1.Anti-NMDA-receptor encephalitis in Filipino adults: Case series and outcomes in a tertiary government hospital in the Philippines.
Rodelia C. Pascua ; Debbie Co Liquete
Philippine Journal of Neurology 2022;25(1):28-35
INTRODUCTION:
We performed a case series of all five (5) confirmed adult Filipino cases of Anti-N-Methyl-D-Aspartate
receptor (anti-NMDA-R) encephalitis in a tertiary government hospital in the Philippines admitted in the
past three years. Two cases were identified with unique features: (1) a 23-year old female who presented
with combined refractory seizures and persistent chorea and orofacial dyskinesias; and (2) a 22-year old
male who presented with refractory epilepsia partialis continuua. The rest of the patients were hereby
presented.
BACKGROUND:
In the past years, anti-NMDA-R encephalitis has been considered a diagnosis of exclusion in lieu of other
infectious causes of encephalitis. It is rare and an emerging disease with an incidence estimated at
approximately 2-3 cases per million. Recent literature recorded severe cases of anti-NMDA-R encephalitis
that presented as intractable first onset seizures, combined with hyperkinetic movement disorders, acute
psychosis without a premorbid condition, and dysautonomia.
OBJECTIVES:
To present the clinicodemographic profile and to discuss the management and outcomes of patients with
anti-NMDAR encephalitis in a tertiary hospital in the Philippines.
RESULTS:
Here, we report five confirmed cases of anti-NMDA-R encephalitis admitted in 2019-2021. The mean age is
23 years old, with 4:1 female to male ratio with a median length of hospitalization of 58 days. All patients
presented with acute psychiatric symptoms without premorbid condition, focal and generalized seizures,
decreased consciousness, dyskinesias, and autonomic instability. Four patients needed airway support for
central hypoventilation, one had first onset seizure that developed into refractory epilepsia partialis
continuua, one had persistent chorea and orofacial dyskinesia. Imaging studies of the brain included
contrast-enhanced CT Scan and MRI with unremarkable findings. No female patients had an ovarian
teratoma as revealed in the whole abdominal ultrasound. All CSF analysis for anti-NMDA-receptor was
done in the same laboratory outside the hospital which revealed positive for NMDA-receptor antibodies,
while CSF lymphocytic pleocytosis was only seen in 1/5 and protein elevation in 4/5. All of the patients
underwent electroencephalogram (EEG) studies which revealed diffuse delta-theta slowing without
epileptiform discharges. The patient who had persistent chorea and orofacial dyskinesias showed extreme
delta brush, while one had normal EEG findings. They all received high-dose steroid and intravenous
Immunoglobulin (IVIg); three patients were able to undergo Rituximab infusion. Only one female patient
had mild deficits, one female was discharged fully functional and ambulatory from being weaned off from
the mechanical ventilator, one female had aborted cardiac arrest and was discharged bedridden at GCS 10,
and two died due to the other concomitant medical conditions. The Modified Rankin Scale (MRS) and
Mini-mental Status Examination (MMSE) were used to assess the neurological and functional outcomes of
our patients.
CONCLUSION
Anti-NMDA-R encephalitis is an emerging neurological disorder that warrants early identification as it
impacts timeliness of management and long-term outcomes.
Anti-N-Methyl-D-Aspartate Receptor Encephalitis
;
Status Epilepticus
2.Severe headache, seizures and supraventricular Tachycardia in a 33-year-old Filipino male with confirmed COVID-19: A case report
Denzelle Diane M. Viray ; Ray P. Aswat ; Maria Lowella F. De Leon ; Debbie C. Liquete ; Prian Kae I. Delos Reyes
Acta Medica Philippina 2020;54(Online):1-5
COVID-19 primarily presents as a pulmonary problem, ranging from mild respiratory illness to fatal acute respiratory distress syndrome. Most common manifestations are fever (89%) and cough (72%), while headache and arrhythmia are found in 28% and 17%, respectively. We aim to present a confirmed COVID-19 case presenting with both neurologic and cardiac manifestations.
A 33-year-old Filipino male nurse initially consulted at the emergency room due to progressive diffuse headache, with associated localized seizures progressing to generalized tonic clonic seizure and arrhythmia. He had no coryza, cough, sore throat, and diarrhea. He was previously well and had no known co-morbidities or direct exposure to confirmed COVID-19 patients. Physical examination showed elevated blood pressure, tachycardia, and sensory and motor deficits in the left upper and lower extremities.
Pertinent diagnostic test results included the detection of SARS-CoV-2 viral RNA via RT-PCR. Imaging studies
demonstrated cortical venous thrombosis with hemorrhagic venous infarction in the right parietal lobe. Ground
glass appearance on the middle lobe of the left lung was also evident. ECG showed supraventricular tachycardia. Prothrombin time, activated partial thromboplastin time, and D-dimer were all within the normal limits. Carotid massage was done. He was treated with anti-epileptics, anticoagulants, antiarrhythmics, antivirals, antibiotics, and supportive management. During the hospital stay, his symptoms resolved; he was discharged after 21 days. Follow-up done after 3 weeks revealed no recurrence of severe headache, seizure, or tachycardia.
It is theorized that an interplay exists between ACE-2 tropism, systemic inflammation, cytokine storm, and hypoxemia in the background of COVID-19 infection. These mechanisms may lead to thrombosis and arrhythmia resulting to neurologic derangements and myocardial injury.
Underlying mechanisms make the cerebro-cardiovascular systems vulnerable to the coronavirus disease 2019
infection. COVID-19 should therefore be part of the differential diagnoses in patients presenting with headache,
seizures, and arrhythmias.
COVID-19
;
Headache
;
Seizures
;
Tachycardia, Supraventricular
3.Severe headache, seizures and supraventricular tachycardia in a 33-year-old Filipino male with confirmed COVID-19: A case report
Denzelle Diane M. Viray, MD ; Ray P. Aswat, MD ; Maria Lowella F. De Leon, MD ; Debbie C. Liquete, MD ; Prian Kae I. Delos Reyes, MD
Acta Medica Philippina 2023;57(8):76-80
COVID-19 primarily presents as a pulmonary problem, ranging from mild respiratory illness to fatal acute respiratory distress syndrome. Most common manifestations are fever (89%) and cough (72%), while headache and arrhythmia are found in 28% and 17%, respectively. We aim to present a confirmed COVID-19 case presenting with both neurologic and cardiac manifestations.
A 33-year-old Filipino male nurse initially consulted at the emergency room due to progressive diffuse headache, with associated localized seizures progressing to generalized tonic clonic seizure and arrhythmia. He had no coryza, cough, sore throat, and diarrhea. He was previously well and had no known co-morbidities or direct exposure to confirmed COVID-19 patients. Physical examination showed elevated blood pressure, tachycardia, and sensory and motor deficits in the left upper and lower extremities.
Pertinent diagnostic test results included the detection of SARS-CoV-2 viral RNA via RT-PCR. Imaging studies
demonstrated cortical venous thrombosis with hemorrhagic venous infarction in the right parietal lobe. Ground
glass appearance on the middle lobe of the left lung was also evident. ECG showed supraventricular tachycardia. Prothrombin time, activated partial thromboplastin time, and D-dimer were all within the normal limits. Carotid massage was done. He was treated with anti-epileptics, anticoagulants, antiarrhythmics, antivirals, antibiotics, and supportive management. During the hospital stay, his symptoms resolved; he was discharged after 21 days. Follow-up done after 3 weeks revealed no recurrence of severe headache, seizure, or tachycardia.
It is theorized that an interplay exists between ACE-2 tropism, systemic inflammation, cytokine storm, and hypoxemia in the background of COVID-19 infection. These mechanisms may lead to thrombosis and arrhythmia resulting to neurologic derangements and myocardial injury.
Underlying mechanisms make the cerebro-cardiovascular systems vulnerable to the coronavirus disease 2019
infection. COVID-19 should therefore be part of the differential diagnoses in patients presenting with headache,
seizures, and arrhythmias.
COVID-19
;
headache
;
seizure
;
supraventricular tachycardia