Visual Disturbances Caused by Anti-Epileptic Medications

Visual disturbances are a common side effect of anti-epileptic medications. However, only vigabatrin has been linked to visual field loss, with patients experiencing blurred vision, tunnel vision, oscillopsia, and difficulty in navigation. Despite these symptoms, visual acuity remains intact.

Other anti-epileptic medications have been associated with different visual disturbances. Carbamazepine has been linked to abnormal color perception and reduced contrast sensitivity, while levetiracetam can cause diplopia. Topiramate has been associated with closed angle glaucoma, and sodium valproate can cause abnormal color perception and altered visual evoked potentials.

It is important for patients to be aware of the potential visual side effects of their anti-epileptic medication and to report any changes in vision to their healthcare provider. Regular eye exams may also be recommended for patients taking these medications.

Subacute Combined Cord Degeneration and its Causes

Subacute combined cord degeneration is a condition that arises from a deficiency in vitamin B12. The most common cause of this deficiency is pernicious anemia, which is often accompanied by other autoimmune diseases such as hypothyroidism and diabetes. Additionally, prolonged use of metformin has been linked to B12 deficiency in up to 10% of patients over a four-year clinical trial. Therefore, it is recommended that patients taking metformin undergo B12 level screenings every few years.

The condition is characterized by absent reflexes and an extensor plantar response, which is due to the presence of peripheral neuropathy. Dorsal column involvement is also typical, with spinothalamic pathways being relatively spared. Overall, subacute combined cord degeneration is a serious condition that can have a significant impact on a patient’s quality of life. It is important to identify and address the underlying causes of this condition in order to prevent further damage and improve outcomes for affected individuals.

This woman is experiencing post-lumbar puncture headache (PLPH), a common complication of a lumbar puncture. It is believed to be caused by excessive leakage of cerebrovascular fluid, resulting in a relatively low intracranial pressure. The headache worsens significantly when assuming a non-supine posture. While there are other potential diagnoses to consider, such as meningitis, migraine, cortical vein thrombosis, intracerebral hemorrhage, and cluster headaches, PLPH can often be diagnosed clinically. Patients may mistakenly attribute their headache to migraine and report that avoiding bright light helps, when in reality lying down is what provides relief. Treatment typically involves conservative measures such as pain relief and adequate hydration. If these methods fail, the gold standard treatment is an epidural blood patch.

Understanding Post-Lumbar Puncture Headache

Post-lumbar puncture headache is a common occurrence in about one-third of patients who undergo lumbar puncture. The exact cause of this headache is not yet clear, but it may be due to the leakage of cerebrospinal fluid (CSF) following dural puncture. This type of headache is more prevalent in young females with a low body mass index.

The headache typically develops within 24-48 hours after the lumbar puncture procedure, but it may also occur up to one week later. It can last for several days and worsens when the patient is in an upright position. However, it improves when the patient is lying down.

Several factors may contribute to post-lumbar puncture headache, including increased needle size, direction of bevel, not replacing the stylet, and increased number of LP attempts. On the other hand, factors that do not contribute to the headache include increased volume of CSF removed, bed rest following the procedure, increased fluid intake post-procedure, opening pressure of CSF, and position of the patient.

Initially, supportive management is recommended, such as analgesia and rest. However, if the pain persists for more than 72 hours, specific treatment is necessary to prevent subdural hematoma. Treatment options include blood patch, epidural saline, and intravenous caffeine.

In summary, post-lumbar puncture headache is a common occurrence that can be managed with supportive measures. However, if the headache persists, specific treatment is necessary to prevent complications.

Autoantibodies are antibodies that mistakenly target and attack the body’s own tissues and organs. Different autoantibodies are associated with different autoimmune diseases. In this context, the following autoantibodies are discussed:- Anti-mitochondrial antibodies (AMAs) are found in 95% of patients with primary biliary cholangitis (PBC). PBC is more common in women and may present with tiredness and itching. Ursodeoxycholic acid can improve bilirubin and symptoms of jaundice, but liver transplantation is the definitive treatment.- Anti-thyroid antibodies are found in Grave’s disease and Hashimoto’s thyroiditis, a small percentage of patients with thyroid carcinoma, and approximately 3% of normal individuals.- Anti-endomysial antibodies are found in association with coeliac disease, which is usually associated with weight loss and diarrhea.- Anti-smooth muscle antibodies are associated with autoimmune hepatitis, not with PBC. In autoimmune hepatitis, a hepatocellular picture of liver function test abnormalities would be expected.- Anti-nuclear antibodies are less specific indicators of autoimmune disease, most likely to be associated with systemic lupus erythematosus.Understanding the association between autoantibodies and different diseases can aid in the diagnosis and treatment of autoimmune conditions.

The Chiari type I malformation is evident on the MRI, with the cerebellar tonsils protruding through the foramen magnum.

Understanding Arnold-Chiari Malformation

Arnold-Chiari malformation is a condition where the cerebellar tonsils are pushed downwards through the foramen magnum. This can occur either due to a congenital defect or as a result of trauma. The condition can lead to non-communicating hydrocephalus, which is caused by the obstruction of cerebrospinal fluid outflow. Patients with Arnold-Chiari malformation may experience headaches and syringomyelia, which is a condition where fluid-filled cysts form in the spinal cord.

The description of the seizure suggests that it may be a pseudoseizure, as the patient’s eyes close with resistance and their post-ictal state is very brief. The patient also appears to become alert and oriented in speech quickly after the seizure. Pseudoseizures are often accompanied by underlying psychiatric issues and the patient may be tearful during the seizure. Additionally, if the patient’s limb jerking is prolonged and increases in intensity (crescendo features), this should raise suspicion. It is important to note that pseudoseizures can occur in patients of any age and that features such as tongue biting and urinary incontinence are not definitive signs of an organic seizure, as they can also be present in pseudoseizures.

Psychogenic non-epileptic seizures, also known as pseudoseizures, are characterized by pelvic thrusting, a family history of epilepsy, and a higher incidence in females. These seizures often involve crying after the event and do not occur when the individual is alone. On the other hand, true epileptic seizures are more likely to involve tongue biting and a gradual onset. Video telemetry is a useful tool for distinguishing between the two types of seizures. It is not fully understood why serum prolactin levels increase following seizures, but it is believed that electrical activity spreads to the ventromedial hypothalamus, leading to the release of a specific prolactin regulator into the hypophyseal portal system.

Motor Compulsions in OCD

This patient is exhibiting motor compulsions, including shoulder and arm movements and blasphemous utterances, which are a result of obsessive-compulsive disorder (OCD). The trigger factor for this behavior is likely the death of his father two years ago, although he has exhibited obsessive tendencies, such as ordering his toys, since childhood. The patient is experiencing anxiety due to his obsessive thoughts and his inability to control them.

It is important to note that these motor compulsions are different from tics, which are not typically associated with obsessive thoughts. Additionally, the patient’s symptoms are not indicative of extrapyramidal movements related to Wilson’s disease, which can present with dystonic posturing, chorea, and tremors. Wilson’s disease is characterized by reduced levels of serum copper and caeruloplasmin and elevated urinary copper levels.

While there are no obvious signs of depression, it is possible for anxiety and depression to co-occur in individuals with OCD. Furthermore, there are no indications in the patient’s history to suggest an underlying tendency towards functional symptoms.

Whooping cough, caused by Bordetella pertussis (B pertussis) infection, is characterized by cold symptoms followed by paroxysms of coughing. In adults, serology testing is the most appropriate method for confirming the diagnosis, especially if the patient has not engaged with vaccination services. Antibiotics have no value in shortening the duration of symptoms at this stage of the disease. Oral fluid testing is recommended for children aged 5-16 who have had a cough with whooping cough features for more than two weeks and have not received a vaccine in the preceding year. Induced sputum culture is primarily used in the diagnosis of pulmonary tuberculosis, while nasopharyngeal swab culture is most sensitive for the diagnosis of whooping cough when performed in the first two weeks of symptoms and in younger individuals. PCR testing is not indicated for this disease, except in severely ill, hospitalized infants.

Brain Stem Death Tests

Brain stem death tests are used to determine if a patient has suffered irreversible damage to their brain stem, which controls vital functions such as breathing and heart rate. These tests include assessing the pupillary light response, corneal reflex, response to supraorbital pressure, vestibulo-ocular reflex, gag reflex, cough reflex, and absence of respiratory effort.

The pupillary light response test involves shining a light into the patient’s eyes and observing if their pupils constrict. This tests the function of cranial nerves II and III. The corneal reflex test involves touching the patient’s cornea with a cotton swab and observing if they blink. This tests the function of cranial nerves V and VII. The response to supraorbital pressure test involves applying pressure to the patient’s forehead and observing if they grimace. This also tests the function of cranial nerves V and VII. The vestibulo-ocular reflex test involves moving the patient’s head and observing if their eyes move in the opposite direction. This tests the function of cranial nerves III and VIII. The gag reflex test involves stimulating the back of the patient’s throat and observing if they gag. This tests the function of cranial nerves IX and X. The cough reflex test involves suctioning the patient’s airway and observing if they cough. This tests the function of cranial nerve X. Finally, the absence of respiratory effort test involves observing if the patient is breathing on their own or if they require mechanical ventilation.

Overall, these tests are crucial in determining brain stem death and can help guide medical decisions regarding end-of-life care.

Management of Myotonia Dystrophica with Grip Weakness

Myotonia dystrophica is a condition that causes muscle stiffness and weakness. In this case, the patient reports grip weakness as the main problem. The grip myotonia can be treated with phenytoin, but caution should be taken as the patient may have cardiac conduction defects. Ankle-foot orthosis and splints can be used to manage foot drop.

The patient is also diabetic, and a glucose tolerance test is unnecessary. The ptosis, or drooping of the eyelids, is a progressive condition, and lid-lifting surgery is not recommended except in severe cases. The patient may require cataract extraction. Overall, a comprehensive approach to managing the symptoms of myotonia dystrophica is necessary to improve the patient’s quality of life.