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Tan YJ, Siow IE, Ong CS, Narasimhalu K, Yong KP. Anti-NMDAR encephalitis in Southeast Asia - A single-centre, longitudinal study. Clin Neurol Neurosurg 2023; 231:107845. [PMID: 37390572 DOI: 10.1016/j.clineuro.2023.107845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 03/14/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
AIMS To describe the clinical features and outcomes of anti-NMDA receptor encephalitis (ANMDARE) in Southeast Asian (SEA) patients. METHOD SEA patients diagnosed and treated for ANMDARE at Singapore General Hospital between January 2010 and June 2020 were included in this observational study, in which their clinical features and outcomes were retrospectively analysed. RESULTS We studied 20 patients: 11 Chinese, 3 Tagalogs, 2 Malays, 2 Indians, 1 Eurasian and 1 Javanese. Their median age was 28 years. 15 were females, amongst whom teratomas were demonstrated in 13 (12 ovarian, 1 mediastinal). Delirium and seizures were the two commonest events leading to their presentation at our facility. 1 male had biliary neuroendocrine tumour. Comparison between genders revealed a strong male predilection for early seizures and insomnia; females were four times likelier than males to develop movement disorders or have underlying neoplasms. Patients with dysautonomia required longer ICU stay beyond 14 days, but their outcomes at 1 year did not differ. When reviewed at 1 year, none had clinical relapses, and outcomes were favourable (mRS 0-2) in nearly two-thirds. CONCLUSIONS SEA patients with ANMDARE frequently present with delirium and seizures. Underlying neoplasms are very common in females. Differences in clinical characteristics may exist between the two genders. Recognition of these can facilitate diagnosis, and permit earlier initiation of appropriate treatment strategies, and thus improve outcomes of SEA patients.
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Affiliation(s)
- You-Jiang Tan
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital), Singapore; Duke-NUS Medical School, Singapore
| | - Isabel E Siow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chiew Sern Ong
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital), Singapore; Duke-NUS Medical School, Singapore
| | - Kaavya Narasimhalu
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital), Singapore; Duke-NUS Medical School, Singapore
| | - Kok Pin Yong
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital), Singapore; Duke-NUS Medical School, Singapore.
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2
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Yeo T, Siew RWE, Gulam MY, Tye JSN, Aw AYY, Sivalingam T, Peng X, Yong KP, Saffari SE, Chao Y, Tan K. COVID-19 infection after SARS-CoV-2 mRNA vaccination in Multiple Sclerosis, AQP4-antibody NMOSD and MOGAD patients during the Omicron subvariant BA.1/2 wave in Singapore. J Neurol 2023; 270:2817-2825. [PMID: 37027019 PMCID: PMC10080502 DOI: 10.1007/s00415-023-11692-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The SARS-CoV-2 Omicron variant appears to cause milder infections, however, its capacity for immune evasion and high transmissibility despite vaccination remains a concern, particularly in immunosuppressed patients. Herein, we investigate the incidence and risk factors for COVID-19 infection in vaccinated adult patients with Multiple Sclerosis (MS), Aquaporin-4-antibody Neuromyelitis Optica Spectrum Disorder (AQP4-Ab NMOSD), and Myelin Oligodendrocyte Glycoprotein-antibody associated disease (MOGAD) during the Omicron subvariant BA.1/2 wave in Singapore. METHODS This was a prospective observational study conducted at the National Neuroscience Institute, Singapore. Only patients who had at least two doses of mRNA vaccines were included. Data on demographics, disease characteristics, COVID-19 infections and vaccinations, and immunotherapies were collected. SARS-CoV-2 neutralising antibodies were measured at various time points after vaccination. RESULTS Two hundred and one patients were included; 47 had COVID-19 infection during the study period. Multivariable logistic regression revealed that receipt of a third SARS-CoV-2 mRNA vaccination (V3) was protective against COVID-19 infection. No particular immunotherapy group increased the risk of infection, however, Cox proportional-hazards regression showed that patients on anti-CD20s and sphingosine-1-phosphate modulators (S1PRMs) had a shorter time to infection after V3, compared to those on other immunotherapies or not on immunotherapy. CONCLUSIONS The Omicron subvariant BA.1/2 is highly infectious in patients with central nervous system inflammatory diseases; three doses of mRNA vaccination improved protection. However, treatment with anti-CD20s and S1PRMs predisposed patients to earlier infection. Future studies are required to determine the protective efficacy of newer bivalent vaccines that target the Omicron (sub)variant, especially in immunocompromised patients.
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Affiliation(s)
- Tianrong Yeo
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Rachel Wan En Siew
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | | | - Janis Siew Noi Tye
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Amelia Yun Yi Aw
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | | | - Xuejuan Peng
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Kok Pin Yong
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Yinxia Chao
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Koh JS, Hoe RHM, Chen GJ, Goh Y, Tan BYQ, Yong MH, Hui ACF, Tu TM, Yong KP, Angon J, Tan K, Quek AML, Umapathi T, Seet RCS. Low incidence of neurological recurrent side-effects following COVID-19 reimmunization. QJM 2023; 116:221-226. [PMID: 36355458 DOI: 10.1093/qjmed/hcac251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Individuals who suffered a neurological adverse event after the Coronavirus disease (COVID-19) vaccine could hesitate and defer reimmunization. AIM We examine the risk of recurrence following reimmunization among patients who developed a neurological event after the first dose of the COVID-19 mRNA vaccine. DESIGN Observational study. METHODS Individuals who developed an adjudicated neurological adverse event (based on Brighton Collaboration criteria) within 6 weeks of the first dose of the COVID-19 vaccine requiring hospitalization were enrolled into a multicenter national registry in Singapore. Neurological recurrence, defined by the development of another neurological event within 6 weeks of the second vaccine dose, was reviewed. Clinical characteristics were compared between patients who chose to proceed or withhold further vaccination, and between those who received timely (3-6 weeks) or delayed (>6 weeks) reimmunization. RESULTS From 235 patients (median age, 67 years; 63% men) who developed an adjudicated neurological event after their first dose of mRNA vaccine between 30 December 2020 and 20 April 2021, 181 (77%) chose to undergo reimmunization. Those who decided against reimmunization were older (median age, 74 vs. 66 years) and had greater physical disability following their primary neurological event (46% vs. 20%, P < 0.001). Patients who suffered greater physical disability were three times more likely to delay their reimmunization (odds ratio 3.36, 95% confidence interval: 1.76-6.40). Neurological recurrence was observed in only four individuals (three with seizures and one with myasthenia gravis exacerbation). CONCLUSIONS A prior neurological event should not necessarily preclude reimmunization and the decision to proceed with reimmunization should consider the overwhelming benefits conferred by vaccination toward ending this pandemic.
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Affiliation(s)
- Jasmine Shimin Koh
- From the Department of Neurology, National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore, Singapore
| | - Rebecca Hui Min Hoe
- From the Department of Neurology, National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore, Singapore
| | - Geraldine Jiangyan Chen
- Clinical Trials and Research Unit, National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore, Singapore
| | - Yihui Goh
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Ming Hui Yong
- Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Andrew Che-Fai Hui
- Division of Neurology, Department of Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Tian Ming Tu
- Division of Neurology, Department of General Medicine, Changi General Hospital, Singapore, Singapore
| | - Kok Pin Yong
- Department of Neurology, Sengkang General Hospital, Singapore, Singapore
| | - Jasmyn Angon
- Department of General Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Kevin Tan
- From the Department of Neurology, National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore, Singapore
| | - Amy May Lin Quek
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Thirugnanam Umapathi
- From the Department of Neurology, National Neuroscience Institute (Tan Tock Seng Hospital Campus), Singapore, Singapore
| | - Raymond Chee Seong Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Healthy Longevity Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Kwan JR, Moy WL, Narasimhalu K, Yong KP. Neuronal intranuclear inclusion disease. Pract Neurol 2023; 23:246-248. [PMID: 36808080 DOI: 10.1136/pn-2022-003582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 02/22/2023]
Abstract
Neuronal intranuclear inclusion disease is a rare genetic condition, previously diagnosed only at postmortem, but its characteristic radiological features now allow its diagnosis in life. The clinical presentation is variable and we hope this case report will raise awareness of this condition.
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Affiliation(s)
- Jia Rui Kwan
- General Medicine, Sengkang General Hospital, Singapore
| | - Wai Lun Moy
- General Medicine, Sengkang General Hospital, Singapore
| | | | - Kok Pin Yong
- Neurology, National Neuroscience Institute, Singapore
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5
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Yeo T, Quek AML, Yong KP, Tye JSN, Ratnagopal P, Soon DTL, Tan K. COVID-19 infection after two doses of SARS-CoV-2 mRNA vaccine in multiple sclerosis, AQP4-antibody NMOSD and MOGAD. Mult Scler Relat Disord 2022; 65:104003. [PMID: 35803084 PMCID: PMC9233746 DOI: 10.1016/j.msard.2022.104003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/01/2022] [Accepted: 06/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND In pre-vaccinated people with multiple sclerosis (MS), certain disease-modifying therapies (DMTs), particularly the anti-CD20 treatments, appear to be associated with an increased risk of COVID-19 infection and indeed with severe infection. It is still not known if such observations extend to vaccinated individuals and there have been considerably fewer studies in aquaporin-4-antibody neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein-antibody associated disease (MOGAD) patients. In this study, we investigated the rates of symptomatic COVID-19 infection in adult patients with MS, AQP4-NMOSD and MOGAD who had received 2 doses of SARS-CoV-2 mRNA vaccine. METHODS This was a prospective observational study conducted at the 2 main neuroimmunology referral centres in Singapore. Only patients on active follow-up were recruited to ensure robust data collection. Data on demographics, disease history, DMTs and SARS-CoV-2 mRNA vaccinations were recorded, and for those infected with COVID-19, data on COVID-19 infection was collected. RESULTS Nineteen (13 MS, 5 AQP4-NMOSD, 1 MOGAD) out of 365 (231 MS, 106 AQP4-NMOSD, 28 MOGAD) patients had COVID-19 infection despite 2 doses of SARS-CoV-2 mRNA vaccine. Amongst the infected patients, 11 patients were on DMTs (3 rituximab, 2 interferons, 1 azathioprine, 1 mycophenolate, 1 prednisolone, 1 cladribine, 1 alemtuzumab, 1 fingolimod), while 8 patients were untreated. The crude infection rate was calculated using time-at-risk analysis, revealing that rituximab had the highest infection rate amongst all the DMTs. A lower crude infection rate was observed in patients who received a third vaccination. The majority of infections were mild and no patients required oxygen supplementation. CONCLUSION Our findings suggest that patients on rituximab are still at risk of COVID-19 infection after 2 vaccinations and the receipt of a third vaccination may help to prevent infection. Future large scale studies will be required to better delineate the infection risk of different DMTs after the second and subsequent vaccinations.
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Affiliation(s)
- Tianrong Yeo
- Department of Neurology, National Neuroscience Institute (Tan Tock Seng Campus), Singapore, Singapore; Duke-NUS Medical School, Singapore, Singapore.
| | - Amy May Lin Quek
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kok Pin Yong
- Duke-NUS Medical School, Singapore, Singapore; Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Janis Siew Noi Tye
- Department of Neurology, National Neuroscience Institute (Tan Tock Seng Campus), Singapore, Singapore
| | - Pavanni Ratnagopal
- Duke-NUS Medical School, Singapore, Singapore; Department of Neurology, National Neuroscience Institute (Singapore General Hospital Campus), Singapore, Singapore
| | - Derek Tuck Loong Soon
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute (Tan Tock Seng Campus), Singapore, Singapore; Duke-NUS Medical School, Singapore, Singapore
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Sim J, Yong KP, Narasimhalu K. A case of rapidly progressive insomnia and dysautonomia. Ann Acad Med Singap 2022; 51:512-513. [PMID: 36047528 DOI: 10.47102/annals-acadmedsg.202238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Jingwei Sim
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore
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Tu TM, Yi SJ, Koh JS, Saffari SE, Hoe RHM, Chen GJ, Chiew HJ, Tham CH, Seet CYH, Yong MH, Yong KP, Hui ACF, Fan BE, Tan BYQ, Quek AML, Seet RCS, Yeo LLL, Tan K, Thirugnanam UN. Incidence of Cerebral Venous Thrombosis Following SARS-CoV-2 Infection vs mRNA SARS-CoV-2 Vaccination in Singapore. JAMA Netw Open 2022; 5:e222940. [PMID: 35297971 PMCID: PMC8931554 DOI: 10.1001/jamanetworkopen.2022.2940] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Reports of cerebral venous thrombosis (CVT) after messenger RNA (mRNA)-based SARS-CoV-2 vaccination has caused safety concerns, but CVT is also known to occur after SARS-CoV-2 infection. Comparing the relative incidence of CVT after infection vs vaccination may provide a better perspective of this complication. OBJECTIVE To compare the incidence rates and clinical characteristics of CVT following either SARS-CoV-2 infection or mRNA-based SARS-CoV-2 vaccines. DESIGN, SETTING, AND PARTICIPANTS Between January 23, 2020, and August 3, 2021, this observational cohort study was conducted at all public acute hospitals in Singapore, where patients hospitalized with CVT within 6 weeks of SARS-CoV-2 infection or after mRNA-based SARS-CoV-2 vaccination (BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) were identified. Diagnosis of SARS-CoV-2 infection was based on quantitative reverse transcription-polymerase chain reaction or positive serology. National SARS-CoV-2 infection data were obtained from the National Centre for Infectious Disease, Singapore, and vaccination data were obtained from the National Immunisation Registry, Singapore. EXPOSURES SARS-CoV-2 infection or mRNA-based SARS-CoV-2 vaccines. MAIN OUTCOMES AND MEASURES Clinical characteristics, crude incidence rate (IR), and incidence rate ratio (IRR) of CVT after SARS-CoV-2 infection and after mRNA SARS-CoV-2 vaccination. RESULTS Among 62 447 individuals diagnosed with SARS-CoV-2 infections included in this study, 58 989 (94.5%) were male; the median (range) age was 34 (0-102) years; 6 CVT cases were identified (all were male; median [range] age was 33.5 [27-40] years). Among 3 006 662 individuals who received at least 1 dose of mRNA-based SARS-CoV-2 vaccine, 1 626 623 (54.1%) were male; the median (range) age was 50 (12-121) years; 9 CVT cases were identified (7 male individuals [77.8%]; median [range] age: 60 [46-76] years). The crude IR of CVT after SARS-CoV-2 infections was 83.3 per 100 000 person-years (95% CI, 30.6-181.2 per 100 000 person-years) and 2.59 per 100 000 person-years (95% CI, 1.19-4.92 per 100 000 person-years) after mRNA-based SARS-CoV-2 vaccination. Six (66.7%) received BNT162b2 (Pfizer-BioNTech) vaccine and 3 (33.3%) received mRNA-1273 (Moderna) vaccine. The crude IRR of CVT hospitalizations with SARS-CoV-2 infection compared with those who received mRNA SARS-CoV-2 vaccination was 32.1 (95% CI, 9.40-101; P < .001). CONCLUSIONS AND RELEVANCE The incidence rate of CVT after SARS-CoV-2 infection was significantly higher compared with after mRNA-based SARS-CoV-2 vaccination. CVT remained rare after mRNA-based SARS-CoV-2 vaccines, reinforcing its safety.
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Affiliation(s)
- Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Shen Jia Yi
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | - Seyed Ehsan Saffari
- Centre of Quantitative Medicine, Duke-NUS Medical School, Singapore
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | | | - Hui Jin Chiew
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | | | - Ming Hui Yong
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Kok Pin Yong
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | | | | | - Amy May Lin Quek
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Kevin Tan
- Department of Neurology, National Neuroscience Institute, Singapore
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8
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Affiliation(s)
- Kok Pin Yong
- From the Department of Neurology (K.P.Y.), National Neuroscience Institute (Singapore General Hospital); Duke-NUS Medical School (K.P.Y.), Singapore; and Department of Neurology (H.J.K.), Research Institute and Hospital of National Cancer Center, Goyang, Korea.,The Article Processing Charge was funded by the authors
| | - Ho Jin Kim
- From the Department of Neurology (K.P.Y.), National Neuroscience Institute (Singapore General Hospital); Duke-NUS Medical School (K.P.Y.), Singapore; and Department of Neurology (H.J.K.), Research Institute and Hospital of National Cancer Center, Goyang, Korea. .,The Article Processing Charge was funded by the authors.
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9
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Chuah BM, Aung TKK, Wong BSS, Yong KP. Painless Aortic Dissection Presenting with Isolated Dysphagia. Am J Med 2021; 134:e285-e286. [PMID: 33144133 DOI: 10.1016/j.amjmed.2020.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
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10
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Wong EYT, Yong MH, Yong KP, Tan EH, Toh CK, Kanesvaran R, Takano A, Ng QS. Immune checkpoint inhibitor-associated myositis and myasthenia gravis overlap: Understanding the diversity in a case series. Asia Pac J Clin Oncol 2020; 17:e262-e267. [PMID: 32985078 DOI: 10.1111/ajco.13442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) have improved survival across tumor types however they cause immune-related toxicities through removal of the inhibition of auto-reactive T cells. In this case review, we present 4 patients with metastatic cancer who developed de-novo neuromuscular side effects of myositis with overlapping seropositive myasthenia gravis after ICI treatment. Declaration: This study was performed in accordance to the ethical standards set by the SingHealth Institutional Review Board, with consent taken from living patients and waiver of consent from deceased patients (CIRB Ref 2019/2485). Supporting data were collected from our institution's digital medical records system.
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Affiliation(s)
| | - Ming Hui Yong
- Department of Neurology, National Neuroscience Institute - Singapore General Hospital Campus, Singapore
| | - Kok Pin Yong
- Department of Neurology, National Neuroscience Institute - Singapore General Hospital Campus, Singapore
| | - Eng Huat Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Chee Keong Toh
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Angela Takano
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Quan Sing Ng
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
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Lee MY, Yong KP, Hyun JW, Kim SH, Lee SH, Kim HJ. Incidence of interattack asymptomatic brain lesions in NMO spectrum disorder. Neurology 2020; 95:e3124-e3128. [PMID: 32928976 DOI: 10.1212/wnl.0000000000010847] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/22/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether aquaporin-4 (AQP4) antibody-seropositive patients with neuromyelitis optica spectrum disorder (NMOSD) develop new asymptomatic brain lesions during the interattack period. METHODS Of 296 consecutive AQP4 antibody-seropositive patients in the NMOSD database of the National Cancer Center from May 2005 to November 2019, 145 patients, who had serial brain MRI scans over an interval of at least 1 year during relapse-free period after immunosuppressive therapy, with 370 longitudinally assessed brain MRI scans were included in this study. We retrospectively analyzed them for presence of new subclinical brain lesions during the relapse-free period. RESULTS Five of 145 patients (3.4%) had detectable new, asymptomatic brain lesions in the deep white matter over a total observed relapse-free period of 708 person-years. All the lesions were smaller than 6 mm and assessed to be nonspecific. No brain lesion characteristic of NMOSD or gadolinium-enhancing lesion was identified. CONCLUSIONS Asymptomatic brain lesions are rarely observed on conventional MRI in clinically stable AQP4 antibody-seropositive patients with NMOSD after immunosuppressive therapy and brain MRI lesions characteristic of NMOSD are not seen in the relapse-free period. These findings may provide further insight regarding currently known diagnostic and disease-monitoring strategies in NMOSD.
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Affiliation(s)
- Min Young Lee
- From the Departments of Neurology (M.Y.L., J.-W.H., S.-H.K., H.J.K.) and Radiology (S.-H.L.), Research Institute and Hospital of National Cancer Center, Goyang, Korea; and Department of Neurology (K.P.Y.), National Neuroscience Institute, Singapore
| | - Kok Pin Yong
- From the Departments of Neurology (M.Y.L., J.-W.H., S.-H.K., H.J.K.) and Radiology (S.-H.L.), Research Institute and Hospital of National Cancer Center, Goyang, Korea; and Department of Neurology (K.P.Y.), National Neuroscience Institute, Singapore
| | - Jae-Won Hyun
- From the Departments of Neurology (M.Y.L., J.-W.H., S.-H.K., H.J.K.) and Radiology (S.-H.L.), Research Institute and Hospital of National Cancer Center, Goyang, Korea; and Department of Neurology (K.P.Y.), National Neuroscience Institute, Singapore
| | - Su-Hyun Kim
- From the Departments of Neurology (M.Y.L., J.-W.H., S.-H.K., H.J.K.) and Radiology (S.-H.L.), Research Institute and Hospital of National Cancer Center, Goyang, Korea; and Department of Neurology (K.P.Y.), National Neuroscience Institute, Singapore.
| | - Sang-Hyun Lee
- From the Departments of Neurology (M.Y.L., J.-W.H., S.-H.K., H.J.K.) and Radiology (S.-H.L.), Research Institute and Hospital of National Cancer Center, Goyang, Korea; and Department of Neurology (K.P.Y.), National Neuroscience Institute, Singapore
| | - Ho Jin Kim
- From the Departments of Neurology (M.Y.L., J.-W.H., S.-H.K., H.J.K.) and Radiology (S.-H.L.), Research Institute and Hospital of National Cancer Center, Goyang, Korea; and Department of Neurology (K.P.Y.), National Neuroscience Institute, Singapore.
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12
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Affiliation(s)
- Kok Pin Yong
- Department of Neurology, National Neuroscience Institute, Singapore.,Duke-NUS Graduate Medical School, Singapore.,Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
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13
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Affiliation(s)
- Kok Pin Yong
- Department of Neurology, National Neuroscience Institute, Singapore/Duke-NUS Medical School, Singapore/Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
| | - Ho Jin Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Korea
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14
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Yong KP, Lo YL. Stiff Person Syndrome Associated with Compartment Syndrome. Case Rep Neurol 2019; 11:217-221. [PMID: 31543806 PMCID: PMC6738138 DOI: 10.1159/000501793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/27/2019] [Indexed: 11/19/2022] Open
Abstract
Stiff person syndrome (SPS) is a rare and disabling neurological disorder of autoimmune origin, characterized by progressive stiffness and muscle spasms affecting the axial and limb muscles, most frequently associated with antibodies against glutamic acid decarboxylase. We describe a patient who presented initially with compartment syndrome and was later diagnosed with SPS.<b><i></i></b>This is the first case report of SPS possibly presenting initially with compartment syndrome. This case illustrates the importance of recognizing that patients with SPS may present with varied manifestations, including compartment syndrome, which by itself is a medical emergency.
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Affiliation(s)
- Kok Pin Yong
- Department of Neurology, National Neuroscience Institute, Academia, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
- *Kok Pin Yong, MB, BCh, BAO, Department of Neurology, National Neuroscience Institute, Level 4, Academia, 20 College Road, Singapore 169856 (Singapore), E-Mail
| | - Yew Long Lo
- Department of Neurology, National Neuroscience Institute, Academia, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
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Yong SYS, Teo JY, Yong KP, Goh BKP. Paraneoplastic Stiff Person Syndrome Secondary to Pancreatic Adenocarcinoma. J Gastrointest Surg 2018; 22:172-174. [PMID: 29110193 DOI: 10.1007/s11605-017-3611-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/15/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Stephanie Yu Shan Yong
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, 169856, Singapore.,National University Singapore, Yong Loo Lin School of Medicine, Singapore, 117597, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, 169856, Singapore
| | - Kok Pin Yong
- National Neuroscience Institute, Neurology, Singapore, 308433, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore. .,Duke NUS Medical School, Singapore, 169857, Singapore.
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Ting SKS, Yong KP, Hameed S. Ictal Asomatognosia With Illusory Limb Movement Secondary to Dominant Parietal Lobe Lesion. J Neuropsychiatry Clin Neurosci 2016. [PMID: 26222976 DOI: 10.1176/appi.neuropsych.15010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Simon Kang Seng Ting
- Dept. of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore
| | - Kok Pin Yong
- Dept. of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore
| | - Shahul Hameed
- Dept. of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore
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Yong KP, Tan BH, Low CY. Severe falciparum malaria with dengue coinfection complicated by rhabdomyolysis and acute kidney injury: an unusual case with myoglobinemia, myoglobinuria but normal serum creatine kinase. BMC Infect Dis 2012; 12:364. [PMID: 23256803 PMCID: PMC3557149 DOI: 10.1186/1471-2334-12-364] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 12/19/2012] [Indexed: 01/06/2023] Open
Abstract
Background Acute kidney injury (AKI) is a complication of severe malaria, and rhabdomyolysis with myoglobinuria is an uncommon cause. We report an unusual case of severe falciparum malaria with dengue coinfection complicated by AKI due to myoglobinemia and myoglobinuria while maintaining a normal creatine kinase (CK). Case presentation A 49-year old Indonesian man presented with fever, chills, and rigors with generalized myalgia and was diagnosed with falciparum malaria based on a positive blood smear. This was complicated by rhabdomyolysis with raised serum and urine myoglobin but normal CK. Despite rapid clearance of the parasitemia with intravenous artesunate and aggressive hydration maintaining good urine output, his myoglobinuria and acidosis worsened, progressing to uremia requiring renal replacement therapy. High-flux hemodiafiltration effectively cleared his serum and urine myoglobin with recovery of renal function. Further evaluation revealed evidence of dengue coinfection and past infection with murine typhus. Conclusion In patients with severe falciparum malaria, the absence of raised CK alone does not exclude a diagnosis of rhabdomyolysis. Raised serum and urine myoglobin levels could lead to AKI and should be monitored. In the event of myoglobin-induced AKI requiring dialysis, clinicians may consider using high-flux hemodiafiltration instead of conventional hemodialysis for more effective myoglobin removal. In Southeast Asia, potential endemic coinfections that can also cause or worsen rhabdomyolysis, such as dengue, rickettsiosis and leptospirosis, should be considered.
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Affiliation(s)
- Kok Pin Yong
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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