Hypertensive encephalopathy (HE) is a subset of posterior reversible encephalopathy syndrome. It typically involves the posterior supratentorial structures, but variations do occur. However, isolated brainstem involvement in HE is rare, with a few cases reported in the literature. Herein, we report a case of acute hypertensive brainstem encephalopathy in which the patient had mild symptoms with very high blood pressure and normal neurological examination. The computed tomography of the brain showed diffuse hypodensity at brainstem. The patient's symptoms improved drastically after hypertension had been controlled. Marked clinical-radiologic dissociation in this particular case was highly suggestive of hypertensive brainstem encephalopathy. Prompt recognition of the condition and aggressive treatment of hypertension in such patients is crucial to relieve oedema and to prevent life-threatening progression. Nevertheless, there is still a lack of awareness among physicians and radiologists regarding this rare clinical entity.
Cryptococcosis is an opportunistic fungal infection commonly seen in HIV cases. We present a case of disseminated cryptococcosis with multiple non-continuous infective foci in a non-HIV, non-transplant case.
Neurosyphilis is a broad term used to describe an infection caused by Treponema pallidum in the central nervous system. While this was a common cause of stroke in the 19th century, it saw a decline after the introduction of penicillin. However, in the recent past, there has been an increase in the incidence of syphilis, especially with HIV coinfection. Neurosyphilis results from an untreated primary syphilis. Neuropsychiatric disorder appears to be the commonest manifestation followed cerebrovascular accident, myelopathy, ocular disease and seizure. Known as the 'great imitator', this entity, however, may be easily missed if not for a high index of suspicion. This is especially so because of its similar presentation to other more common clinical conditions. We describe the case of a 39-year-old man displaying acute global aphasia and right-sided facial weakness in keeping with a left middle cerebral artery infarct. This was confirmed with computed tomography of the brain, and subsequently, further investigations revealed a diagnosis of neurosyphilis. The patient was treated with intravenous benzylpenicillin and recovered well with treatment.
Guillain-Barré syndrome (GBS) is an acute immune-mediated demyelinating disease. Early recognition of this disease is crucial as it can progress to life-threatening conditions such as respiratory failure or autonomic dysfunction. Typical clinical manifestations of GBS include progressive weakness of the limbs, bulbar, facial muscles and ophthalmoplegia. Sensory level and bladder dysfunction are more suggestive of acute myelopathy. We report a case of GBS presenting with acute urinary retention and T6 sensory level, which was successfully treated with plasma exchange.
Pain is common among older people. However, it remains underrecognised and under-treated. A comprehensive assessment of pain involves identifying its cause, establishing its severity, determining its impact on the person experiencing it and reviewing the person's response to treatment. Addressing their pain requires a different approach compared to a younger person because there is usually concomitant frailty, multimorbidity, polypharmacy, sensory deficits and cognitive impairment. This review will summarise a comprehensive approach to pain management in the older person.
Thiamine (vitamin B1) deficiency may present with diverse symptoms and is often triggered by chronic alcoholism, severe malnutrition or hyperemesis gravidarum. While typically diagnosed clinically, atypical presentations may delay recognition and treatment. We report a 26-year-old pregnant woman in her second trimester with prolonged nausea and vomiting since early pregnancy. She developed ascending lower limb paralysis, dysarthria, horizontal nystagmus, and lagophthalmos. Initially managed as hypokalaemia periodic paralysis with thyrotoxicosis and later Guillain-Barré syndrome (GBS), her symptoms worsened despite treatment. Subsequent MRI brain imaging revealed findings indicative of Wernicke encephalopathy, prompting high-dose thiamine therapy. This resulted in significant neurological improvement. This case underscores the importance of considering thiamine deficiency in atypical neurological presentations, particularly in pregnancy. Early recognition and prompt treatment can mitigate irreversible neurological damage, emphasising the necessity of maintaining a high index of suspicion in clinical practice.