BACKGROUND: This paper synthesizes two unique cases of an adult Filipino patient presenting with involuntary unilateral extremity movements which upon further workup revealed cerebral toxoplasmosis as their primary etiology, further revealing their immunocompromised states. To our best knowledge there is limited available data on cerebral toxoplasmosis in our local setting.
RATIONALE AND OBJECTIVES: The Filipino population is not spared from the pervasive global upsurge of AIDS cases as well as HIV-related infections. The aim of this report is to document the clinical features and diagnostics of two patients with cerebral toxoplasmosis presenting with unilateral involuntary extremity movements to heighten the level of awareness of Filipino physicians on the need to further explore possible etiologies of common neurological signs and symptoms as well as document additional cases of HIV-related infection in our country.
CASE DESCRIPTION: The first case is a 30 year old male with no comorbidities who presented with fever and sudden onset of choreoathetoid movements of the left extremities. MRI revealed a rim enhancing nodule in the left supraorbital frontal lobe and in the middle cerebral peduncle. The second case is a 40 year old male, known hypertensive, initially diagnosed to have pulmonary tuberculosis, who presented with sudden onset of focal left arm myoclonic jerks. MRI revealed a rim enhancing cortical nodule on the right precentral gyrus. Both lesions were consistent with characteristics of toxoplasmosis. Both patients also showed positive serological titers for toxoplasmosis and had low CD4 T-cell count on flow cytometry. Both patients were treated with high dose trimethoprim-sulfamethoxazole and were further worked up for HIV-related infections.
CONCLUSION: Majority of Filipino patients are still not provided with the opportunity to be diagnosed and treated for HIV-related infections, with one reason being the low index of suspicion for such cases. There is still limited amount of data available locally regarding patients presenting with Cerebral Toxoplasmosis, and that common neurological signs and symptoms as presented in this report should provide the much needed enlightenment in a physician's clinical eye to entertain such etiologies.

Human ; Male ; Adult ; Acquired Immunodeficiency Syndrome ; Cd4-positive T-lymphocytes ; Cerebral Peduncle ; Hiv Infections ; Myoclonus ; Toxoplasmosis, Cerebral ; Trimethoprim, Sulfamethoxazole Drug Combination ; Tuberculosis, Pulmonary ; Chorea

Coronary heart disease, which includes acute coronary syndromes (ACS) is a major cause of death and morbidity. Treatment for this condition includes dual anti-platelet treatment combined with an anti-coagulant and an anti-dyslipidemic. Bleeding complications may occur and one fatal adverse event is intracerebral hemorrhage (ICH). ACS cases in a tertiary hospital for the years 2014-2018 showed that there were 7 patients who presented with symptomatic ICH after treatment administration that accounts for 0.01% of a total of 1,097 patients. These patients were over the age of 50, but with no sex predilection. Common comorbidities were hypertension and malignancy. All patients presented with acute onset neurologic deficits within 1-4 days after administration of ACS regimen, with ICH scores of 3-4 signifying a high mortality rate of 72-90%. 6 out 7 patients had significant volume of ICH with mass effects, and 1 with subarachnoid hemorrhage. This lead to poor outcome in all patients with 6 out of 7 mortalities and 1 left with substantial disability. It was found that given the total number of patients administered with the said treatment, there is a low incidence of ICH.
Myocardial Infarction

OBJECTIVE: To describe the profile, management, and outcome of adult patients admitted for tetanus. METHODOLOGY: A search of the hospital and department database was conducted for patients with admitting or final diagnosis of tetanus. Patients below 19 years old, with alternative diagnosis, incomplete or unavailable records, transferred to another institution, and went home against medical advice were excluded. Data on patient demographics, source of infection, symptom severity, and management were obtained. Data was described using proportions and averages. RESULTS: Thirty-two patients were included in the study. Twenty-seven were male with a mean age of 45.63 ± 13.39. All cases had no history of tetanus vaccination. The most common focus of infection was acute injuries. More than half of patients would be diagnosed within 72 hours of symptom onset. The most common symptoms on presentation were trismus, rigidity, dysphagia, and spasms. On admission, Cole severity for 11 (34.4%) cases was mild, 17 (53.1%) moderate, and 4 (12.5%) severe. Prophylactic tracheostomy was performed in 31 patients and 19 (59.4%) were placed on assisted ventilation. All cases were treated with metronidazole. A benzodiazepine was started in all cases for spasm control. Baclofen, magnesium sulfate, and antiepileptic drugs such as carbamazepine were also used. Twenty (62.5%) patients suffered from complications, the most common of which was nosocomial pneumonia, which resulted in longer ICU and hospital stays. Eleven patients exhibited progression in Cole severity: 8.6% at stage 1, 57.1% at stage 2, and 34.3% cases were at stage 3. Mortality rate was 19% with the proportion increasing with Cole severity. CONCLUSION We describe the presentation and course of patients admitted for tetanus in our institution. Most cases were males and all cases had no vaccination history. Trismus was the most common presenting symptom. Metronidazole was the antibiotic of choice and benzodiazepines were the mainstay for spasm control. Majority of cases were mild to moderate in severity on presentation. Advanced disease stages were associated with higher fatality rates. Complications were associated with longer ICU and hospital stay. These findings suggest that prevention of progression of disease severity and complications must be the focus of tetanus protocols to shorten hospital stay and decrease mortality rate. Promoting vaccination of at-risk adults is recommended to lower the incidence of tetanus.
Tetanus ; Clostridium tetani ; Clostridium Infections

BACKGROUND: Despite the availability of clinical guidelines for stroke, variation exists in the management patterns of stroke among neurologists.
OBJECTIVE: To determine the current practice patterns of Filipino adult neurologists in stroke and their adherence to the current clinical guidelines of the Stroke Society of the Philippines (SSP).
METHODS: Cross-sectional survey using a 3-page, 17-item questionnaire reviewed by the Stroke Council of the Philippine Neurological Association (PNA).
RESULTS AND OBSERVATIONS: From November 2013 to July 2014, 136 of 277 (49%) locally practicing board certified adult neurologists of the PNA were surveyed. Some important findings from the survey include: (1) 70% of respondents underestimated the benefit of warfarin in stroke prevention in nonvalvular atrial fibrillation (NVAF); (2) for acute ischemic stroke, although the recommended systolic blood pressure (SBP) threshold is >220 mm Hg, 43% would initiate antihypertensive therapy at SBP >180 mm Hg; (3) for acute primary intracerebral hemorrhage (ICH), 42% would start antihypertensives at SBP >140 mm Hg; (4) despite the absence of guidelines recommending the use of neuroprotectant drugs for acute stroke, 75% and 56% of neurologists have prescribed it to >80% of their patients with infarcts and ICH respectively; (5) 46% of neurologists have not experienced giving thrombolytic therapy to any of their patients with acute ischemic stroke; (6) among patients with clinically stable hemorrhagic strokes, 77% of neurologists would give antithrombotics, while 28% of them would start it 30 days after the onset of stroke; (7) only 21% of respondents have ordered carotid studies as part of their work up in >80% of their patients with ischemic strokes; and (8) 64% of respondents have requested carotid revascularization procedures for patients with significant carotid stenosis, and about 38% of these patients underwent the procedure.
CONCLUSION: The management patterns in stroke remain varied among Filipino neurologists, although the patterns show increasing adherence toward guideline recommendations. The following practices are noted: underestimation of the benefits of oral anticoagulation for stroke prevention among patients with NVAF; use of pharmacologic control of blood pressure below the recommended threshold for acute ischemic stroke; widespread use of neuroprotectant drugs despite lack of definite evidence for its use; low utilization of carotid studies in the work-up of patients with ischemic stroke and the low rate of revascularization procedures in confirmed cases of carotid stenosis; and a relative increase in experience with thrombolysis.

Practice Guideline ; Surveys and Questionnaires ; Stroke

Sulodexide was evaluated in an investigator-initiated, multi-center, randomized, controlled, open-labeled study to determine its safety and tolerability profile, and effect on the neurological recovery and functional outcome of patients with acute ischemic stroke. Sixty-five (65) patients were randomized to Standard care group and 46 to Standard care plus Sulodexide Treatment group. Sulodexide was observed to be safe and well-tolerated among patients included in this study. Although not statistically significant, Modified Rankin Scale Responder Analysis consistently showed higher proportions of functionally improved patients in the Sulodexide group than in the Standard Care group on treatment days 10, 30, and 90 respectively.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Glucuronyl Glucosamine Glycan Sulfate ; Research Personnel ; Stroke ; Glycosaminoglycans

Background: Status epilepticus (SE) is a neurological emergency requiring prompt evaluation and management to prevent disease refractoriness associated with significant mortality and morbidity. Thus, estimating costs attributable to the treatment of SE is important because of the severity of this disease. In the Philippines, healthcare provisions are mostly out-of-pocket expenses; hence the cost of treatment is a critical determinant for disease management. Unfortunately, the availability of data regarding the cost of illness of SE in developing countries is limited. Objectives: To determine the frequently used anticonvulsant drug regimen and direct inpatient costs of acute treatment for status epilepticus within five years in a private tertiary hospital in the Philippines. Methods: Records from patients diagnosed with SE who were admitted under or referred to the Adult Neurology Service in a private tertiary hospital from January 2015 to December 2019 were retrospectively evaluated. The SE type was classified as non-refractory (NRSE), refractory (RSE), and super refractory (SRSE). Demographic data, clinical features, SE type, etiology, antiepileptic drugs (AEDs) and anesthetic drugs used, total cost of AEDs and anesthetic drugs, total cost of 5-day hospitalization, and total cost of entire length of stay were recorded. Results: We retrieved the records of 61 patients admitted for SE. Of these patients, 23 were classified as nonrefractory, 20 as refractory, and 18 as super refractory. Diazepam was given to all SE patients as first-line treatment. Valproic acid and levetiracetam were used as second-line treatments. The most frequently given anesthetic drug was midazolam. The mean hospitalization cost per patient was ₱52,0982.3 for SE, ₱659,638.7 for RSE, and ₱134,1451 for SRSE. The mean cost of 5-day hospitalization was ₱193,572.3 for NRSE, ₱358,808.5 for RSE, and ₱652,781 for SRSE. The mean cost of medications was ₱18,546 for NRSE, ₱30,780 for RSE, and ₱128,263 for SRSE. Conclusion The direct cost of SE varied depending on subtype and response to treatment. Costs increased with disease refractoriness. Direct inpatient treatment costs for SRSE were twice as high as that of NRSE and RSE.
epilepsy ; status epilepticus ; hospitalization

Background & Objective: Currentlythere is limitedintervention for acute ischemic stroke. Recombinant tissue plasminogen activator (rTPA) has been approved for immediate recanalization after a steno-occlusive lesion of cerebral vessels. rTPA has shown its efficacy and safety from several clinical trials. The present study reports our experience with intravenous rTPA from several centers in the Philippines.Method:This is a retrospective cohort study consisting of 157 patients who qualified to receive rTPA following the NINDS trial inclusion and exclusion criteria. The primary outcome is in-hospital and 3-months mortality. Other outcome measures were determined: intracranial hemorrhage secondary to hemorrhagic conversion and functional outcome as measured by modified Rankin Scale. Additionally, standard dose (0.9mg/kg) was compared to low dose (0.6mg/kg) of rTPA in terms of mortality, intracranial bleeding and functional outcome.Results:The in-hospital mortality was seen in 23 (14.6%) and total death within 3 months was 18.3%. Independent patient (mRS 0-2) was seen in 69 (51.1%) at discharge and 95 (73.1%) at 3 months. Intracranial bleeding due to asymptomatic hemorrhagic transformation occurred in 39 (24.8%) and symptomatic hemorrhagic transformation was seen in 19 (12.1%).Conclusion: Comparing our results with SITS-MOST and Cochrane collaborations, our data showed that we have more independent patients however death and intracranial bleeding was noted to be high in our cohort of patients. Additionally, the study showed more independent patients in the low dose group.

Introduction. Migraine is a common, debilitating primary headache. Memantine is a non-competitive N-methyl D-aspartate (NMDA) antagonist that lowers neuronal excitability that could prevent migraine attacks. This study aimed to determine the efficacy and safety of memantine in patients with episodic migraine attacks using a systematic review and meta-analysis.

Methods. We searched CENTRAL, MEDLINE, Scopus, Cochrane, LILACS, ClinicalTrials.gov, HERDIN and Google Scholar for relevant studies until July 31, 2020. Prespecified screening and eligibility criteria for inclusion were applied. Included studies underwent methodological quality assessment. Study design, patient characteristics, interventions given, and relevant outcomes were extracted and synthesized.

Results. This review included five relevant articles - two randomized controlled trials (RCT) and three non randomized studies (one retrospective records review and survey, two prospective open-label single-arm trials). There were 109 patients included in the RCTs and 197 patients reported in the non-randomized studies. Pooled data from the two RCTs showed that memantine at 10 mg/day significantly decreased the monthly number of migraine days at 12 weeks compared to placebo with a mean difference of -1.58 [95% confidence interval (CI) -1.84, -1.32]. Non-randomized studies also showed a decrease in migraine days per month with memantine (5 to 20 mg/day) after 12 weeks [95% CI]: -9.1 [-11, -7.23], -7.2 [-8.85, -5.55], and -4.9 [-6.29, -3.51]. Adverse drug events (ADE) did not differ significantly between patients treated with memantine compared to placebo.

Conclusion. Memantine may be effective and well-tolerated as prophylaxis for episodic migraine.

Memantine ; Episodic migraine ; Systematic Review ; Meta-Analysis