Cerebrospinal Fluid Examination Research Articles

Rheumatoid meningitis in the absence of rheumatoid arthritis: 2 cases

Rheumatoid meningitis (RM) is a rare extra-articular manifestation of rheumatoid arthritis (RA) that has been increasingly recognized by neurologists. However, the diversity of its clinical manifestations makes its diagnosis difficult. RM does not have a unified diagnostic standard, and its link with RA needs to be studied further. Here we report two cases of RM without a history of RA. The first patient, an 80-year-old woman, presented with sudden unilateral limb weakness, with brain MR showing abnormal signals in the leptomeningeal of the right frontal parietal. Subarachnoid hemorrhage was excluded after imaging examination, and infectious meningitis was ruled out after cerebrospinal fluid (CSF) examination. The patient was diagnosed as having RM, she had increased levels of CCP and AKA, the markers of RA, but no history of the disease or other clinical manifestations of it. Another case, a 65-year-old man, was hospitalized with Bell’s palsy. We found that he had intracranial imaging changes highly consistent with those characteristic of RM during his routine examination. Except for the left peripheral facial palsy, the patient had no other neurological signs or symptoms and no RA history. After a careful physical examination, we found no joint or other manifestations or serological abnormalities consistent with RA (RF, CCP, AKA, etc.). However, after excluding infection meningitis and considering the patient’s unique imaging results, we diagnosed him as having RM. We report these two cases as references for clinical diagnosis and treatment of RM, providing a discussion of our rationale.

Resolution of anti-LGI1-associated autoimmune encephalitis in a patient after treatment with efgartigimod.

Anti leucine-rich, glioma inactivated 1 (LGI1) antibody-associated autoimmune encephalitis (AE) is the second most common AE, where the trafficking and recycling of the pathogenic immunoglobulin (IgG) can be controlled by the neonatal crystallizable fragment receptor (FcRn), making the latter as a candidate therapeutic target. Efgartigimod is an antagonist of FcRn, its ability to increase the degradation of IgGs and improve the health and quality of life of patients. ADAPT trail indicated its rapid efficacy and safety on myasthenia gravis. However, there is currently no case reported using efgartigimod for the treatment of anti-LGI1-associated AE. The patient presented with five episodes of generalized tonic-clonic seizures in the past 2weeks. The patient had no abnormal signs on magnetic resonance imaging. Electroencephalogram examinations showed an increase in bilateral symmetric or asymmetric slow activity, without any clear epileptic waves. The cerebrospinal fluid (CSF) examination results indicated a slight increase in protein (47mg/dL). The anti-LGI1 antibody titer in serum was 1:100 and that in CSF was 1:3.2. The treatment with intravenous methylprednisolone 1000mg once a day combined with levetiracetam tablets failed to completely control the patient's seizures. Thus, 10mg/kg efgartigimod was administered intravenously once a week for 2weeks. After 2weeks of treatment, serum levels of anti-LGI1 antibody and IgG decreased and the patient's epilepsy did not recur in the next 3months. This is the first case report of using efgartigimod to treat anti-LGI1-associated AE. The combination of efgartigimod and methylprednisolone resulted in favorable outcomes, indicating that this is an optional treatment plan.

Resolution of anti-LGI1-associated autoimmune encephalitis in a patient after treatment with efgartigimod.

Anti leucine-rich, glioma inactivated 1 (LGI1) antibody-associated autoimmune encephalitis (AE) is the second most common AE, where the trafficking and recycling of the pathogenic immunoglobulin (IgG) can be controlled by the neonatal crystallizable fragment receptor (FcRn), making the latter as a candidate therapeutic target. Efgartigimod is an antagonist of FcRn, its ability to increase the degradation of IgGs and improve the health and quality of life of patients. ADAPT trail indicated its rapid efficacy and safety on myasthenia gravis. However, there is currently no case reported using efgartigimod for the treatment of anti-LGI1-associated AE. The patient presented with five episodes of generalized tonic-clonic seizures in the past 2weeks. The patient had no abnormal signs on magnetic resonance imaging. Electroencephalogram examinations showed an increase in bilateral symmetric or asymmetric slow activity, without any clear epileptic waves. The cerebrospinal fluid (CSF) examination results indicated a slight increase in protein (47mg/dL). The anti-LGI1 antibody titer in serum was 1:100 and that in CSF was 1:3.2. The treatment with intravenous methylprednisolone 1000mg once a day combined with levetiracetam tablets failed to completely control the patient's seizures. Thus, 10mg/kg efgartigimod was administered intravenously once a week for 2weeks. After 2weeks of treatment, serum levels of anti-LGI1 antibody and IgG decreased and the patient's epilepsy did not recur in the next 3months. This is the first case report of using efgartigimod to treat anti-LGI1-associated AE. The combination of efgartigimod and methylprednisolone resulted in favorable outcomes, indicating that this is an optional treatment plan.

Role of Serum Procalcitonin in Monitoring the Response to Treatment of Pediatric Bacterial Meningitis

Abstract Background Early diagnosis and initial therapy are important to reduce the complications of acute bacterial meningitis (ABM). The gold standard in diagnosing bacterial meningitis is by demonstrating the presence of bacteria in cerebrospinal fluid (CSF) samples via CSF cultures. However, CSF culture requires at least a day or more, and has limited sensitivity. Serum procalcitonin (PCT) is one of the most sensitive biomarkers for identification of bacterial from non-bacterial meningitis. This study was done to evaluate serum PCT as a marker to help in ABM diagnosis specially after oral antibiotics intake or when cerebrospinal fluid (CSF) culture is negative and to assess its correlation with outcome of ABM in children. Methods This is a prospective cohort study that included children who presented to Ain Shams University Children hospital over a period of 6 months. Participants were confirmed cases of ABM (laboratory- confirmed by culture) or suspected to have ABM (presented with sudden onset high fever and signs of meningeal irritation with CSF examination showing at least one of the following: 1. turbid appearance; 2. leukocytosis (> 100cells/mm3); 3. leukocytosis (10-100 cells/mm3) and either an a) elevated protein (> 100 mg/dl) or b) decreased glucose (< 40mg/dl)). The PCT levels were measured on admission and 72hours after treatment. Results A total of 38 ABM cases participated in this study. All the 38 cases showed elevated levels of PCT on admission. There was a significant drop in the mean of PCT level after 72h of treatment compared to level on admission (7.1±6.5 vs. 11.4±3.7, p = 0.001) respectively. There was a significant difference in the mean of PCT level between cases with good outcome (full recovery) versus poor outcome (death or neurological sequalae), on admission (7.2±2.8 vs. 13.2±4.4, p < 0.001) and 72h after treatment (4.2±3.5 vs. 12.9±5.3, p < 0.001) respectively. Conclusion Serum PCT levels were high in all patients with ABM, including those who received oral antimicrobials for 1-3 days before admission. The decline in PCT levels after treatment was associated with good outcome in our cohort.

Inflammatory and immunopathological differences in brains of permissive and non-permissive hosts with Angiostrongylus cantonensis infection can be identified using 18F/FDG/PET-imaging.

Angiostrongylus cantonensis is a parasite that mainly infects the heart and pulmonary arteries of rats and causes human eosinophilic meningitis or meningoencephalitis in certain geographical areas. Current diagnostic methods include detection of the parasite in cerebrospinal fluid (CSF) and eosinophilic immune examination after lumbar puncture, which may be risky and produce false-positive results. 18F- Fluorodeoxyglucose (FDG), a Positron emission tomography (PET) tracer, has been used to assess different pathological or inflammatory changes in the brains of patients. In this study, we hypothesized that A. cantonensis infection-induced inflammatory and immunomodulatory factors of eosinophils result in localized pathological changes in the brains of non-permissive hosts, which could be analyzed using in vivo 18F-FDG PET imaging. Non-permissive host ICR mice and permissive host SD rats were infected with A. cantonensis, and the effects of the resulting inflammation on 18F-FDG uptake were characterized using PET imaging. We also quantitatively measured the distributed uptake values of different brain regions to build an evaluated imaging model of localized neuropathological damage caused by eosinophilic inflammation. Our results showed that the uptake of 18F-FDG increased in the cerebellum, brainstem, and limbic system of mice at three weeks post-infection, whereas the uptake in the rat brain was not significant. Immunohistochemical staining and western blotting revealed that Iba-1, a microglia-specific marker, significantly increased in the hippocampus and its surrounding area in mice after three weeks of infection, and then became pronounced after four weeks of infection; while YM-1, an eosinophilic chemotactic factor, in the hippocampus and midbrain, increased significantly from two weeks post-infection, sharply escalated after three weeks of infection, and peaked after four weeks of infection. Cytometric bead array (CBA) analysis revealed that the expression of TNF in the serum of mice increased concomitantly with the prolongation of infection duration. Furthermore, IFN-γ and IL-4 in rat serum were significantly higher than in mouse serum at two weeks post-infection, indicating significantly different immune responses in the brains of rats and mice. We suggest that 18F-FDG uptake in the host brain may be attributed to the accumulation of large numbers of immune cells, especially the metabolic burst of activated eosinophils, which are attracted to and induced by activated microglia in the brain. An in vivo 18F-FDG/PET imaging model can be used to evaluate live neuroinflammatory pathological changes in the brains of A. cantonensis-infected mice and rats.

Streptococcus gallolyticus subspecies pasteurianus causing late onset neonatal sepsis and meningitis: a case report

Streptococcus gallolyticus is a gram-positive microbe rarely isolated from cases of neonatal sepsis. Prompt identification, management and monitoring is necessary in such cases due to potential complications like meningitis and endocarditis. We report a preterm baby referred to us on day 18 of life with fever, respiratory distress and lethargy with seizure. Blood culture revealed S. gallolyticus subspecies pasteurianus with meningitis on cerebrospinal fluid examination. He was treated with 21 days of injectable vancomycin and teicoplanin. Baby had no neurological sequelae or other end organ complications. To the best of our knowledge, this is the first case report from eastern India describing sepsis secondary to this rare organism.

A Case Report of Cryptococcal Meningitis Presenting with Psychiatric Abnormalities

Introduction: Cryptococcal infection is a significant pathogen causing meningitis, often manifesting early with psychiatric abnormalities. Due to the lack of other specific symptoms, these behavioral changes are frequently misattributed to other mental disorders or overlooked, leading to delays in diagnosis. This article reports on the diagnosis and treatment process of a patient with cryptococcal meningitis and summarizes the abnormal behavior in terms of mental and behavioral aspects of cryptococcal meningitis patients, providing a reference for the diagnosis and treatment of cryptococcal meningitis. Case Presentation: We present a case of cryptococcal meningitis where the initial abnormal behaviors were attributed to stress, resulting in a lack of emphasis on cryptococcal treatment and subsequent failure of standard anti-infective therapy. Ultimately, we discovered abnormalities through cerebrospinal fluid examination and conducted targeted tests for Cryptococcus, resulting in a clear diagnosis and timely adoption of appropriate treatment measures. The patient's condition improved, and they were discharged. Conclusions: It is crucial for clinicians to deepen their understanding of cryptococcal meningitis. When encountering patients with unexplained fever accompanied by psychiatric and behavioral changes, a high suspicion for cryptococcal infection should be maintained.

Elizabethkingia meningoseptica Carbapenem Resistance in Cerebrospinal Fluid Cultures of Patients Suspected of Bacterial Meningitis: A Case Report

Background: Elizabethkingia meningoseptica is a Gram-negative bacterium that rarely causes meningitis in children. These infections are often resistant to carbapenem antibiotics, making diagnosis and treatment more complicated. Case presentation: A 1-month-old male patient was treated to the PICU of Dr. M. Djamil General Hospital Padang with symptoms of decreased consciousness, seizures, and fever. The patient was diagnosed with bacterial meningitis and was referred from Sungai Dareh Regional General Hospital with previous therapy for 4 days. A cerebrospinal fluid examination showed increased protein and decreased glucose, and a CT scan showed hydrocephalus. The cerebrospinal fluid culture showed growth of Elizabethkingia meningoseptica which was resistant to imipenem and meropenem. The patient was treated with a combination of non-carbapenem antibiotics and recovered from meningitis. Conclusion: Carbapenem-resistant Elizabethkingia meningoseptica is a rare causative agent of meningitis in children. Early diagnosis and treatment with appropriate non-carbapenem antibiotics are essential to increase the chance of cure.

Guillain-Barre syndrome after allogeneic hematopoietic stem cell transplantation: a case report and literature review

Guillain-Barre syndrome rarely develops after allogeneic hematopoietic stem cell transplantation (allo-HSCT), and only a few reports exist in China. Guillain-Barre syndrome is an acute and life-threatening condition that requires early diagnosis and treatment. A patient with acute myeloid leukemia underwent allogeneic HSCT for >5 months and gradually developed limb muscle weakness and limited eye movement after coexisting with delayed acute intestinal graft-versus-host disease. After the examination of cerebrospinal fluid and electromyography, the diagnosis of Guillain-Barre syndrome was confirmed. After a high-dose intravenous immunoglobulin (IVIg) treatment, muscle strength gradually recovered, and the prognosis was good.

Evaluation of Ema, Töllner and Rodwell scores in the diagnosis of neonatal sepsis

Introduction: There are no specific signs, symptoms and rapid laboratory tests to definitively diagnose sepsis in the neonatal period. This makes it difficult to diagnose sepsis in newborns in a timely manner and initiate appropriate treatment, or causes babies without sepsis to receive unnecessary antibiotics. Purpose: Therefore, in this study, we planned to investigate the clinical adequacy and reliability of EMA (European Medicines Agency), Töllner and Rodwell hematological scoring in the early diagnosis of neonatal sepsis. Method: EMA, Töllner and Rodwell hematological scoring was performed on each patient. Complete blood count, peripheral smear, C-reactive protein, procalcitonin, blood gas and blood sugar values of newborn babies with suspected sepsis were recorded, blood culture, urine culture and cerebrospinal fluid examination and cultures taken when necessary were evaluated. Using statistical analysis, the 'Positive Expected Value and Negative Expected Values' ratios of the scores were obtained, and the performance results were examined. Results: 95 newborns with a preliminary clinical diagnosis of sepsis were included in the study. These babies were divided into two groups: clinical (n:71) and proven sepsis (n:24) according to blood culture results. Positive and negative predictive values of scoring systems in definitive sepsis diagnosis; for EMA respectively; 21.5%, 56.3% for Töllner; It was determined as 31.3%, 77.8%, and 100%, 77.8% for Rodwell. Conclusion: Our study showed that clinician opinion and standard laboratory tests are limited in the diagnosis of neonatal sepsis, and Rodwell hematological scoring is more prominent in recognizing proven sepsis compared to the other two scores .

Parenchymal Neuro-Behçet's disease or Comorbid Behçet's disease with multiple sclerosis: A discriminative analysis of a complex clinical entity

BackgroundPatients with Behçet's disease (BD) may rarely manifest with cerebral white matter lesions resembling multiple sclerosis (MS). This may result in misdiagnosis due to diagnostic difficulties between parenchymal neuro-BD (pNBD) and MS. This study aims to elucidate the distinguishing features of patients with comorbid BD and MS (BD+MS) in comparison to those with pNBD and MS alone by focusing on clinical and laboratory features. We also aimed to identify the distinctive characteristics of BD+MS patients by comparing them to patients with pNBD and MS. MethodsThe methodology of this study involved a retrospective analysis of patient records followed in the Department of Neurology at the Istanbul Faculty of Medicine, Istanbul University. The study population included patients diagnosed with pNBD, MS, and a comorbid condition of BD and MS (BD+MS). We assessed clinical, radiological, and laboratory data, including disease onset, annual relapse rates, Expanded Disability Status Scale (EDSS) progression, and cerebrospinal fluid examination. Several parameters were examined between the pNBD, MS, and BD+MS patient groups to find similarities and differences between subgroups. ResultsOur study included 1,764 patients: 172 with pNBD, 1,574 with MS, and 18 with BD+MS. A predominance of females was noted in the BD+MS (72%, p < 0.001) and MS (69 %, p < 0.001) groups compared to pNBD (30 %). The median age at the onset of neurological symptoms was 35.5 (IQR: 16.8) years for BD+MS, 34.6 (13.6) years for pNBD, and 27.6 (13.3) years for MS (BD+MS vs. MS; p = 0.3, pNBD vs. MS, p = 0.7). Additionally, the number of attacks was notably different, with BD+MS patients experiencing a median of 3.5 (2.0) attacks compared to 3.0 (3.0) for MS patients and only 1.0 (1.0) for pNBD patients, suggesting a more active disease course in the MS and BD+MS groups compared to pNBD (p < 0.001). The median annualized relapse rate for BD+MS was 0.3 (0.2), which was lower than the rate of 0.4 (0.4) in MS (p = 0.048) and equivalent to the rate of 0.2 (0.3) in pNBD (p = 0.2). The time to the first relapse was similar to those with BD+MS and MS, but considerably shorter than in individuals with pNBD (p < 0.0001). The cerebrospinal fluid (CSF) analysis showed no significant differences in neutrophil and lymphocyte counts between BD+MS and MS patients but elevated levels in pNBD patients (p < 0.05). CSF protein levels were consistent across all groups (p = 0.1 and p = 0.7). Oligoclonal bands were detected in all patients with BD+MS, in the majority of MS patients (83.6 %), and a small percentage of pNBD patients (19.7 %), showing a notable distinction between the BD+MS and pNBD groups (p < 0.001). ConclusionOur study underscores the need for a skeptical approach in diagnosing and treating patients with BD who exhibit symptomatic MS-like MRI lesions. Our findings suggest that BD+MS is a distinct clinical entity, warranting specific diagnostic and treatment approaches. Our findings highlight that BD patients with MS-like lesions meeting MS diagnostic criteria should be managed as patients with comorbid MS and BD rather than pNBD.

Abnormal EEG microstates in Alzheimer's disease: predictors of β-amyloid deposition degree and disease classification.

Electroencephalography (EEG) microstates are used to study cognitive processes and brain disease-related changes. However, dysfunctional patterns of microstate dynamics in Alzheimer's disease (AD) remain uncertain. To investigate microstate changes in AD using EEG and assess their association with cognitive function and pathological changes in cerebrospinal fluid (CSF). We enrolled 56 patients with AD and 38 age- and sex-matched healthy controls (HC). All participants underwent various neuropsychological assessments and resting-state EEG recordings. Patients with AD also underwent CSF examinations to assess biomarkers related to the disease. Stepwise regression was used to analyze the relationship between changes in microstate patterns and CSF biomarkers. Receiver operating characteristics analysis was used to assess the potential of these microstate patterns as diagnostic predictors for AD. Compared with HC, patients with AD exhibited longer durations of microstates C and D, along with a decreased occurrence of microstate B. These microstate pattern changes were associated with Stroop Color Word Test and Activities of Daily Living scale scores (all P < 0.05). Mean duration, occurrences of microstate B, and mean occurrence were correlated with CSF Aβ 1-42 levels, while duration of microstate C was correlated with CSF Aβ 1-40 levels in AD (all P < 0.05). EEG microstates are used to predict AD classification with moderate accuracy. Changes in EEG microstate patterns in patients with AD correlate with cognition and disease severity, relate to Aβ deposition, and may be useful predictors for disease classification.

Cryptococcal meningitis patients associated with HIV co-infection admitted in tertiary care hospital–A Case Series

Meningitis is a significant infection of the central nervous system that is followed by inflammation of the meninges, resulting in catastrophic neurologic consequences. The inflammation may be caused by infection with viruses, bacteria, fungi, or other microorganisms and less commonly by certain drugs. Meningitis can be life-threatening because of the inflammation’s proximity to the brain and spinal cord; therefore, the condition is classified as a medical emergency. In the present case series, we encompass patient demographics, initial clinical symptoms, physical examinations, laboratory results, cerebrospinal fluid examination findings, treatment side effects, the occurrence of complications, and hospital outcomes. Furthermore, documented were any instances of recurrent cryptococcal meningitis (CM) during follow-up, along with the potential causes of recurrence, the treatment modalities administered, any complications that arose, and the ultimate outcomes. This series reveals CM can manifest alongside HIV co-infection in male patients. Therefore, it is essential to consider the possibility of CM when an immune-compromised patient presents with symptoms such as headaches and other indications of central nervous system involvement. These cases reveal cryptococcosis with HIV-infected patients for rapid and early diagnosis and appropriate treatment of opportunistic infections.

SEIZURE CONTROL IN PATIENTS WITH ANTI-NMDAR ENCEPHALITIS : CASE SERIES

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Anti N-methyl-D-aspartate Receptor (anti-NMDAR) encephalitis is a rare, yet has had increasing number of cases. Patients often require airway protection, mechanical ventilation and intensive care because the patients’ complex symptoms accompanied by seizures that are difficult to control. Here, we present two related case reports that discuss intensive care management and focus on the administered sedation/anesthesia methods and their outcomes.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Case illustration: &lt;/strong&gt;Male patients, 19 and 21 years old, presented with neuropsychiatric symptoms, seizures, dyskinesia. Both require airway protection and mechanical ventilation as well as Intensive Care Unit (ICU) care. Radiodiagnostic head Computed Tomography (CT) scan and head Magnetic Resonance Imagng (MRI) showed no cerebral abnormalities. Cerebrospinal Fluid (CSF) examination showed positive NMDAR antibodies. First patient had failed to improve clinically even with multiple anti-convulsants, ketamine, dexmedetomidine, immunotherapy, and chemotherapy. Second patient clinically improved with benzodiazepine (midazolam) and propofol as anti-convulsants followed by plasma exchange immunotherapy. The two cases had different outcomes. The first case deceased from septic shock, while the second case was treated by outpatient procedure.&lt;/p&gt;&lt;strong&gt;Conclusion : &lt;/strong&gt;Our presented cases suggest that midazolam, propofol, dextemedetomidine, ketamine do not provide satisfying results for seizure control in patients with anti-NMDAR encephalitis, unless immunotherapy is carried out as early as possible and optimally.&lt;strong&gt;&lt;em&gt;&lt;/em&gt;&lt;/strong&gt;&lt;strong&gt;&lt;/strong&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Hypocretin-1/orexin-A, sleep and excessive daytime sleepiness in patients with nonconvulsive status epilepticus: A cross-sectional cohort study

Background and objectivesNonconvulsive status epilepticus (NCSE) manifests as a change in mental status without a coma (NCSE proper) or comatose NCSE. Hypocretin-1/orexin-A (H/O) is involved in alertness and sleep maintenance. Sleep impairment and excessive daytime sleepiness (EDS) have a negative impact on cognitive functions and activities of daily living (ADL). MethodsPatients meeting the NCSE criteria underwent cerebrospinal fluid and brain magnetic resonance imaging examinations, polysomnographies (PSG), multiple latency sleep tests (MSLT), and completed Epworth Sleepiness Scale (ESS). Montreal Cognitive Assessment was used to evaluate cognitive functions, and the Barthel Index was used to assess ADL in the acute phase (V1) and three months follow-up (V2). ResultsFrom May 2020 to May 2023, we enrolled 15 patients, eight (53.3 %) women, with a median age of 69 (14) years. The median H/O CSF concentration was 250 (63.6) pg/ml; however, only three CSF samples (20 %) decreased below the borderline concentration of 200 pg/ml. Fourteen out of 15 patients (93.3 %) completed the PSG study. The median of wakefulness after sleep onset was 167 (173.5) min, sleep efficiency (SE) was 62.9 (63) %, sleep latency (SL) was 6 (32) min, REM sleep was 2.85 (7.2) %, and REM first episode latency was 210.5 (196.5) minutes. The medians of the stages N1 NREM were 4.65 (15) %, N2 NREM 68.4 (29.9) %, and N3 NREM 21.8 (35.5) %. MSLT mean latency was 7.7 (12.6) minutes. A significant negative correlation exists between H/O CSF concentrations and the stage N1 NREM (rs = −0.612, p = 0.02), and the proportion of cumulative sleep time with oxygen saturation below 90 % in total sleep time (TST) t90 (rs = −0.57, p = 0.03). MSLT had significant negative correlation with TST (rs = −0.5369, p = 0.0478), with SE (rs = −0.5897, p = 0.0265), with apnea-hypopnea index (rs = −0.7631, p = 0.0002) and with deoxygenation index (rs = −0.8009, p = 0.0006). A positive correlation exists between MSLT and SL (rs = 0.6284, p = 0.0161) and between ESS and t90 (rs = 0.9014, p = 0.0004). The correlation between H/O CSF concentrations and EDS, cognitive performance, and ADL was not proved. ConclusionsPatients after NCSE exhibited sleep impairment and excessive daytime sleepiness. Hypocretin-1/orexin-A concentrations decreased only in 20 % of these cases.

A Clinicopathological study of Guillain-Barrḗ Syndrome in a Tertiary Level Hospital

Background: Guillain-Barre syndrome (GBS) stands out as the most prevalent autoimmune neurological disorder. This investigation involves a comparative analysis of clinical observations, neurophysiological assessments, and cerebrospinal fluid examination, outcomes among patients with GBS. Method: A retrospective review of medical records constituted the methodology for this study, spanning from July 1, 2023, to December 31, 2023. Sociodemographic traits, antecedent illnesses, clinical progression, laboratory results, therapeutic interventions, and ultimate outcomes were assessed and compared among the study participants. Results: The study encompassed 8 patients, with an average age of 42.75 years. Respiratory complications were evident in 87.5% of the patients. In CSF analysis, 62.50% exhibited a normal cell count, while 37.50% displayed an elevated count. Elevated CSF protein levels were observed in 50% of patients, with a corresponding 50% revealing normal CSF protein levels. Increased CSF protein was associated with delayed lumbar puncture, demyelinating nerve conduction study subtype, and sensory motor variant. Regarding treatment modalities, 37.5% received intravenous immunoglobulin, and 25% underwent plasma exchange therapy. The acute phase of the disease resulted in a 25% mortality rate among patients. Conclusion: Guillain-Barre syndrome manifests diverse clinical presentations and laboratory findings. Notably, a high cerebrospinal fluid cell count challenges the widely accepted Brighton criteria for GBS diagnosis. Further investigations are warranted to elucidate the correlation between elevated CSF cell count and other factors influencing pathogenesis and outcomes in GBS patients. Bangladesh Crit Care J March 2024; 12 (1): 25-28

Neuroimaging Abnormalities in Patients with Subacute Sclerosing Panencephalitis : Prospective Follow-up Study.

This study aimed to assess the neuroimaging abnormalities and their progression in patients with Subacute sclerosing panencephalitis (SSPE) and identify clinical predictors of these imaging findings. This prospective observational study evaluated clinical and neuroimaging features in patients with SSPE. Patients were categorized using Dyken's criteria, Jabbour's staging system, and the definition of fulminant SSPE. They underwent comprehensive clinical assessments, cerebrospinal fluid examination, Electroencephalogram (EEG), and Magnetic Resonance Imaging (MRI) scans. Treatment involved intrathecal interferon‑α and antiepileptic medications. Functional disability was assessed using the modified Barthel index. Follow-ups were performed at 6 months, including reassessment of Modified Barthel Index (MBI) and Jabbour's staging and EEG and MRI scans. The mean age was 13.9 ± 6.7years, with males comprising 81.5% (44/54) of the cohort. Fulminant SSPE was noted in 33% (18/54) of cases. Disease duration before presentation varied significantly between fulminant and non-fulminant forms (p = 0.001). Neuroimaging abnormalities were more prevalent in JSIII stage patients, with diffuse cerebral atrophy being asignificant finding (p = 0.011). Basal ganglia involvement correlated with movement disorders. The 6‑month follow-up showed increased cerebral atrophy (p = 0.004). Increasing disease duration was an independent predictor of cerebral atrophy. An Intercomplex interval (ICI) of more than 10minutes correlated with normal neuroimaging, 10 patients died within the study period, 8 of whom had fulminant SSPE. Parieto-occipital White matter hyperintensity (WMH) is the most prevalent and sensitive neuroimaging finding for the diagnosis of SSPE. Despite interferon treatment, cerebral atrophy progressed in both aggressive and fulminant SSPE. Increasing disease duration is an independent predictor of cerebral atrophy.

Risk Factors for Stroke in Children with Tuberculous Meningitis: A Prospective Observational Study.

The purpose of the study is to establish the prevalence of stroke as well as the clinical and radiological correlates of stroke in children with tuberculous meningitis (TBM). A prospective observational study was conducted at the Pediatric Department, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India. Using a computed tomography (CT) scan/brain magnetic resonance imaging (MRI), patients were divided into stroke and non-stroke groups. Demographic characteristics, clinical presentations, cerebrospinal fluid examination, basal meningeal enhancement, hydrocephalus, tuberculoma, and clinical outcome were compared between the two groups. Seventy-eight TBM patients, aged between 6 months and 14 years, were included. Out of 78 enrolled patients, 3 (3.8%) had definite TBM, 73 (91%) had probable TBM, and 4 (5.1%) had possible TBM (LCS). As per the Medical Research Council (MRC) staging, 13% had Stage 1 TBM, 26% had stage 2, and 61% had stage 3 TBM. Out of 78 patients with chest X-ray findings, 42 (53%) had findings suggestive of tuberculosis (TB), which included 33 (42%) with hilar lymphadenopathy and 9 (11%) with a miliary pattern. On neuroimaging, hydrocephalous was seen in 62.8% of cases, basal meningeal enhancement in 64.1%, tuberculoma in 6.4% of cases, and infarction in 53.8% of cases. There was no statistically significant association found between the staging of TBM and the presence of infarction as the majority of cases involved were in stage 3 of the disease (61.5%). TBM patients with stroke had poor clinical outcomes. Age, altered sensorium, focal neurological deficits, vomiting, and basal meningeal enhancement can predict the occurrence of stroke in young adults with TBM.

CSF levels of Chitinase3like1 correlate with early response to cladribine in multiple sclerosis.

Cladribine has been introduced as a high-efficacy drug for treating relapsing-remitting multiple sclerosis (RRMS). Initial cohort studies showed early disease activity in the first year after drug initiation. Biomarkers that can predict early disease activity are needed. To estimate cerebrospinal fluid (CSF) markers of clinical and radiological responses after initiation of cladribine. Forty-two RRMS patients (30F/12M) treated with cladribine were included in a longitudinal prospective study. All patients underwent a CSF examination at treatment initiation, clinical follow-up including Expanded Disability Status Scale (EDSS) assessment, and a 3T MRI scan after 6,12 and 24 months, including the evaluation of white matter (WM) and cortical lesions (CLs). CSF levels of 67 inflammatory markers were assessed with immune-assay multiplex techniques. The 'no evidence of disease activity' (NEDA-3) status was assessed after two years and defined by no relapses, no disability worsening measured by EDSS and no MRI activity, including CLs. Three patients were lost at follow-up. At the end of follow-up, 19 (48%) patients remained free from disease activity. IFNgamma, Chitinase3like1, IL32, Osteopontin, IL12(p40), IL34, IL28A, sTNFR2, IL20 and CCL2 showed the best association with disease activity. When added in a multivariate regression model including age, sex, and baseline EDSS, Chitinase 3 like1 (p = 0.049) significantly increased in those patients with disease activity. Finally, ROC analysis with Chitinase3like1 added to a model with EDSS, sex, age previous relapses, WM lesion number, CLs, number of Gad enhancing lesions and spinal cord lesions provided an AUC of 0.76 (95%CI 0.60-0.91). CSF Chitinase 3 like1 might provide prognostic information for predicting disease activity in the first years after initiation of cladribine. The drug's effect on chronic macrophage and microglia activation deserves further evaluation.

Intracranial tuberculomas: review of MRI findings and clinical features

To present a comprehensive analysis of the clinical features and magnetic resonance imaging (MRI) findings of intracranial tuberculomas in Indonesia. This was a retrospective analysis of brain MRI from 58 patients (29 women), mean age±SD=39±2 years, diagnosed with intracranial tuberculomas. Clinical data, including symptoms, cerebrospinal fluid examination results, and MRI were also analysed. The diagnosis of intracranial tuberculoma was confirmed based on observed MRI changes following anti-tuberculosis therapy. A total of 603 tuberculomas were fully detected via MRI in all patients. Among these lesions, 507 (84%) were located in the cerebrum, 61 (10%) in the cerebellum, 19 (3%) in the basal ganglia, 12 (2%) in the brain stem, and four (1%) in the thalamus. The MRI signals were classified into two groups: tuberculomas with caseating granulomas and tuberculomas with non-caseating granulomas. Among the patients, 29 had concomitant meningitis, seven had hydrocephalus, and four had cerebral infarction. Evidence of pulmonary tuberculosis was found in 16 patients, with one patient having coexisting thoracic vertebral tuberculosis. The present study confirmed the significance of MRI as a valuable tool in the diagnosis of intracranial tuberculomas and the detection of associated abnormalities. The combination of MRI findings with clinical features can enhance the overall diagnostic accuracy for intracranial tuberculomas.