Lightning strike-induced brachial plexopathy

We describe a patient who presented with a history of lightning strike injury. Following the injury, he sustained acute right upper limb weakness with pain. Clinically, the lesion was located to the upper and middle trunk of the right brachial plexus, and the same confirmed with electrophysiological studies. Nerve damage due to lightning injuries is considered very rare, and a plexus damage has been described infrequently, if ever. Thus, the proposed hypothesis that lightning rarely causes neuropathy, as against high-voltage electric current, due to its shorter duration of exposure not causing severe burns which lead to nerve damage, needs to be reconsidered

Clinico-radiological correlation between serum calcium and acute ischemic stroke

Background: Ischemic injury in stroke leads to intracellular calcium accumulation, which activates the enzyme cascade causing cell death. Aims: To determine the correlation between serum calcium (Ca) and albumin-corrected calcium (CCa) levels with acute ischemic stroke (AIS) for short-term outcome and infarct size (IS). Methods: An observational study was carried out in 50 patients in a tertiary care hospital in India over 2 years (from December 2008 to December 2010). Patients presenting within 72 h of stroke onset and aged ≥40 years were included. Ca was measured, CCa calculated, and head computed tomography (CT) scan was done. National Institute of Health Stroke Scale (NIHSS) was calculated on admission and after 1 week, and Barthel Index (BI) was calculated at 1 week. Pearson′s correlation coefficient was calculated between NIHSS, BI, and IS with both, Ca and CCa. Also, subgroup analysis was done in lacunar, lobar, anterior circulation, posterior circulation, unilateral, and bilateral stroke subgroups. Results: Ca had a significant correlation with NIHSS, BI, and IS (all patients), with BI in lacunar and unilateral strokes and both NIHSS (admission) and BI in lobar, anterior circulation, and bilateral strokes. CCa had a significant correlation with IS and with BI in all patients and in anterior circulation strokes. NIHSS (admission) and BI had a significant correlation with IS. Conclusions: Higher Ca (CCa in some subgroups) is associated with better prognosis and recovery after AIS (except in posterior circulation strokes), and higher Ca and CCa are both associated with smaller IS

A rare case of occult abdominal tuberculosis with Poncet′s disease mimicking Adult onset Still′s disease

A 50-year-old female presented with fever, symmetrical arthralgias, rash, painful oral ulcerations and alopecia since 8 weeks. Examination showed mild hepatospleenomegaly. Investigations revealed leucocytosis, neutrophilia, elevated sedimentation rate and raised ferritin levels (3850 ng/ml). Computerized tomography (CT) abdomen showed hepatospleenomegaly, mild ascitis and mild bilateral pleural-effusion. After ruling out occult infections, tuberculosis, malignancies and autoimmune diseases by appropriate investigations, and due to raised ferritin levels, adult onset stills disease (AOSD) was diagnosed. Patient responded to oral steroids initially, but after 7 days developed severe abdominal pain. Repeat CT showed multiple enlarged, necrotic and matted retroperitoneal lymph nodes with caseating granuloma on histopathology suggesting tuberculosis. Patient was given four-drug anti-tubercular treatment and she improved. Thus our patient of occult abdominal tuberculosis with reactive arthritis (Poncet′s disease) presented with hyperferritinemia mimicking AOSD. We postulate that extreme hyperferritinemia can be seen in tuberculosis and tuberculosis must be conclusively ruled out before diagnosing AOSD in tropics

Disseminated neurocysticercosis presenting as isolated acute monocular painless vision loss

Neurocysticercosis, the most common parasitic infection of the nervous system, is known to affect the brain, eyes, muscular tissues and subcutaneous tissues. However, it is very rare for patients with ocular cysts to have concomitant cerebral cysts. Also, the dominant clinical manifestation of patients with cerebral cysts is either seizures or headache. We report a patient who presented with acute monocular painless vision loss due to intraocular submacular cysticercosis, who on investigation had multiple cerebral parenchymal cysticercal cysts, but never had any seizures. Although such a vision loss after initiation of antiparasitic treatment has been mentioned previously, acute monocular vision loss as the presenting feature of ocular cysticercosis is rare. We present a brief review of literature along with this case report

Carpal tunnel syndrome: Analyzing efficacy and utility of clinical tests and various diagnostic modalities

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, but not adequately studied in India. Objectives: To study clinical tests, nerve conduction studies (NCS), ultrasonography (USG), and magnetic resonance imaging (MRI) in diagnosing CTS. Materials and Methods: We diagnosed CTS in 54 patients (93 hands) out of 60 screened patients with symptoms compatible with CTS, including 19 control patients (23 hands). We conducted provocative tests and calculated Boston Carpal tunnel Questionnaire (BCTQ) symptom (S) and function (F) scores. NCS positive patients were classified into mild, mild-to-moderate, moderate, severe, and all-CTS groups. Median nerve anteroposterior, transverse, circumference (CIR), and cross-sectional area (CSA) at inlet (I), middle (M), and outlet (O) each was measured by USG in all patients. MRI was done in 26 patients (39 hands). Results: Phalen, hand elevation and pressure provocation tests had higher sensitivity, Tinel's test had higher specificity and tethered median nerve and tourniquet tests had low sensitivity and moderate specificity. USG had low sensitivity but high specificity, and MRI had moderate sensitivity. USG in patients compared to controls was significantly abnormal in CSA-I, CIR-I, and CSA-O. Significant correlation was found between BCTQ-S and NCS and BCTQ-S and CIR-O. CIR-M, CIR-O, CSA-M, and CSA-I had correlation with NCS. MRI was significant in moderate and in moderate + severe groups combined and associated pathologies were detected in 59% patients. Conclusion: NCS remain gold standard but USG and MRI help increase sensitivity and detect mass lesions amenable to surgery