Etiological profile of noncompressive myelopathies in a tertiary care hospital of Northeast India

Myelitis preceding anti-N-terminal of α-enolase antibody-positive Hashimoto's encephalopathy

Hashimoto's encephalopathy is an autoimmune disease characterized by diverse clinical and imaging manifestations, often presenting considerable challenges in its diagnosis, especially when myelitis occurs before the onset of encephalopathy. Anti-N-terminal of α-enolase antibodies targeting the N-terminal of α-enolase are specific serum markers of Hashimoto's encephalopathy; however, studies analyzing their association with myelitis are lacking. Herein, we describe the case of a patient with myelitis who later developed encephalopathy. Owing to positivity for anti-N-terminal of α-enolase antibodies in the serum, a diagnosis of Hashimoto's encephalopathy was made. Detecting anti-NAE antibodies can be useful in diagnosing myelitis of unknown etiology.

NMR Spectroscopy in Diagnosis and Monitoring of Methylmalonic and Propionic Acidemias

Although both localized nuclear magnetic resonance spectroscopy (MRS) and non-localized nuclear magnetic resonance spectroscopy (NMR) generate the same information, i.e., spectra generated by various groups from the structure of metabolites, they are rarely employed in the same study or by the same research group. As our review reveals, these techniques have never been applied in the same study of methylmalonic acidemia (MMA), propionic acidemia (PA) or vitamin B12 deficiency patients. On the other hand, MRS and NMR provide complementary information which is very valuable in the assessment of the severity of disease and efficiency of its treatment. Thus, MRS provides intracellular metabolic information from localized regions of the brain, while NMR provides extracellular metabolic information from biological fluids like urine, blood or cerebrospinal fluid. This paper presents an up-to-date review of the NMR and MRS studies reported to date for methylmalonic and propionic acidemias. Vitamin B12 deficiency, although in most of its cases not inherited, shares similarities in its metabolic effects with MMA and it is also covered in this review.

Surgical treatment of Candida albicans spondylodiscitis

Introduction

Spinal infection poses a demanding diagnostic and treatment problem for which a multidisciplinary approach with spine surgeons, radiologists, and infectious disease specialists is required. Infections are usually caused by bacterial microorganisms, although fungal infections can also occur. Most patients with spinal infections diagnosed in the early stages can be successfully managed conservatively with antibiotics, bed rest, and spinal braces. In cases of gross or pending instability, progressive neurological deficits, failure of conservative treatment, spinal abscess formation, severe symptoms indicating sepsis, and failure of previous conservative treatment, surgical treatment is required.

Case presentation

A 64-year-old male presented to the Outpatient Department with a complaint of pain in bilateral upper extremities for 4 months. The pain was shooting in type, radiating to bilateral arms, forearms, and hands with no aggravating and relieving factors. He is a known case of carcinoma pyriform sinus for which he underwent various cycles of chemotherapy. Ten years later, a tracheostomy was performed for laryngeal edema, and again, an endoscopic gastrostomy was performed due to feeding difficulties. He then developed fever and cervical pain along with pain in the bilateral upper extremities. An infectious etiology was suspected for which multiple antibiotics were started with no positive response. An MRI was performed, which was suggestive of spondylodiscitis probably of tubercular origin. A biopsy was done to confirm the diagnosis, following which antitubercular (HRZE) therapy was started. He was also treated with Duloxetine and gabapentin, which resulted in minor improvements. Subsequent MRIs showed diffuse involvement of the multiple cervical vertebrae along with cord compression. Two stages of anterior corpectomy followed by posterior instrumentation were done. Following the procedure, the patient developed an infection, which was managed with antibiotics. The titanium implant was not removed. A muscle graft was planned with the pectoralis muscle and flap closure was done. The tissue was also sent for Gram stain, AFB stain, and GeneXpert, which showed normal findings. Finally, in tissue culture, Candida albicans was isolated. On performing the enzyme immunoassay test, it was found to be Aspergillus (Galactomannan antigen) positive as well. Antitubercular treatment was stopped. Then, he was managed with an antifungal, oral voriconazole, for the duration of 1 and a half years.

Clinical discussion

Patients diagnosed with Candida spondylodiscitis tend to have favorable outcomes, likely linked to timely identification, thorough surgical debridement, and proper azole medication. Our case achieved success by promptly identifying and confirming it through tissue culture, detecting spinal cord compression, decompressing it, and initiating specific antifungal treatment. A delay in commencing antifungal therapy has been associated with poorer outcomes, especially in neurological health. Our patient received voriconazole for a full year, suggesting that favorable outcomes are achievable for fungal spondylodiscitis with swift and appropriate surgery and antifungal medication.

Conclusion

In summary, evaluation for fungal infection is essential in all cases of unexplained spinal infection in immunocompromised patients, regardless of presentation. If the antifungal treatment proves ineffective, a surgical approach is typically employed for the management of fungal spondylodiscitis. Our report details a successful case of fungal spondylodiscitis treated with a surgical approach and highlights the potential for a fungal infection to be a causative factor in noncompressive myelopathy, which may be sometimes mistaken for radiation myelitis.

Bilateral Diffuse Leukoencephalopathy in an Electrocuted Patient Where the Brain Was Not in the Pathway of Conduction

Electrocution, damage caused by electric current passing through the body, is usually a serious event causing significant morbidity or even mortality. Graded damage is seldom encountered. According to Ohm's law, the current is directly proportional to the applied voltage and inversely proportional to the resistance of a circuit. Electric current is expected to travel through cells that have the least resistance. Therefore, cells that allow action potential to travel down their cell membrane are presumably the ones with the least resistance. Among these are neurons and cells within the cardiac conduction system. Within a neuron, the axon will conduct electricity better than the cell body. While there have been a few cerebral white matter lesions caused by electrocution described in the literature, the mechanism is not fully understood. We report a patient with bilateral symmetrical subcortical abnormality where the electric current entered one hand and exited through her legs without affecting the head directly. We reviewed the literature and we hope it will further our understanding of how electrocution affects the central nervous system and which groups and parts of neurons are more susceptible than others.

Etiological and Radiological Spectrum of Longitudinal Myelitis: A Hospital-Based Study in North East India

Introduction  An inflammatory lesion of the spinal cord where three or more than three vertebral segments of the cord is involved is called longitudinal extensive myelitis (LETM). It has several varied causes out of which neuromyelitis optica (NMO) and its spectrum disorder have received a distinct entity. Various radiological and clinical features help us to suspect an etiology which then further guides us into the treatment protocol and prognosis of the patients.

Materials and Methods  A retrospective study performed in a referral center in North East India in 15 months. Thirty-two patients of LETM were enrolled based on clinical and radiological available data. An attempt was made to classify the various etiologies and correlate with their radiological findings.

Results  The most common etiology noted was NMO seen in 7 patients (21.8%) followed by tuberculosis (TB) (18.7%) and post-infection myelitis (18.7%). Other etiology seen was acute disseminated encephalomyelitis (6.24%), spinal cord infarct (3.12%), radiation myelitis (6.24%), Japanese encephalitis sequalae (3.12%), systemic lupus erythematosus (3.12%), and remained undiagnosed in six patients (18.7%). Radiologically, cervico-dorsal spine was most common location in NMO (71%) whereas dorsolumbar in TB (50%). The lesion was predominantly central in both NMO (100%) and TB (80%) as compared with the other causes of LETM. It was noted that more than 50% of the transverse area of the cord was involved in both NMO (71%) and TB (50%), but < 50% involvement were more common in the post-infectious and others causes of LETM.

Conclusion  LETM has a various differential diagnosis, infection need to be kept in mind while ruling out NMO. Radiological features can suggest or help differentiate the various etiologies of LETM but NMO and infection like TB almost has the same features except for a different cord site predilection.

Various Neurological Symptoms with Vitamin B12 Deficiency and Posttreatment Evaluation

Background:

Vitamin B12 deficiency occurs primarily as a result of insufficient dietary intake in children in developing countries. Vitamin B12 deficiency produces a cluster of neurological symptoms in children.

Aim:

The aim of this study was to describe the vitamin B12 status of patients who were admitted with neurological symptoms and to evaluate the clinical response to vitamin B12 treatment.

Materials and Methods:

This study was conducted on children who had vitamin B12 deficiency presented with neurological findings from January 2014 to October 2016. Patients with serum vitamin B12 levels lower than 300 pg/mL received intramuscular or oral vitamin B12 treatment.

Results:

Three hundred and fifty-one patients presenting with neurologic symptoms and who had low serum vitamin B12 deficiency were analyzed. Our study population was composed mainly of adolescent age. The most common symptom with respect to age was headache. In infant patients, most common symptoms were seizure and developmental delay.

Conclusion:

Early diagnosis and vitamin B12 treatment are advocated to avoid long-term injury. Our study shows that patients with serum vitamin B12 levels lower than 300 pg/mL showed clinical improvement of neurological symptoms after receiving vitamin B12 treatment.

Rationalization of Using the MR Diffusion Imaging in B12 Deficiency

Context:

The structural imaging of brain does not demonstrate any changes in the vast majority of patients with vitamin B12 deficiency, even in the advanced stages.

Aims:

We investigated the microstructural changes in the brain with diffusion imaging among patients with biochemical evidence of B12 deficiency.

Patients and Methods:

We retrospectively analyzed all diffusion-weighted MRI images between the periods 2014–2016 who had biochemical evidence of B12. The age-sex matched controls were chosen from the group with normal B12 levels. Patients with pathological findings in conventional MRI images were excluded from the study.

Results:

About 37 patients were recruited (22 women, 15 men; mean age, 34.1 ± 9.9 years; age range). They were about thirty-four age-and sex-matched controls (with normal B12 levels), which were also included in the study. The mean apparent diffusion coefficient (ADC) value of amygdala (773.8 ± 49.9 vs. 742.2 ± 24.2, P = 0.01), hypothalamus (721.3 ± 39.2 vs. 700.2 ± 38.2, P = 0.02), striate cortex (737.6 ± 77.6 vs. 704.3 ± 58.2, P = 0.04), suprafrontal gyrus (740.7 ± 46.9 vs. 711.6 ± 40.7, P = 0.007) and medulla oblongata-olivary nucleus (787.3 ± 56.4 vs. 759.7 ± 46.2, P = 0.02) were significantly higher in B12 deficiency group compared to controls, whereas ADC values were similar at hippocampus, thalamus, insula, corpus striatum, cingulate gyrus, occipital gyrus, dentate nucleus, cerebral pedicle, tegmentum, pons, and posterior medulla oblongata.

Conclusions:

Our study indicates that a significant increase in ADC values occurs in multiple brain regions in patients with vitamin B12.