S, Kathiravan S. Acute and transient psychotic disorders: A review of Indian research. Indian J Psychiatry 2023; 65:895-913. [PMID: 37841545 PMCID: PMC10569331 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_254_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/26/2023] [Accepted: 08/09/2023] [Indexed: 10/17/2023] Open
Abstract
Background Acute and transient psychotic disorder (ATPD) was recognized as separate from other psychotic disorders and described in the International Classification of Diseases (ICD) tenth revision for the first time. A lot of research on ATPD has been conducted in India over the last six decades, but a review focusing exclusively on Indian research on ATPD is not available. Aim This paper aims to review the literature on ATPD emerging from India. Methodology A combination of search terms "Acute and Transient Psychosis," "acute psychosis," "non-affective psychosis," "non-affective psychotic disorder," "reactive psychosis," "first-episode psychosis," and "India" were searched on various search engines like PUBMED, Medknow, Hinari, and Google Scholar. We also did a hand search for additional relevant articles, including published abstracts of the Indian Journal of Psychiatry from 2007 to 2023. Relevant papers were selected. Results The prevalence of ATPD varies across different study settings, and it tends to have an abrupt to acute onset, and is primarily associated with stress. Few studies have assessed the subtypes of ATPD, and symptom profile has been inconsistently reported. There is a lack of trials on the effectiveness or efficacy of antipsychotics in ATPD patients. In a large proportion of patients initially diagnosed with ATPD, the diagnosis remains stable, with recurrence varying from 10% to 46.6% based on the duration of follow-up. Conclusion There is a need for more multicentric studies, studies with larger sample sizes, and consistency in data about risk factors. There is a need to evaluate symptom profile, course, outcome, and treatment outcomes in patients with ATPD using validated instruments to improve our understanding. Further, there is a need for comparative studies to evaluate the risk factors for ATPD.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjana Kathiravan
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Chaudhary SK, Chavan A, Tandon R. Anti-NMDA receptor encephalitis with "Hockey stick sign" mimicking CJD. Neurol Sci 2023; 44:741-743. [PMID: 36251206 DOI: 10.1007/s10072-022-06455-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Sarvesh Kumar Chaudhary
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ajay Chavan
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ruchika Tandon
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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Chowdhury D, Panda AK, Gupta A, Chowdhury S, Duggal A, Koul A. Anti- N-methyl D-aspartate Receptor Encephalitis in India: A Literature Review. Ann Indian Acad Neurol 2023; 26:17-32. [PMID: 37034048 PMCID: PMC10081549 DOI: 10.4103/aian.aian_519_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Anti N-methyl D-aspartate receptor encephalitis (NMDAR-E) though rare, is currently considered as the commonest antibody mediated encephalitis in the world. No review on perspectives of NMDAR-E from India is available. The aim of the study was to review all the cases of NMDAR-E reported from India until June 2021 in terms of clinical features, diagnosis, and treatment, and perform a comparison of adult and paediatric cases. A literature review of NMDAR-E case reports/case series published from India till June 2021 was done. Demography, clinical profile, triggers, electroencephalography (EEG), neuroimaging, treatment details and outcomes were analysed. Sixteen case series and 35 case reports with a total of 249 cases were analysed. 82% of cases were from paediatric age group. The female to male ratio was 3:1. Psychiatric deficits, movement disorders, seizures, and language abnormalities were the most common clinical features. MRI brain abnormalities were seen in 45% patients. Electroencephalographic abnormalities were seen in 85% of patients. Infective triggers (herpes simplex virus and various other agents) were reported in 11% of the cases. Pediatric patients as compared with adults had more encephalopathy, autonomic dysfunctions, and normal imaging whereas the latter had more cognitive dysfunctions and delta brush pattern in electroencephalography (p<0.005). Therefore, to conclude, this literature review suggests that overall, the clinical spectrum of Indian cases is like cases described from other parts of the world. However, most reported cases from India belonged to paediatric age group who had more encephalopathy, autonomic dysfunctions, and normal brain imaging compared to adults. A few novel infectious agents as triggers were described from India.
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Affiliation(s)
- Debashish Chowdhury
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashwin K. Panda
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashutosh Gupta
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Samiran Chowdhury
- Department of Internal Medicine, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashish Duggal
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Arun Koul
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Han Y, Gong S, Wan Y, Fu X, He E, Liu M, Deng F. Case report: Anti-NMDA receptor encephalitis manifesting as rapid weight loss and abnormal movement disorders with alternating unilateral ptosis and contralateral limb tremor. Front Immunol 2022; 13:971514. [PMID: 36189268 PMCID: PMC9520482 DOI: 10.3389/fimmu.2022.971514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/24/2022] [Indexed: 01/17/2023] Open
Abstract
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, associated with immunoglobulin G (IgG) autoantibodies against the GluN1 subunit of the NMDAR, is one of the most common types of autoimmune encephalitis. In patients with anti-NMDAR encephalitis, movement disorders (MDs) are often frequent, mainly presenting as facial dyskinesias and stereotyped movements. The alternating clinical manifestation of limb tremor with unilateral ptosis is rare. Here, we report an interesting case of a 22-year-old woman with rapid weight loss presenting with staged dyskinesia. Interestingly, she typically showed persistent tremor of the right upper limb, which would stop when her left upper eyelid drooped uncontrollably, a phenomenon that lasted for a few seconds, followed by automatic upper eyelid lift and continued persistent tremor of the upper limb. Moreover, it was fortunate to find anti-NMDAR antibodies in her cerebrospinal fluid (CSF), which indicated the patient had anti-NMDAR encephalitis. And abnormal apparent diffusion coefficient (ADC) hyperintense signals on the left midbrain interpeduncular fossa explained this manifestation of focal neurological deficit. After the systematic administration of immunotherapy (intravenous immunoglobulin, IVIG), steroid pulse therapy, and symptomatic treatment, the initial symptoms were significantly relieved except for limb tremor. The MDs were becoming less visible for the next six months under topiramate prescriptions. Noteworthy, there are no specific MD phenotypes in anti-NMDAR encephalitis. We describe the young women with unique MDs and rapid weight loss to help us get a more comprehensive understanding of anti-NMDAR encephalitis.
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Long Q, Lv Z, Zhao J, Shi K, Li C, Fan B, Zheng J. Cerebral gray matter volume changes in patients with anti-N-methyl-D-aspartate receptor encephalitis: A voxel-based morphometry study. Front Neurol 2022; 13:892242. [PMID: 35959389 PMCID: PMC9358280 DOI: 10.3389/fneur.2022.892242] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/04/2022] [Indexed: 01/19/2023] Open
Abstract
Background: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disease with typical clinical features. Whether and how cerebral gray matter structural damage inherent to the disorder affects cognitive function in patients is still unclear. Therefore, this study aimed to explore the changes in cerebral gray matter volume and whether these alterations contribute to cognitive impairment and mood disorders. Methods Forty patients with anti-NMDAR encephalitis and forty healthy controls (HCs) matched for gender, age, and education were recruited. All participants underwent attention network tests (ANT), neuropsychological tests and magnetic resonance imaging (MRI). Voxel-based morphological analysis (VBM) and correlation analysis was performed on all participants. Finally, according to the course of disease, patients were divided into two groups: NMDARE_SD (short duration; course ≤ 2 years since diagnosis) and NMDARE_LD (long duration; course >2 years since diagnosis), to evaluate gray matter volume changes that differ as a function of disease course. Results Compared to HCs, patients with anti-NMDAR encephalitis showed decreased executive control ability and lower MoCA score, while increased anxiety and depression as reflected by HAMA and HAMD24 scores (all P < 0.05). In VBM analysis, patients showed decreased gray matter volume in bilateral thalamus, left medial prefrontal cortex (mPFC_L), left superior temporal gyrus (STG_L), and left rectus gyrus. In the analysis stratified by disease course, the NMDARE_LD group exhibited decreased gray matter volume in the left precuneus and right posterior cerebellar lobe compared to the NMDARE_SD group. Conclusions Patients with anti-NMDAR encephalitis have cognitive, executive, and emotional dysfunction, and the sites of gray matter atrophy are concentrated in the thalamus, frontal lobe, and temporal lobe. These abnormalities may be involved in the process of cognitive and affective dysfunction.Patients with different courses of anti-NMDAR encephalitis have different brain atrophy sites. These results may help to clarify the contradiction between clinical and imaging manifestations of anti NMDAR encephalitis, which is worthy of further longitudinal studies.
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Ghosh R, Dubey S, Mukherjee A, Benito-León J. Rapidly progressive dementia with generalized myoclonus in an adult: Do not forget subacute sclerosing panencephalitis. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:415-418. [PMID: 35672127 DOI: 10.1016/j.nrleng.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/30/2021] [Indexed: 10/18/2022] Open
Affiliation(s)
- R Ghosh
- Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, West Bengal, India
| | - S Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, India
| | - A Mukherjee
- Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, West Bengal, India
| | - J Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Department of Neurology, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Complutense University, Madrid, Spain.
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Ghosh R, Dubey S, Mukherjee A, Benito-León J. Rapidly progressive dementia with generalized myoclonus in an adult: Do not forget subacute sclerosing panencephalitis. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Biyajima M, Satoh S, Morikawa T, Morita Y, Watanabe R, Matsui D, Konno M, Morimoto N, Yatsu Y, Hirasaki A, Yahikozawa H. Bromisoval-induced bromism with status epilepticus mimicking Wernicke's encephalopathy: report of two cases. BMC Neurol 2022; 22:181. [PMID: 35578314 PMCID: PMC9109394 DOI: 10.1186/s12883-022-02712-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/10/2022] [Indexed: 12/01/2022] Open
Abstract
Background Bromine compounds are used in several drugs, including over-the-counter drugs. They sometimes cause intoxication known as bromism. Although the acute neurological symptoms and sequelae of bromism vary, few reports have mentioned acute encephalopathy. Case presentation We report two cases of bromisoval-induced bromism with status epilepticus. Presence of pseudohyperchloremia and history of over-the-counter medication use guided the diagnosis. In the acute phase, our patients showed bilateral medial thalamic lesions on magnetic resonance imaging. The imaging findings were similar to those of Wernicke’s encephalopathy. Although these findings improved in the chronic phase, neuropsychiatric sequelae, such as confabulation and amnesia, occurred. Conclusion Bromism can cause acute encephalopathy, and it is important to differentiate it from Wernicke–Korsakoff syndrome.
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Affiliation(s)
- Masahiro Biyajima
- Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan.
| | - Shunichi Satoh
- Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan
| | - Takahiro Morikawa
- Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan
| | - Yuki Morita
- Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan
| | - Rie Watanabe
- Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan
| | - Daisuke Matsui
- Department of Nephrology, Nagano Red Cross Hospital, Nagano, Japan
| | - Masataka Konno
- Department of Psychiatry, Nagano Red Cross Hospital, Nagano, Japan
| | - Nobutoshi Morimoto
- Department of Neurology, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Yuichi Yatsu
- Department of Anesthesiology, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Akihito Hirasaki
- Department of Anesthesiology, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Hiroyuki Yahikozawa
- Department of Neurology, Nagano Red Cross Hospital, 5-22-1, Wakasato, Nagano, 380-8582, Japan
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Bensaidane MR, Picher-Martel V, Émond F, De Serres G, Dupré N, Beauchemin P. Case Report: Acute Necrotizing Encephalopathy Following COVID-19 Vaccine. Front Neurol 2022; 13:872734. [PMID: 35572945 PMCID: PMC9099242 DOI: 10.3389/fneur.2022.872734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Acute necrotizing encephalopathy (ANE) is a rare neurological disorder arising from a para- or post-infectious "cytokine storm. "It has recently been reported in association with coronavirus disease 2019 (COVID-19) infection. Methods A 56-year-old male with a diagnosis of ANE 48 h following the first dose of ChAdOx1 nCoV-19 vaccination was investigated. Cytokine analyses on serum and cerebrospinal fluid (CSF) were performed. The patient was treated with high-dose corticosteroids and followed clinically and radiologically. Results Favorable clinical and radiological outcomes were noted. There was an upregulation in serum levels of CXCL5, CXCL1, Il-8, IL-15, CCL2, TGF-B, and EGF, and up-regulation in CSF levels of CXCL5, IL-2, IL-3, and IL-8. Discussion As COVID-19 infection has been previously reported as a possible rare cause of ANE, we speculate on an aberrant immune response mechanism that was brought about by the vaccine. To increase our understanding of the pathogenesis of ANE in the context of COVID-19 vaccination and to better define its clinical features and outcomes, clinicians and scientists should continue reporting convincing cases of such entities.
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Affiliation(s)
- Mohamed Reda Bensaidane
- Department of Medicine, Faculty of Medicine, Centre Hospitalier Universitaire de Québec—Université Laval, Quebec, QC, Canada
| | - Vincent Picher-Martel
- Department of Medicine, Faculty of Medicine, Centre Hospitalier Universitaire de Québec—Université Laval, Quebec, QC, Canada
- Department of Psychiatry and Neuroscience, Faculty of Medicine, CERVO Brain Research Centre, Quebec, QC, Canada
| | - François Émond
- Department of Medicine, Faculty of Medicine, Centre Hospitalier Universitaire de Québec—Université Laval, Quebec, QC, Canada
| | - Gaston De Serres
- Institut National de Santé Publique du Québec, Quebec, QC, Canada
| | - Nicolas Dupré
- Department of Medicine, Faculty of Medicine, Centre Hospitalier Universitaire de Québec—Université Laval, Quebec, QC, Canada
| | - Philippe Beauchemin
- Department of Medicine, Faculty of Medicine, Centre Hospitalier Universitaire de Québec—Université Laval, Quebec, QC, Canada
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Dubey S, Ghosh R, Chatterjee S, Dubey MJ, Sengupta S, Chatterjee S, Kanti Ray B, Modrego PJ, Benito-León J. Frontal Dysexecutive Syndrome in Brain Tumors: A Pragmatic Insight to an Old Problem. Case Rep Oncol 2021; 14:325-332. [PMID: 33776724 PMCID: PMC7983608 DOI: 10.1159/000513744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/19/2022] Open
Abstract
Brain tumors have long been considered one of the most prevalent causes of potentially reversible cognitive impairment. An accurate underlying cause of cognitive impairment due to brain tumor needs to be evaluated pragmatically. Patterns of cognitive impairment associated with brain tumors depend mainly on their location, lateralization, pathological classification and secondary effects of the treatment, as well as the structural plasticity and diaschisis. Hence, it is not rare that lesions with different locations and histologies may manifest with a similar pattern of cognitive impairment due to the complex interplay of determinants. We herein report 3 patients with brain tumors affecting different locations and with differing histologies, who shared a similar presentation as “frontal dysexecutive syndrome” masqueraded as psychiatric conditions. Detailed examination of saccades and pursuit along with eye movements and conventional motor examinations were essential not only to diagnose brain tumor as the potential cause of cognitive impairment, but also to rule out other coexisting etiologies with completely different underlying pathological mechanisms (i.e., Huntington's disease in 1 of the cases). A detailed neurological examination, including eye movement assessment, in patients with psychiatric symptoms provides not only important clues to delineate the underlying anatomical substrate involved, but also helps clinicians to make an accurate diagnosis and to select appropriate therapeutic options.
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Affiliation(s)
- Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, India
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Mahua Jana Dubey
- Department of Psychiatry, Berhampore Mental Hospital, Murshidabad, India
| | - Samya Sengupta
- Department of General Medicine, Apollo Gleneagles Hospitals, Kolkata, India
| | - Subham Chatterjee
- Department of Psychiatry, Institute of Psychiatry, Institute of Post-Graduate Medical Education and Research, Kolkata, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, India
| | - Pedro J Modrego
- Department of Neurology, University Hospital Miguel Servet, Zaragoza, Spain
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
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