Autistic Regression Sequelae or Relapse for NMDA Receptor Antibody Encephalitis

Objective

To highlight a pediatric presentation of autistic regression secondary to relapsing NMDA receptor antibody encephalitis (NMDARAE) post-HSV infection.

Background

It is reported that 30% of patients develop NMDA receptor antibodies (NMDARA) after HSV Encephalitis. Previous studies have demonstrated a significant association between prior HSV-1 infection and NMDARAE, a diagnosis often overlooked due to diverse neurological manifestations.

Design/Methods

NA.

Results

This case highlights a 5-year-old female presenting with fever and refractory status epilepticus, was diagnosed with HSV Encephalitis requiring prolonged hospitalization. At discharge she had insomnia, mutism, dyskinetic movements, atonic seizures, and developmental regression. At 3 months post-discharge EEG exhibited multiple generalized myoclonic, myoclonic tonic, and atonic seizures, MRI brain demonstrated right temporal lobe encephalomalacia with immunologic workup demonstrating positive serum and CSF NMDARA. She underwent treatment with intravenous steroids followed by plasmapheresis and then rituximab with an improved clinical response and seizure control at 6 months. At 9 months, she displayed behavioral changes with diagnosis of ADHD with autistic regression. Workup was positive for NMDARA in the CSF (18 months post-presentation) and EEG showed diffuse epileptiform discharges activated during sleep. She was treated with steroids followed by rituximab. At follow-up, she showed improved social interaction, sleep, and seizure control with persistence of some autistic and ADHD features.

Conclusions

About 90% of patients with NMDARE present with prominent behavioral manifestations, with challenges in differentiating from psychiatric diseases. Relapse is reported in 12-24% of cases and is associated with delayed treatment and the female gender. NMDARAE relapse post-HSV Encephalitis is underreported, especially cases demonstrating autistic regression, as in our case. In conclusion, given overlapping and subtle symptoms, it is crucial to recognize the varying presentations and early diagnosis of NMDARAE relapse for effective treatment and better outcome.

Autoimmune Encephalitis With Ganglionic a3-AChR Antibodies

Objective

To describe a case of autoimmune encephalitis presented as new onset refractory nonconvulsive status epilepticus and autonomic failure caused by alpha-3 ganglionic acetylcholine receptor autoantibodies (a3-AChR Ab).

Background

Autoimmune autonomic ganglionopathy (AAG) is rare acquired dysautonomia in adults due to a3-AChR Ab. A patient typically presents with subacute autonomic dysfunction, and encephalitis has not been reported yet.

Design/Methods

NA.

Results

A 60 years old female presented with progressive worsening of mental status for two weeks. Vital signs were normal. The patient was somnolent, nonverbal, with tonic non-reactive pupils on the exam. CT head showed multiple subcortical hypodensities. MRI brain demonstrated T2-FLAIR hyperintense lesions in bifrontal lobes sparing the U-fibers, with abnormal leptomeningeal/pial perivenular type enhancement. MRI C/T spine, CT chest/Abd/pelvis were negative. Although serum and CSF testing showed inflammatory markers, meningoencephalitis and autoimmune encephalitis panel were negative, except for the serum Paraneoplastic panel was positive with high titer a3-AChR Abs. EEG showed nonconvulsive status epilepticus, which required management with three antiseizure medications. Initially, the patient had little response to empirical pulse methylprednisolone therapy. Later showed good clinical response with plasmapheresis. Later on she presented with nonobstructive small bowel obstruction, resolved with another pulse steroid therapy, discharged on dexamethasone taper. On a three-month follow-up, the patient was in near clinical remission, supported with resolved lesions on a repeat MRI. She never relapsed after two years of follow-up.

Conclusions

Studies have shown that a3-AChR Abs can result in diverse neurological manifestations, mainly dysautonomia. Our patient presented with encephalitis, dysautonomia, and refractory nonconvulsive status epilepticus. Scans suggested diffuse leukoencephalopathy, patient was found to have high 3-ACHR antibody seropositivity. Initially, the patient was steroid-resistant but showed clinical improvement with plasmapheresis. We have described an interesting case of encephalitis likely associated with a3-AChR Ab that has not been previously described. More studies are required to confirm this association.

Unusual Post–COVID-19 Presentation With Tetra Ventricular Hydrocephalus: A Case Report

Objective:

COVID 19 infection is suggested as one of the causes for hydrocephalus (HCP) of unknown etiology. COVID-19 infection may present with a range of neurologic symptoms given viral neurotropic and neuroinvasive properties. Post-infectious hydrocephalus is a severe complication as a potential sequela of COVID-19 infection.

Methods:

We identified a patient with a history of recent COVID-19 infection who presented with chronic progressive headaches with nausea, vomiting, and blurry vision over two weeks.

Results:

Neurological examination showed bilateral papilledema. Head CT scan showed tetraventricular enlargement and marked fourth ventricular dilation. Cine MRI showed fourth ventricular turbulent CSF flow. The patient underwent external ventricular drain (EVD) placement and exploratory suboccipital craniotomy, which revealed a sub-arachnoid web that was microsurgically resected. Reconstituted CSF flow resolved the patient's symptoms and prevented complications.

Discussion:

Fourth ventricular outlet obstruction is a rare cause of tetraventricular hydrocephalus. In most cases, it is associated with a history of inflammatory conditions or hemorrhage. In our case, history of recent COVID-19 infection and normal imaging prior to COVID-19 make COVID-19 the most probable explanation for HCP. We suggest considering COVID-19 infection in the differential diagnosis of HCP of unclear etiology

Practical implication:

A pearl of wisdom for the practicing clinician: “Consider COVID-19 as the cause of Hydrocephalus of unclear etiology”.

Prevalence and incidence of venous leg ulcers-a protocol for a systematic review

BACKGROUND

Venous leg ulcers (VLUs) are chronic wounds characterized by slow healing and high recurrence. Information on prevalence and incidence is essential for ascertaining the burden of VLU on the health care system and to inform epidemiological research, priority setting, and health care planning. The objective of this protocol is to present a transparent process for how we plan to review the existing international literature on the prevalence and incidence of VLU as well as the characteristics of the population reported within these studies.

METHODS

An exploratory search was performed using MEDLINE via PubMed and CINHAL via Ebsco to identify concepts, keywords, MeSH terms, and headings to identify study types looking at data of VLU prevalence and/or incidence and related patient characteristics. The findings of this exploratory search will determine the final search strategy. The titles and abstracts of the identified articles will be screened independently be two authors for relevance. Study which pass the quality assessment will be included. Data extraction will be performed independently by two authors and in accordance with a pre-designed data extraction form. If the data allows, a meta-analysis will be performed otherwise a descriptive summary of the findings will be conducted.

DISCUSSION

The results of this review will contribute to the evidence base on VLU occurrence and may inform the decision making of healthcare professionals, policy-makers, and consumers. It will also inform future research in this area of VLU care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020205855.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018)

BACKGROUND

A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels.

AIM

To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions.

METHODS

The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23^rd-August 25^th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability.

CONCLUSION

In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

A functional circadian clock is required for proper insulin secretion by human pancreatic islet cells

AIM

To determine the impact of a functional human islet clock on insulin secretion and gene transcription.

METHODS

Efficient circadian clock disruption was achieved in human pancreatic islet cells by small interfering RNA-mediated knockdown of CLOCK. Human islet secretory function was assessed in the presence or absence of a functional circadian clock by stimulated insulin secretion assays, and by continuous around-the-clock monitoring of basal insulin secretion. Large-scale transcription analysis was accomplished by RNA sequencing, followed by quantitative RT-PCR analysis of selected targets.

RESULTS

Circadian clock disruption resulted in a significant decrease in both acute and chronic glucose-stimulated insulin secretion. Moreover, basal insulin secretion by human islet cells synchronized in vitro exhibited a circadian pattern, which was perturbed upon clock disruption. RNA sequencing analysis suggested alterations in 352 transcript levels upon circadian clock disruption. Among them, key regulators of the insulin secretion pathway (GNAQ, ATP1A1, ATP5G2, KCNJ11) and transcripts required for granule maturation and release (VAMP3, STX6, SLC30A8) were affected.

CONCLUSIONS

Using our newly developed experimental approach for efficient clock disruption in human pancreatic islet cells, we show for the first time that a functional β-cell clock is required for proper basal and stimulated insulin secretion. Moreover, clock disruption has a profound impact on the human islet transcriptome, in particular, on the genes involved in insulin secretion.

The systemic control of circadian gene expression

The mammalian circadian timing system consists of a central pacemaker in the brain's suprachiasmatic nucleus (SCN) and subsidiary oscillators in nearly all body cells. The SCN clock, which is adjusted to geophysical time by the photoperiod, synchronizes peripheral clocks through a wide variety of systemic cues. The latter include signals depending on feeding cycles, glucocorticoid hormones, rhythmic blood-borne signals eliciting daily changes in actin dynamics and serum response factor (SRF) activity, and sensors of body temperature rhythms, such as heat shock transcription factors and the cold-inducible RNA-binding protein CIRP. To study these systemic signalling pathways, we designed and engineered a novel, highly photosensitive apparatus, dubbed RT-Biolumicorder. This device enables us to record circadian luciferase reporter gene expression in the liver and other organs of freely moving mice over months in real time. Owing to the multitude of systemic signalling pathway involved in the phase resetting of peripheral clocks the disruption of any particular one has only minor effects on the steady state phase of circadian gene expression in organs such as the liver. Nonetheless, the implication of specific pathways in the synchronization of clock gene expression can readily be assessed by monitoring the phase-shifting kinetics using the RT-Biolumicorder.

The mammalian circadian timing system: synchronization of peripheral clocks

Mammalian physiology has to adapt to daily alternating periods during which animals either forage and feed or sleep and fast. The adaptation of physiology to these oscillations is controlled by a circadian timekeeping system, in which a master pacemaker in the suprachiasmatic nucleus (SCN) synchronizes slave clocks in peripheral organs. Because the temporal coordination of metabolism is a major purpose of clocks in many tissues, it is important that metabolic and circadian cycles are tightly coordinated. Recent studies have revealed a multitude of signaling components that possibly link metabolism to circadian gene expression. Owing to this redundancy, the implication of any single signaling pathway in the synchronization of peripheral oscillators cannot be assessed by determining the steady-state phase, but instead requires the monitoring of phase-shifting kinetics at a high temporal resolution.

Regulation of circadian gene expression in liver by systemic signals and hepatocyte oscillators

The mammalian circadian timing system has a hierarchical structure, in that a master pacemaker located in the suprachiasmatic nuclei (SCN) coordinates slave oscillators present in virtually all body cells. In both the SCN and peripheral organs, the rhythm-generating oscillators are self-sustained and cell-autonomous, and it is likely that the molecular makeup of master and slave oscillators is nearly identical. However, due to variations in period length, the phase coherence between peripheral oscillators in intact animals must be established by daily signals emanating directly or indirectly from the SCN master clock. The synchronization of individual cellular clocks in peripheral organs is probably accomplished by immediate-early genes that interpret the cyclic systemic signals and convey this phase information to core clock components. This model predicts that circadian gene expression in peripheral organs can be influenced either by systemic signals emanating from the SCN master clock, local oscillators, or both. We developed a transgenic mouse strain in which hepatocyte clocks are only operative when the tetracycline analog doxycycline is added to the food or drinking water. The genome-wide mapping of genes whose cyclic expression in liver does not depend on functional hepatocyte oscillators unveiled putative signaling pathways that may participate in the phase entrainment of peripheral clocks.

Approaches to sample pretreatment in the determination of perchlorate in real world samples

Perchlorate can be determined by the tandem technique of ion chromatography (IC) coupled to electrospray ionization mass spectrometry (ESI-MS). However, detection by ESI-MS can be compromised by the coelution of matrix components that can suppress the analyte signal. In addition, the presence of surface-active and other types of matrix components can cause fouling of the electrospray inlet, reducing overall signal and requiring frequent maintenance. The influences of matrix components can be minimized by using analytical columns with different selectivities, in-line diversion of separated matrix components, and off-line selective removal of matrix components via ion exchange or adsorption. This paper will discuss these sample preparation approaches for samples containing anionic species including surfactants and inorganic ions that elute in the vicinity of perchlorate.

Determination of inorganic anions in environmental waters with a hydroxide-selective column

US Environmental Protection Agency Method 300.0 specifies the use of an IonPac AS4A anion-exchange column with a carbonate-hydrogencarbonate eluent and suppressed conductivity detection for the determination of inorganic anions in environmental waters by ion chromatography. Hydroxide eluents have not typically been used for the routine analysis of common inorganic anions due to the lack of an appropriate hydroxide selective column and the difficulty in preparing contaminant free hydroxide eluents. The use of ion chromatography with a hydroxide-selective IonPac AS17 column, automated eluent generation and potassium hydroxide gradient represents a new approach to the routine determination of inorganic anions in environmental waters. This new approach, which is a modification of Method 300.0, allows equivalent method performance with improved linearity, precision, and method detection limits. The AS17 column provides superior retention of fluoride from the column void volume and improved resolution from small organic acids, such as formate and acetate, compared to the AS4A column. Quantitative recoveries were obtained for all the common inorganic anions spiked into typical environmental waters using this new approach, and the Performance Based Measurement System Tier 1 method validation quality control acceptance criteria are well within the acceptable ranges defined by Method 300.0. In addition, the EG40 eluent generator eliminates the need to manually prepare eluents, increasing the level of automation and ease-of-use of the ion chromatography system.

Synthesis and chemical properties of ibopamine and of related esters of N-substituted dopamines--synthesis of ibopamine metabolites

The therapeutic usefulness of intravenously infused dopamine in congestive heart failure and in shock prompted us to synthesize a wide series of 3,4-O-diesters of dopamine and N-substituted derivatives to obtain an orally active dopamine-like prodrug having adequate absorption and duration of action. The pharmacological results and in particular, the hemodynamic studies in the dog led to the selection of ibopamine, i.e. the 3,4-diisobutyryl ester of N-methyldopamine and to its development as a useful drug for the chronic treatment of congestive heart failure. The choice of ibopamine from among several analogs was also influenced by other favourable properties such as good chemical stability in pharmaceutical formulations and in the biopharmaceutical phases of the absorption, and fast enzymatic activation of the prodrug by plasma and peripheral tissue esterases; the latter property appeared desirable to avoid any accumulation in the central nervous system and consequent undesired side effects. The isomeric mixture of 3-O- and 4-O-isobutyrates of N-methyldopamine as well as the main conjugated metabolites, i.e. the 3-O- and 4-O-sulphate and 4-O-beta-glucuronide of N-methyldopamine were synthesized as analytical references in metabolic studies and for the investigation on their pharmacokinetic and pharmacological properties. Dopamine O-sulphates were also prepared using the methods developed for the corresponding N-methyl derivatives.