An Atypical Presentation of Acoustic Neuroma With Facial Paresthesia: A Case Report

Acoustic neuromas are benign neoplasms of the brain composed of Schwann cells, arising most commonly from the nerve sheath of the vestibular division of the VIII cranial nerve. They usually manifest as unilateral hearing loss, tinnitus, and unsteadiness. Some patients may present atypically with symptoms like orofacial pain, hemifacial numbness, sudden onset hearing loss, or trigeminal neuralgia. Here we report an interesting case of acoustic neuroma in which the patient presented with unilateral facial numbness and tooth pain. Persistent atypical symptoms should always raise clinical suspicion of this pathology, necessitating the need for higher radiological investigations (CT or MRI) to aid in the early diagnosis and treatment.

A Rare Presentation of Guillain-Barré Syndrome With Associated Horner Syndrome: A Case Report

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy involving the peripheral nervous system. Autonomic dysfunctions are well-known complications of GBS and are major contributors to mortality. Autonomic dysfunctions are classically described during the acute phase of illness. In the literature, Horner syndrome as a manifestation of GBS has been reported in very few cases. Here, we describe a case of GBS with an acute presentation of flaccid paraparesis associated with unilateral Horner syndrome. Detecting the cause of acute flaccid paraparesis with unilateral Horner syndrome poses a diagnostic challenge, making it crucial for clinicians to maintain a heightened awareness for distinguishing between GBS and its variants, as well as other potential mimics.

Mumps and Splenic Abscess: Is There a Link?

Mumps is an acute viral illness occurring in children and young adults transmitted via droplets. It is a vaccine-preventable illness caused by the mumps virus, an RNA (ribonucleic acid) virus belonging to theParamyxoviridaefamily. It typically presents with fever, parotitis, epididymo-orchitis, oophoritis, meningitis, encephalitis, pancreatitis and arthritis. Although viremia with multiorgan involvement is known to be commonly seen in mumps, there have been no reported cases of splenic abscess in a case of mumps. Here we present the case of a 16-year-old girl with unknown vaccination history who presented with fever, rash, bilateral parotid swelling, myocarditis, pneumonitis with pleural effusion and shock. Enzyme-linked immunosorbent assay (ELISA) for mumps Immunoglobulin M (IgM) antibody was positive (ratio: 7.26, reference: 1.10). She was managed conservatively with parenteral antibiotics, oxygen, inotropic support and bronchodilators. As she complained of abdominal pain in the left hypochondrium on the 13th day since onset of symptoms, ultrasound scan of abdomen was done which showed a hypoechoic lesion with internal echoes in the inferior pole of spleen (2.9 cm x 2.2 cm) suggestive of splenic abscess. Computed tomography (CT) of abdomen confirmed similar findings. The splenic abscess completely regressed with parenteral antibiotics. Therefore, one must suspect splenic abscess in a case of mumps when the presentation includes abdominal pain and tenderness so that appropriate treatment may be provided for the best outcome for the patient.

Physiological Cost Index of Walking among Non Smokers, Smokers and Smokers with Chronic Obstructive Pulmonary DiseaseAn Observational Study

Introduction: Most of the Chronic Obstructive Pulmonary Disease (COPD) patients are smokers and their disease progresses with increasing age. The energy cost of walking has strong association with aging and cigarette smoking. Its implication in COPD remains unclear. Aim: To evaluate the Physiological Cost Index (PCI) of walking among non smokers, smokers and smokers with COPD and to find its association with age and duration of cigarette smoking. Materials and Methods: The cross-sectional study was carried out in the Department of Physical medicine and Rehabilitation (PMR) at Rajah Muthiah Medical College and Hospital, Annamalai University at Chidambaram, Tamil Nadu, India, from November 2019 to February 2020. The PCI was carried out in 77 males, aged between 50-75 years with body mass index between 18.5-24.9 kg/m2 . There were 24 smokers with COPD, 27 were smokers and 26 were non smokers. The evaluation of six minute walk distance, resting, and post walk heart rate was applied in MacGregor's equation to estimate the PCI. Results: The mean PCI of smokers with COPD was 0.67±0.3 which was significantly (p-value=0.001) higher than those of smokers (0.22±0.07) and non smokers (0.14±0.04). The smokers and non smokers had no significant variation in PCI (p-value=0.122). Age had no association with PCI (p-value=0.213) whereas the duration of smoking years was found to have significant association (p=0.014). Conclusion: The PCI was found to be significantly higher in smokers with COPD and a significant association was established with years of smoking rather than age.

Effect of Short-term Respiratory Proprioceptive Neuromuscular Facilitation on Peak Expiratory Flow Rate and Six-minute Walk Test in Patients with Stable Chronic Obstructive Pulmonary Disease: A Quasi-experimental Study

Introduction: Proprioceptive Neuromuscular Facilitation (PNF) of respiratory muscles was found to improve lung function and haemodynamic parameters in mechanically ventilated patients. It has been proven that respiratory PNF had immediate significant effects in Chronic Obstructive Pulmonary Disease (COPD) patients. As pulmonary rehabilitation for COPD patients is a long-term hospital based service, there arises a need to provide a therapy that provides optimal benefit in short term. Aim: To study the effect of short term respiratory PNF on Peak Expiratory Flow Rate (PEFR) and six-minute walk test in patients with stable COPD. Materials and Methods: This quasi-experimental study was carried out in the Department of Physical Medicine and Rehabilitation, Rajah Muthiah Medical College and Hospital at Annamalai University, Chidambaram, Tamil Nadu, India. Twelve male COPD patients attending Medicine Department outpatient service between December 2020 to January 2021 were conveniently recruited. They were assessed for their PEFR using peak flow meter and exercise tolerance by six-minute walk test. They were treated with three respiratory PNF techniques namely, intercostal stretch, vertebral pressure high and anterior stretch by lifting posterior basal area for five consecutive days. Each treatment session lasted for about 30-40 minutes. The post intervention assessment of PEFR and six-minute walk was made. The pre and post intervention data were statistically analysed using paired samples t-test. Results: In this study, the mean age of the participants was 63.0 ± 5.80 years. The mean post intervention measurement of PEFR (226.67±51.09 L/min) and six-minute walk distance (271.92±50.55 m) was found to be significantly higher (p=0.001) than the mean pre interventional values (165.42±46.19; 219.58±43.24 respectively). Conclusion: Implementation of respiratory PNF techniques on short term basis optimally improves the functional exercise capacity and PEFR in patients with stable COPD.

Burden of Type 2 Diabetes and Associated Cardiometabolic Traits and Their Heritability Estimates in Endogamous Ethnic Groups of India: Findings From the INDIGENIUS Consortium

To assess the burden of type 2 diabetes (T2D) and its genetic profile in endogamous populations of India given the paucity of data, we aimed to determine the prevalence of T2D and estimate its heritability using family-based cohorts from three distinct Endogamous Ethnic Groups (EEGs) representing Northern (Rajasthan [Agarwals: AG]) and Southern (Tamil Nadu [Chettiars: CH] and Andhra Pradesh [Reddys: RE]) states of India. For comparison, family-based data collected previously from another North Indian Punjabi Sikh (SI) EEG was used. In addition, we examined various T2D-related cardiometabolic traits and determined their heritabilities. These studies were conducted as part of the Indian Diabetes Genetic Studies in collaboration with US (INDIGENIUS) Consortium. The pedigree, demographic, phenotypic, covariate data and samples were collected from the CH, AG, and RE EEGs. The status of T2D was defined by ADA guidelines (fasting glucose ≥ 126 mg/dl or HbA1c ≥ 6.5% and/or use of diabetes medication/history). The prevalence of T2D in CH (N = 517, families = 21, mean age = 47y, mean BMI = 27), AG (N = 530, Families = 25, mean age = 43y, mean BMI = 27), and RE (N = 500, Families = 22, mean age = 46y, mean BMI = 27) was found to be 33%, 37%, and 36%, respectively, Also, the study participants from these EEGs were found to be at increased cardiometabolic risk (e.g., obesity and prediabetes). Similar characteristics for the SI EEG (N = 1,260, Families = 324, Age = 51y, BMI = 27, T2D = 75%) were obtained previously. We used the variance components approach to carry out genetic analyses after adjusting for covariate effects. The heritability (h²) estimates of T2D in the CH, RE, SI, and AG were found to be 30%, 46%, 54%, and 82% respectively, and statistically significant (P ≤ 0.05). Other T2D related traits (e.g., BMI, lipids, blood pressure) in AG, CH, and RE EEGs exhibited strong additive genetic influences (h² range: 17% [triglycerides/AG and hs-CRP/RE] - 86% [glucose/non-T2D/AG]). Our findings highlight the high burden of T2D in Indian EEGs with significant and differential additive genetic influences on T2D and related traits.

Hyperemesis Gravidarum With Paraparesis and Tetany

Subacute-onset muscle weakness can result from channelopathies, inflammatory myopathies, thyroid dysfunction, hypoparathyroidism, vitamin D deficiency, and dyselectrolytemias like hypokalemia, hypocalcemia, and hypomagnesemia. We report a curious and extremely rare case of a 29-year-old woman with hyperemesis gravidarum presenting with disabling muscle weakness involving her lower limbs and trunk, and concurrent features of tetany. Following voluminous vomiting over the last two months, she presented with history of weakness of her lower limbs of 14 days duration, resulting in difficulty in her getting out of bed or walking unassisted. On examination, she was hypotensive (80/60 mmHg) and tachycardic (110 bpm), with flaccid weakness of her lower limbs (proximal weakness more than distal weakness - power of 1/5 at the hips bilaterally, and 3/5 at the knees and ankles bilaterally) and diminished deep tendon reflexes. She also had positive Trousseau’s sign and Chvostek’s sign. Interestingly, she also had thinned-out bluish sclerae, a high-arched palate, short stature, and bilateral conductive hearing loss. Laboratory evaluation revealed anemia, hyponatremia, hypokalemia, hypomagnesemia, hypochloremia, hypophosphatemia, and low vitamin D levels. Electrocardiogram showed prolonged QT interval. Her thyroid function test and parathyroid levels were normal. With parenteral replenishment of the electrolytes and vitamin D, her power improved and she was discharged on oral supplements. Thus, this case report demonstrates the importance of aggressive, early, and adequate management of hyperemesis gravidarum to prevent dyselectrolytemia-associated paraparesis.