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Displaying publications 41 - 54 of 54 in total

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Disease-modifying therapies enter the World Health Organization Essential Medicines List: A victory now requiring a roadmap of implementation

Yamout BI, Viswanathan S, Laurson-Doube J, Sokhi D

Mult Scler, 2024 Jan;30(1):3-6.
PMID: 37850437 DOI: 10.1177/13524585231205970
Fulltext A Rare Case of Isolated Abducens Nerve Palsy With Contemporaneous Thalamic Infarct

Zhong Yang L, Ngoo QZ, Viswanathan S, Sudarno R

Cureus, 2024 Mar;16(3):e56268.
PMID: 38623103 DOI: 10.7759/cureus.56268

We report a case of isolated left abducens nerve palsy accompanying a right thalamic infarct. The patient, a 43-year-old Malay male with newly diagnosed hypertension, diabetes mellitus, and dyslipidemia, initially reported binocular diplopia on left lateral gaze persisting for five weeks. Subsequently, he experienced acute left-sided body weakness and slurred speech for over one day. Clinical examination revealed restricted left eye lateral gaze (-3) with no relative afferent pupillary defect. Additionally, decreased power (4/5) was noted in the left upper and lower limbs. Brain magnetic resonance imaging (MRI) revealed restricted diffusion in the right thalamus extending to the right posterior internal capsule, left anterior cingulate gyrus, and left caudate nucleus. The patient was initiated on antiplatelet, antihypertensive, and oral hypoglycemic agents, resulting in symptom improvement. This rare neuroophthalmological finding has not been reported previously.
Therapeutic Plasma Exchange in Neuromyelitis Optica Spectrum Disorders and Related Disorders in Resource-Limited Settings: Outcomes in a Multiethnic Single-Center Population

Ong ZM, Schee JP, Viswanathan S

Ther Apher Dial, 2020 Jun;24(3):312-323.
PMID: 31654607 DOI: 10.1111/1744-9987.13446

We evaluated therapeutic plasma exchange (TPE) efficiency in treatment of a single relapse in steroid-refractory patients with neuromyelitis optica spectrum disorders (NMOSD) in a multi-ethnic resource-limited setting. This was a historical cohort study on the clinical outcomes post-TPE in a multiethnic cohort of 53 steroid-refractory NMOSD patients at a single Malaysian tertiary center. Primary outcomes, assessed both pre- and post-TPE, were Medical Research Council scale of muscle power, Modified Rankin Scale, Expanded Disability Status Scale (EDSS), and visual acuity. Secondary outcomes were ambulatory status and target neurological deficit (TND)-based TPE response. Significant improvements in Medical Research Council, Modified Rankin Scale, EDSS, and visual acuity (P 14 days (P = 0.047) were significantly associated with improved EDSSΔ6. TND-based TPE response was significant in absence of cord atrophy (P = 0.030). TPE is an effective treatment for steroid-refractory acute relapses of NMOSD in a multiethnic Malaysian population despite its resource-limited setting. The predictive factors of EDSSΔ6 improvement were anti-aquaporin 4 seronegativity, longer cord lesions, and higher pre-TPE EDSS. Absence of cord atrophy was predictive of better TND-based TPE response. Unexpectedly, our study showed that delayed TPE initiation of more than 14 days and up to 60 days may also be beneficial.
Acute disseminated encephalomyelitis complicating dengue infection with neuroimaging mimicking multiple sclerosis: A report of two cases

Viswanathan S, Botross N, Rusli BN, Riad A

Mult Scler Relat Disord, 2016 Nov;10:112-115.
PMID: 27919476 DOI: 10.1016/j.msard.2016.10.001

Acute disseminated encephalomyelitis (ADEM) complicating dengue infection is still exceedingly rare even in endemic countries such as Malaysia. Here we report two such cases, the first in an elderly female patient and the second in a young man. Both presented with encephalopathy, brainstem involvement and worsening upper and lower limb weakness. Initial magnetic resonance imaging (MRI) of the brain was normal in the first case. Serum for dengue Ig M and NS-1 was positive in both cases. Cerebrospinal fluid (CSF) showed pleocytosis in both with Dengue IgM and NS-1 positive in the second case but not done in the first. MRI brain showed changes of perpendicular subcortical palisading white matter, callosal and brainstem disease mimicking multiple sclerosis (MS) in both patients though in the former case there was a lag between the onset of clinical symptoms and MRI changes which was only clarified on reimaging. The temporal evolution and duration of the clinical symptoms, CSF changes and neuroimaging were more suggestive of Dengue ADEM rather than an encephalitis though initially the first case began as dengue encephalitis. Furthermore in dengue encephalitis neuroimaging is usually normal or rarely edema, haemorrhage, brainstem, thalamic or focal lesions are seen. Therefore, early recognition of ADEM as a sequelae of dengue infection with neuroimaging mimicking MS and repeat imaging helped in identifying these two cases. Treatment with intravenous steroids followed by maintenance oral steroids produced good outcome in both patients.
Fulltext Anti-NMDAR Encephalitis in Association with Herpes Simplex Virus and Viral and Bacterial Zoonoses

Yan Hung SK, Hiew FL, Viswanathan S

Ann Indian Acad Neurol, 2019 1 30;22(1):102-103.
PMID: 30692769 DOI: 10.4103/aian.AIAN_232_18

Multiple co-infections can predispose a patient to autoimmune encephalitis. Out of thirty cases of N-methyl-D-aspartate receptor (NMDAR) encephalitis seen at a single tertiary referral center, only two cases of co-infection with NMDAR encephalitis were identified. One of these cases was highly interesting due to the presence of more than one co-infections along with the presence of cortical dysfunction, seizures, and orofacial dyskinesias at the onset in a male in the absence of tumors, which was refractory to initial treatment.
Pure spinal multiple sclerosis: A possible novel entity within the multiple sclerosis disease spectrum

Schee JP, Viswanathan S

Mult Scler, 2019 07;25(8):1189-1195.
PMID: 29771191 DOI: 10.1177/1352458518775912

We identified five female patients retrospectively with relapsing short-segment partial myelitis whose clinical and paraclinical features were suggestive of cord involvement of multiple sclerosis (MS)-type albeit not rigidly fulfilling the 2017 McDonald criteria. Notably, these patients had not developed any typical MS-like brain lesions despite repeated neuroimaging assessments over years. Comprehensive work-up for differential diagnoses of MS and other causes of transverse myelitis particularly neuromyelitis optica spectrum disorders had been consistently negative on longitudinal follow-up. Thus, we postulate a possible entity of pure spinal MS which may represent a novel forme fruste within the MS disease spectrum.
A nationwide epidemiological study on the prevalence of multiple sclerosis and neuromyelitis optica spectrum disorder with important multi-ethnic differences in Malaysia

Viswanathan S, Wah LM

Mult Scler, 2019 10;25(11):1452-1461.
PMID: 30113245 DOI: 10.1177/1352458518792430

OBJECTIVES: This study looked at observed crude prevalence/incidence of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) in Malaysia and identified any inter-ethnic differences for MS/NMOSD.
METHODS: This was a nationwide tertiary hospital-based retrospective cross-sectional study using the capture-recapture method. It looked at the estimated crude prevalence of confirmed MS and NMOSD and annual incidence on 29 December 2017. Recapture of data was done between February and March 2018 on 1 March 2018. Public and referring private institutions were accessed.
RESULTS: The survey identified 767 MS and 545 NMOSD subjects, with crude prevalence rates of 2.73 per 100,000 (95% confidence interval (CI): 2.53; 2.92 per 100,000 population) and 1.94 per 100,000 (95% CI: 1.77; 2.10 per 100,000 population) with observed crude annual incidence of 0.55 (95% CI: 0.43; 0.58) for MS and 0.39 per 100,000 (95% CI: 0.35; 0.47) for NMOSD. The MS:NMOSD ratios were 1.4:1.0. The capture-recapture method revealed 913 MS (95% CI: 910; 915.9) and 580 (95% CI: 578.8; 581.2) NMOSD with prevalence per 100,000 of 3.26 (95% CI: 3.05; 3.47) and 2.07 (95% CI: 1.90; 2.24), respectively. In the MS group, 59.4% were Malay, 16.6% Chinese, 20.5% Indian, and 3.5% were from indigenous groups. In the NMOSD group, 47.3% were Malay, 46.9% Chinese, 3.5% Indian, and 2.3% were from other indigenous groups. The ratio of NMOSD to MS among the Chinese was 2:1, but the ratio of MS to NMOSD among the Malays was 1.8:1, and that in Indians was 8.3:1.
CONCLUSION: There is a modest increase in the prevalence of MS and NMOSD in Malaysia with inter-ethnic differences for MS/NMOSD.
A call for more research and global collaboration in South-East Asia to address challenges of DMT access and MS management in the region

Vijayasingham L, Viswanathan S

Mult Scler, 2019 01;25(1):130-131.
PMID: 30132396 DOI: 10.1177/1352458518797290
A curious case of neuromyelitis optica spectrum disorder co-existing with idiopathic intracranial hypertension

Viswanathan S, Wong LC

J Clin Neurosci, 2017 07;41:104-106.
PMID: 28343917 DOI: 10.1016/j.jocn.2017.03.026
The establishment of in-house neurology driven therapeutic plasma exchange infrastructure in a resource-limited public hospital in Malaysia: Adopting and integrating evidenced-based health care technology through time

Viswanathan S, Hiew FL

J Clin Apher, 2019 Aug;34(4):434-444.
PMID: 30829434 DOI: 10.1002/jca.21696

There has been an increase in the use of therapeutic plasma exchange (TPE) in immune-mediated neurological disorders in recent years. However, accessibility and availability of TPE remains low and costly, especially for a country with limited healthcare funding like Malaysia. With expanding clinical indications in neurological disorders, and increasingly expensive conventional immunomodulatory treatment such as intravenous immunoglobulin and monoclonal antibodies, TPE remains an effective part of first or second-line treatment. In this article, we detailed the historical aspects of the use of TPE in neurological disorders in Malaysia over the last four decades and discussed the challenges behind the establishment of the first in-house neurology-driven TPE service in the country. Local TPE database from a national neurology centre in Kuala Lumpur over the past 20 years was analyzed. We observed a remarkable three folds increase in the use of TPE at our center over the past 10 years (total 131 TPE treatments) compared to a decade prior, with expanding clinical indications predominantly for central nervous system demyelinating disorders. Besides using membrane filtration method, centrifugal technique was adopted, providing new opportunities for other clinical beneficiaries such as a neurologist driven "in-house TPE unit". However, there were real world challenges, especially having to provide services with limited funding, human resources, and space. In addition, much has to be done to improve accessibility, availability, and sustainability of TPE services at our center and nationwide. Nevertheless, even with limited resources and support, it is possible with concerted efforts to work within the confines of these limitations to establish a safe, successful, and sustainable TPE service.
Wasted tongue in neuromyelitis optica spectrum disorders due to hypoglossal nerve involvement

Viswanathan S

Mult Scler, 2015 Apr;21(4):488-91.
PMID: 24948685 DOI: 10.1177/1352458514537698

We report two cases of neuromyelitis optica spectrum disorder with hypoglossal nerve involvement resulting in a wasted tongue associated with other brainstem symptoms of hypogeusia, hypersalivation, hiccough, increased sweating, hyperemesis and myelitis (in the second patient). This occurred due to involvement of the hypoglossal, tractus solitarius and dorsal vagal nuclei. Though the myelitis and other brainstem signs recovered the hypoglossal nerve involvement resulting in a unilateral wasted tongue did not. It is important to consider neuromyelitis optica and its spectrum disorders in the differential diagnosis of a wasted tongue though its occurrence is rare.
Efficacy and safety of Fingolimod therapy in multi-ethnic Malaysian patients with relapsing remitting multiple sclerosis: A longitudinal observational study

Viswanathan S

J Clin Neurosci, 2018 Aug;54:25-28.
PMID: 29764703 DOI: 10.1016/j.jocn.2018.04.062
Fulltext Management of Idiopathic CNS inflammatory diseases during the COVID-19 pandemic: Perspectives and strategies for continuity of care from a South East Asian Center with limited resources

Viswanathan S

Mult Scler Relat Disord, 2020 Sep;44:102353.
PMID: 32653804 DOI: 10.1016/j.msard.2020.102353

The Covid-19 pandemic poses a grave health management challenge globally of unprecedented nature. Management of idiopathic Central Nervous system inflammatory disorders (iCNSID) such as Multiple sclerosis, Neuromyelitis optica and its spectrum disorders and related conditions during this pandemic needs to be addressed with affirmative and sustainable strategies in order to prevent disease related risks, medication related complications and possible COVID-19 disease associated effects. Global international iCNSIDs agencies and recent publications are attempting to address this but such guidance is not available in South East Asia. Here we outline prospectively qualitatively and quantitatively novel strategies at a tertiary center in Malaysia catering for neuroimmunological disorders despite modest resources during this pandemic. In this retrospective study with longitudinal follow-up, we describe stratification of patients for face to face versus virtual visits in the absence of formal teleneurology, stratification of patients for treatment according to disease activity, rescheduling, deferring initiation or extending treatment intervals of certain disease modifying therapies(DMT's) or immunosuppressants(IS), especially those producing lymphocyte depletion in MS and the continuation of IS in patients with NMO/NMOSD. Furthermore, we highlight the use off-label treatments such as Intravenous immunoglobulins/rituximab,bridging interferons/Teriflunomide temporarily replacing more potent DMT choices,supply challenges of IS/DMT's and tailoring blood watches and neuroimaging surveillance based on the current health needs to stave off the pandemic and prevent at risk patients with iCNSID/health care workers from possibly being exposed to the COVID-19.
Fulltext Regional and global perspectives on the incidence of multiple sclerosis and neuromyelitis optica and its spectrum disorders from Asia with emphasis on China

Viswanathan S

Lancet Reg Health West Pac, 2020 Oct;3:100039.
PMID: 34327387 DOI: 10.1016/j.lanwpc.2020.100039