Skeletal muscle injury in COVID infection: Frequency and patterns

INTRODUCTION/AIMS

Little is known about skeletal muscle injury with coronavirus disease 2019 (COVID-19). We estimate the frequency and explore the patterns of skeletal muscle injury in acute COVID-19.

METHODS

A cohort of COVID patients with mild to moderate symptoms were evaluated in a COVID-designated hospital between May and December 2021 and followed for 2 weeks. Skeletal muscle injury was assessed according to creatine kinase (CK) levels, Manual Muscle Test-8 (MMT-8) score, and the Health Assessment Questionnaire (HAQ) score. Injury was defined as CK >200 IU/L with an MMT-8 score < 76. The association between such injury and severity and outcomes were evaluated using cross-tabulations.

RESULTS

Two hundred fifty participants with a mean age of 50.2 years (SD: 17.2) were included. One hundred nine (43.6%) were women; 84 (34%) developed severe disease. Median CK levels were 91 IU/L (IQR 56-181). [Correction added on 17 November 2023, after first online publication: In the preceding sentence, the IQR was corrected from '56,181'.] Patients with weakness on the MMT-8 (n = 247, 98.8%) and disability on the HAQ (n = 107; 42.8%) were common. Neck flexor muscles were prominently affected. Skeletal muscle injury was seen in 22.4% (95% CI: 17.4-28.1). There was no significant association between skeletal muscle injury and maximal severity of illness or short-term outcomes. Disability increased over 14 days in most survivors (n = 172, 72.3%) and this was not seen in those with mild disease (OR: 0.4, 95% CI: 0.22-0.70).

DISCUSSION

Skeletal muscle injury appears to be common in people presenting with mild to moderate COVID infection.

Bilateral Optic Neuritis and Facial Palsy Following COVID-19 Infection

Cases of optic neuritis have been reported following the novel coronavirus disease 2019 (COVID-19), with most being unilateral and associated with demyelinating illness. We report a case of a 22-year-old woman who presented with sudden onset painless diminution of vision in both eyes six weeks following COVID-19 infection. She also had a history of left lower motor neuron (LMN) facial palsy immediately following COVID-19 disease that recovered fully on steroids. Ocular examination and ancillary and laboratory investigations pointed to bilateral atypical optic neuritis. The patient responded well to the standard optic neuritis treatment protocol. We diagnosed her as a case of left LMN facial palsy and parainfectious bilateral optic neuritis following COVID-19. Parainfectious bilateral optic neuritis and facial nerve palsy associated with COVID-19 can occur following COVID-19 disease. Ours is the first case to report the occurrence of both in a patient.

Interictal autonomic changes in persons with epilepsy (PWE) on carbamazepine (CBZ) versus other anti-seizure drug monotherapy: A cross-sectional study

OBJECTIVE

Epilepsy is one of the most prevalent neurological conditions and carbamazepine is a commonly used anti-seizure drug (ASD), especially in developing nations. There are reports of carbamazepine causing atrioventricular conduction defects and autonomic dysfunctions and its implication in Sudden Unexpected Death in Epilepsy (SUDEP) is controversial. We planned this study to assess the effect of carbamazepine (CBZ) on autonomic function compared to other ASDs in persons with epilepsy.

METHODS

In this cross-sectional study, we assessed the sympathetic and parasympathetic autonomic functions in persons with epilepsy (PWE) on CBZ versus other anti-seizure monotherapy using tests of heart rate variability including its time-, frequency- and non-linear domains, heart rate response to deep breathing, valsalva maneuver, and blood pressure response to isometric handgrip.

RESULTS

Persons with epilepsy on CBZ monotherapy did not show a significant reduction in the time domain parameter SDRR compared to other ASDs used as monotherapy (mean ± SD, 38.04 ± 18.75 ms vs 44.37 ± 20.35 ms; p = 0.125). However, PWE on CBZ had significantly lower time-domain measurements including RMSSD (mean ± SD 31.95 ± 17.29 ms vs 42.02 ± 22.29 ms; p = 0.018), SDSD (mean ± SD 31.91 ± 17.26 ms vs 41.96 ± 22.27 ms; p 0.018), and pNN50 [median (IQR) 05.45(0.69-25.37) vs 16.38(2.32-36.83); p = 0.030]. Frequency domain measures of HRV, heart rate responses to deep breathing, valsalva maneuver and tilt-testing and BP responses to valsalva and tilt-testing were not significantly different between the groups.

CONCLUSION

The findings of our study indicate reduced parasympathetic activity in persons on CBZ monotherapy compared to other ASDs, which may pose risk of SUDEP. Carbamazepine may thus be avoided in those at risk of autonomic dysfunction and SUDEP.

Atherogenic Risk Factors among Young Indian Adults with Epilepsy on Treatment with Phenytoin: Need for Novel Therapeutic Strategies

Background

Risk for the development of coronary heart disease and diabetes is found to be more among people with epilepsy especially when on treatment. Redox imbalance contributes to this risk especially in India as it is the diabetic capital of the world with higher prevalence of inflammation.

Objectives

The aim of this study was to evaluate atherogenic risk factors; dyslipidemia, oxidative stress, and systemic inflammation among young Indian adults with epilepsy on treatment with Phenytoin.

Material and Methods

Three groups of age and gender-matched young subjects were recruited. Group 1-Healthy control subjects, Group 2- Newly diagnosed epileptic young adults with recent epileptic seizures, Group 3- Epileptic adults on treatment with Phenytoin for more than 6 months were recruited.

Results

Dyslipidemia was found among the newly diagnosed epileptic subjects in comparison to healthy subjects. The LDL-cholesterol further increased, and HDL-cholesterol further decreased in the third group treated with Phenytoin. Body mass index of these treated epileptic subjects was more in comparison to healthy control. Low-grade inflammation as assessed by hsCRP and oxidative stress were significantly higher among the newly diagnosed epileptic subjects when compared to the healthy controls which further increased on treatment with phenytoin. We found dyslipidemia, oxidative stress, and low-grade inflammation among newly diagnosed epileptic subjects which further increased on treatment with Phenytoin for more than 6 months.

Conclusion

From this study, we conclude that dyslipidemia, oxidative stress and low-grade inflammation are identified among the newly diagnosed young adult Indian epileptic patients. Phenytoin treatment further augmented these complications.

Magnetic Resonance Imaging in Peripartum Encephalopathy: A Pictorial Review

Acute neurological problems are significant disorders of pre- and postpartum period in women. We analyzed the magnetic resonance imaging (MRI) profile of patients presenting with peripartum encephalopathy over 2 years. Of 51 patients, MRI was abnormal in 40 patients and normal in 11 patients. Posterior reversible encephalopathy (13/40), cerebral venous thrombosis (6/40), and postpartum angiopathy (3/40) are the three most common causes of peripartum encephalopathy as identified in MRI. The other less common but important etiology include HELLP (Hemolysis, Elevated Liver enzymes and Low Platelet) syndrome (2), osmotic demyelination (2), antiphospholipid syndrome (2), tubercular meningitis/cerebritis (3), pituitary hyperplasia with hemorrhage (2), postictal edema (2), cerebellitis (1), transient splenial lesion (1), and changes of old trauma and stroke (one each).

Study of Sexual Dysfunction in People Living with Epilepsy at a Tertiary Care Center of South India

Background

The people living with epilepsy (PWE) have a higher prevalence of sexual dysfunction (sexual dysfunction) as compared to the general population. About 20-66% of the PWE develop sexual dysfunction. In spite of being so common, it is still an underdiagnosed co-morbidity in epilepsy patients.

Purpose

To estimate the proportion of sexual dysfunction among PWE, and determine the associated demographic and clinical factors.

Material and Methods

This cross-sectional study was conducted at an Epilepsy clinic of a tertiary care hospital located in South India, from March 2017 to May 2017. The PWE satisfying the inclusion criteria were given Changes in Sexual Functioning Questionnaire (CSFQ), Patient Health Questionnaire 9 (PHQ-9) and Generalized Anxiety Disorder-7 questionnaire (GAD-7). The demographic and clinical details were recorded. We estimated the proportion of sexual dysfunction, depression and anxiety and other factors associated with sexual dysfunction.

Results

After screening 3225 PWE, 108 patients were recruited. Sixtyfive (60.2%) PWE had sexual dysfunction, 64 (59.3%) had depression and 63 (58.3%) had anxiety. The sexual dysfunction had a significant association with depression (P = 0.01) and anxiety (0.04). Patients receiving sodium valproate had significantly lower rates of sexual dysfunction (P = 0.007). Other factors like seizure type, seizure frequency, enzyme inducer drugs and poly-therapy were not associated with Sexual dysfunction.

Conclusions

We found Sexual dysfunction in 60% of the PWE in our setting. The proportion of depression and anxiety was 59.3% and 58.3% respectively. The depression, anxiety, and low-valproate use were significantly associated with sexual dysfunction.

High Frequency of Depressive Symptoms among Adults with Epilepsy: Results from a Hospital-based Study

Context:

Assessment of comorbid burden of depression and associated factors among adult people living with epilepsy (PWE) has the potential to inform clinical evaluation and management to improve outcomes.

Aim:

The aim of this study is to determine frequency of depressive symptoms and factors associated with it among PWE attending a tertiary care hospital.

Setting and Design:

This was a cross-sectional observational study conducted in the outpatient clinic of a tertiary care center.

Subjects and Methods:

One hundred and fifty patients with epilepsy were recruited between May 2016 and August 2016. For assessing depression, Tamil validated version of Patient Health Questionnaire-12 was used. Frequency of depression and its association with various sociodemographic and clinical factors were assessed.

Statistical Analysis Used:

Student t-test and Chi-square test for univariate analysis and logistic regression for multivariate analysis were used for statistical analysis.

Results:

Of the 150 subjects, 89 (59.3%) were males. Generalized tonic–clonic seizures were present in 131 people (87.3%). Genetic and unknown epilepsies contributed higher proportion (44.7%) as compared to structural epilepsies (37.3%). Majority (88%) were on one or two antiepileptic drugs. Thirty-one people (20.3%) had less than one seizure per year. Depressive symptoms were present in 95 patients (63.3%). In multivariate regression analysis, secondary generalized seizures and seizure frequency >1/month emerged as significant predictors of depression ([OR]: 5.48 [95% (CI): 1.35–22.28] and OR: 2.53 [95% CI: 1.11–5.75], respectively).

Conclusion:

Depression is prevalent in a majority of adult PWE. Hence, a routine screening for depression as part of comprehensive epilepsy care is advisable for PWE attending the outpatient clinic.

Barriers of Drug Adherence among Patients with Epilepsy: in Tertiary Care Hospital, South India

Introduction: Epilepsy is a treatable and curable brain disorder. However major proportion of individuals with this disease in developing countries receives no treatment because of misunderstandings of the public. Other than that, poor adherence to ordered medication is considered the primary cause of drug therapy failure in epilepsy. This study conducted to assess the adherence pattern to antiepileptic regimen, among patients with epilepsy and to identify the clinical and patient-related factors contributing as barriers. Methods: A cross sectional survey design was used in 100 epilepsy patients in an Outpatient unit of tertiary care center. A Convenient sampling technique was used to enroll the patients who meet inclusion criteria. Structured interview with pre-tested questionnaire and eight item Morisky Medication Adherence Scale was used to collect the data. Descriptive and inferential statistics were used for analysis of data. Descriptive statistics (mean, standard deviation, frequency and percentages) were used to describe the clinical and demographic variables of study participants. The determinants of medication adherence were analyzed using Chi-Square test and independent student t- test. The analysis was done with SPSS 20th version. Results: Majority (71%) of patients were not adherent to antiepileptic treatment. Severity of seizure (indicated by the presence of seizure last year), medication frequency and complexity of treatment were found to have significant association with the Anti-Epileptic Drugs (AED) adherence status. Status of adherence is significantly associated with frequency of seizure/year and positive life style. Conclusion: As Medication adherence was observed to be low, services for adherence counseling and health educational interventions in the epilepsy clinics is recommended.

New-onset interictal headache in Persons with epilepsy (PWE): A case-control study

PURPOSE

In our personal experience, headache is a frequent complaint in Persons with epilepsy (PWE) receiving antiepileptic drugs (AEDs), carbamazepine (CBZ) in particular. There is hardly any systematic study on AEDs-associated headache. We assessed the association of new-onset interictal headache in PWE with CBZ compared with other AEDs and factors associated with it.

METHODS

Two thousand PWE on AEDs were screened, and 165 persons having new-onset interictal headache were identified. Eight persons were excluded because of comorbid illnesses that could potentially contribute to a headache. Finally, 157 were recruited for the study. One hundred fifty-seven age- and sex-matched PWE on AEDs, without headache, were recruited as controls. Headache questionnaire based on the International Classification of Headache Disorders (ICHD-II) criteria was used. Demographic factors, seizure characteristics, type and dose of AEDs, findings on electroencephalogram (EEG), and magnetic resonance imaging (MRI)/computerized tomography (CT) were recorded.

RESULTS

Among PWE with headache, the majority [88 (56.1%)] were on CBZ compared with other AEDs but not significantly different from controls. In 71 (45%) persons, the headache had migrainous character. In both univariate and multivariate analyses, lower seizure frequency and fewer EEG abnormalities were found to be independent predictors of headache.

CONCLUSIONS

New-onset interictal headache is a significant issue in PWE; nonmigrainous headache is more common than the migrainous type. Carbamazepine was not found to have any predilection for new-onset interictal headache compared with other AEDs. A lower frequency of seizures and EEG abnormalities in PWE with headache may suggest that seizures contribute less to the development of headache and may further support the hypothesis that AEDs may be significant contributing factors for the headache.

Tethered Cord Syndrome-A Study of the Short-Term Effects of Surgical Detethering on Markers of Neuronal Injury and Electrophysiologic Parameters

OBJECTIVE

Several studies have assessed clinical and radiologic outcomes after detethering of the cord for tethered cord syndrome (TCS). However, no data regarding the impact of detethering on the metabolism or electrophysiologic functioning of the cord are available. The aim of this study was to assess the changes in the cerebrospinal fluid (CSF) levels of markers of neuronal injury and alterations in the electrophysiologic functioning of the spinal cord after detethering.

METHODS

This prospective study included patients with congenital TCS. Patients underwent clinical assessment, magnetic resonance imaging, somatosensory evoked potentials (SSEP) study, and CSF biochemical analysis (to estimate lactate, glial fibrillary acidic protein, and S100B levels), before and 3 months after surgery. Clinical and radiologic outcomes were assessed. We studied changes in biochemical and electrophysiologic parameters before and after detethering as surrogate markers for the effects of this intervention.

RESULTS

Twenty-one patients were recruited over 2 years. Detethering led to clinical improvement in 75% of patients with motor deficits, 60% of patients with bladder symptoms, and 50% of patients with gait problems. At 3 months follow-up, 43% (median) of the preoperative vertical tethering was found to be corrected. There was significant reduction in CSF lactate, glial fibrillary acidic protein, and S100B levels as well as a significant decrease in the latencies of the SSEP waves 3 months after surgery.

CONCLUSIONS

Surgical detethering led to a reduction in the CSF levels of the markers of anaerobic metabolism and neuronal injury. There was also a reduction in the latencies of the SSEP waves, indicating better electrophysiologic functioning of the cord.

Sporadic Creutzfeldt-Jakob disease (sCJD) with asymmetric findings

We report a case of a patient with probable Creutzfeldt-Jakob disease (CJD) who had psychiatric manifestation in the form of withdrawn depressive behaviour at the onset, followed by rapidly progressive ataxia, parkinsonism, mutism and cognitive decline with generalised asynchronous multifocal myoclonic jerks. His EEG exhibited focal (lateralised) periodic triphasic sharp waves on the background of generalised delta slowing, which later on became more generalised. MRI of the brain showed hyperintensity in basal ganglia with cortical ribbon sign in bilateral frontal region. Clinical course showed progressive deterioration to an akinetic-abulic stage. He died 2 months after the onset of symptoms.

Refractory status epilepticus complicated by drug-induced involuntary movements

New onset refractory status epilepticus (NORSE) is a neurological emergency and difficult to treat condition. We report a case of involuntary movements resulting from thiopentone sodium infusion during the management of refractory status epilepticus. A young woman was admitted with fever and NORSE in the neurology intensive care unit. In addition to supportive measures, she was treated with intravenous lorazepam, phenytoin sodium, sodium valproate, midazolam and thiopentone sodium. While on thiopentone sodium, she developed involuntary twitches involving her upper limbs and face with EEG showing no evidence of ongoing status epilepticus. Because of the temporal relationship with thiopentone infusion, we tapered the dose of thiopentone sodium, which resulted in the disappearance of the movements. The patient recovered well with no recurrence of the seizures during the hospital stay.

Does the chronic inflammatory demyelinating polyradiculoneuropathy due to secondary cause differ from primary?

BACKGROUND

The clinical presentation, neurophysiological findings, and outcome may vary between primary and secondary chronic inflammatory demyelinating polyradiculopathy (CIDP).

OBJECTIVE

To compare clinical and electrodiagnostic features of primary and secondary CIDP.

SETTING

Tertiary care teaching referral hospital.

MATERIALS AND METHODS

The CIDP patients who were diagnosed as per European Federation of Neurological Societies/Peripheral Nerve Society criteria were included and subjected to detailed history and examinations. The clinical disability was graded on a 0-10 scale. Neurophysiology included motor and sensory nerve conductions and F wave studies of all four limbs. Based on investigations for underlying diseases, the patients were categorized into primary or secondary CIDP. Prednisolone was prescribed in all and azathioprine added in resistant cases. The secondary CIDP group received specific treatment in addition. The outcome was assessed at 3 months, 6 months, and last follow-up.

RESULTS

A total of 65 patients aged 17 to 72 years were included and 20 were females. Twenty-five patients had secondary CIDP and include diabetes mellitus (16), POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) (4), monoclonal gammopathy of undetermined significance (2), myeloma (1), lymphoma (1), and malignancy (1). The secondary CIDP patients were older (48.35 vs 41.0 years), had less relapsing remitting (0 vs 6) and more frequent dysautonomia (7 vs 1). The demyelinating features were more marked in primary CIDP group and had better outcome compared with secondary CIDP.

CONCLUSIONS

Of the total patients with CIDP, 38.5% of patients had secondary CIDP which was associated with progressive course, less demyelinating features, and worse prognosis.

Usefulness of various MRI sequences in the diagnosis of viral encephalitis

There is paucity of studies regarding the utility of various conventional MRI sequences in the diagnosis of viral encephalitis. The present study evaluates the usefulness of various MRI sequences in acute viral encephalitis. 88 consecutive viral encephalitis patients, aged 2-72 years were subjected to clinical evaluation. Consciousness was assessed by Glasgow Coma Scale (GCS). Serum or cerebrospinal fluid (CSF) was analyzed for dengue, Japanese encephalitis (JE), herpes, measles, echo, coxsackie and polio viruses using ELISA or PCR. Cranial MRI was done and T1, T2, FLAIR and DW images were obtained. The MRI changes were correlated with type of encephalitis and duration of illness. All the patients had altered sensorium and 37 had seizures. 22 patients had JE, 9 had dengue, 8 had herpes simplex encephalitis (HSE), 2 had Epstein-Barr virus encephalitis (EBVE) and 47 had non-specific encephalitis. The median duration of MRI study from onset was 10 days. In JE (20/22), HSE (8/8), and EBVE (2/2), MRI abnormalities were more common compared to dengue (2/9) and non-specific (20/47) encephalitis. The MRI abnormalities were more common in FLAIR (57.1%) compared to T2 (52.9%), DWI (38.1%) and T1 (19.3%) sequences. The mean ADC value in JE patients was lower (974.0±110.85×10⁻⁶ mm²/s) than HSE (1024.33±485.76×10⁻⁶ mm²/s). Additional MRI lesions were seen in 12.6% cases on FLAIR sequence. FLAIR and T2 sequences were more sensitive in revealing abnormalities in viral encephalitis.