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OBJECTIVES: The objectives of this study were to determine the relationship between genetic polymorphisms in gene encodings for CYP3A4 and carbamazepine (CBZ)-induced dose-related side effects in North Indian people with epilepsy. PATIENTS AND METHODS: The current prospective study included 37 patients with CBZ-induced dose-related side effects and 102 patients who did not experience side effects while on CBZ. The genotyping for CYP3A4 allele (CYP3A4*16) was done using real-time polymerase chain reaction (RT-PCR) in Applied Biosystems 7500 RT-PCR System (USA). CBZ was administered in all patients at a dose varying from 15 to 20 mg/kg daily. RESULTS: Various demographic variables were comparable between the groups except that control of seizures was far better in controls. After testing, it was found that none of our patients had the presence of CYP3A4*16 allele. CONCLUSION: CYP3A4*16 allele is not represented significantly in North Indian people with CBZ-induced dose-related side effects.

Context: Parkinson's disease (PD) is associated with sleep disturbances, attributed to the neurodegenerative process and therapeutic drugs. Studies have found levodopa to increase wakefulness in some patients while increasing sleepiness in others. Aims: To confirm sleep disturbances in drug naïve PD patients and understand the impact of levodopa on their sleep. Materials and Methods: Twenty-three drug naïve PD patients and 31 age-gender matched controls were compared using the Parkinson's Disease Sleep Scale (PDSS) and Epworth Sleepiness Scale (ESS). A polysomnogram objectively compared sleep quality. Of the 23 patients, the 12 initiated on levodopa were reassessed subjectively and through polysomnography after 2 months of therapy. Statistical Analysis: Data was expressed as mean ± standard deviation, median, and range. Continuous variables were analyzed by Student's T test for normally distributed data and Mann–Whitney U test for skewed data. Discrete variables were compared by Chi Square tests (Pearson Chi square Test or Fisher's Exact Test). Wilcoxon signed ranks test was applied in the analysis of paired data pre- and post-levodopa. A P value < 0.05 was considered as statistically significant. Statistical analysis of the data was done using the Statistical Package for the Social Sciences (SPSS) version 12. Results: Drug naïve PD patients had lower PDSS scores than controls. The sleep architecture changes observed on polysomnogram were reduced NREM Stage III and REM sleep and increased sleep latency and wake after sleep onset time. Following levodopa, improved sleep efficiency with reduced sleep latency and wake after sleep onset time was noted, coupled with improved PDSS scores. However, NREM Stage III and REM sleep duration did not increase. Discussion: PD patients take longer to fall asleep and have difficulty in sleep maintenance. Sleep maintenance is affected by nocturia, REM behavioral disorder, nocturnal cramps, akinesia, and tremors, as observed in PDSS scores. Levodopa improves sleep efficiency by improving motor scores without altering sleep architecture. Conclusions: Poor sleep quality and sleep architecture changes occur secondary to the neurodegenerative process in PD patients. Though levodopa improves sleep quality by reducing rigidity and tremor, it does not reverse sleep architecture changes.

Diaschisis is the inhibition of function produced by focal disturbances in a portion of the brain at a distance from original site of injury. Many studies using brain SPECT (single-photon emission computed tomography) have demonstrated crossed cerebellar diaschisis (CCD) in patients with cerebral cortical infarct. We report a case of cerebrovascular accident involving the left middle cerebral artery territory. PET/CT performed one month after stroke showed hypometabolism in the left cerebral hemisphere with hypometabolism of the contralateral cerebellum. The finding of diminished glucose metabolism in the contralateral cerebellum represents CCD.

Background: Rapid and specific diagnosis of tubercular meningitis (TBM) is of utmost importance. Aim: To evaluate polymerase chain reaction (PCR) using protein b primers directed against M. tuberculosis for the diagnosis of tuberculous meningitis. Materials and Methods: PCR using protein b primers was performed in ten patients with confirmed TBM (culture positive), 60 patients with clinically suspected TBM and 40 patients with no TBM (control group). Results: Protein b PCR had a sensitivity of 90% and a specificity of 100% in patients with confirmed TBM. In 60 clinically diagnosed TBM patients, protein b PCR was positive in 49 (81.7%) patients. The overall sensitivity of microscopy, culture and PCR using protein b primers was 1.4%, 14.3%, and 82.8% and specificity was 100%, 100%, and 100% respectively. Conclusion: Protein b PCR is valuable in rapid diagnosis of TBM.

Idiopathic CD4 T-lymphocytopenia (ICL) is a syndrome characterized by depletion of CD4 T-cells without evidence of human immunodeficiency virus (HIV) infection. There are a few reported cases of ICL associated with different diseases and clinical conditions, most commonly the opportunistic infections like Tuberculosis, fungal and parasitic diseases which are also seen in HIV-positive patients. We report a case without risk factors or laboratory evidence of HIV infection who presented with refractory cryptococcal meningitis and was found to have ICL.

A 39-year-old male,a chronic smoker, presented with vertigo, dysphagia, hoarseness of voice, and imbalance while walking of 6 hours duration. On examination, his blood pressure was 140/90 at admission and the neurological examination revealed sensory loss on the right side of the face and left half of the body with right-sided cerebellar signs, conforming to right LMS. A non contrast computed tomography (CT) scan showed an infarct in the right inferior cerebellum and a CT angiography showed non visualisation of the right vertebral with a thrombus extending into the proximal basilar artery [Figure 1]. The proximal right vertebral artery was well visualised in the CT angiography. Considering the risk of progression to complete basilar artery occlusion, the patient was taken in for an intra-arterial (IA) thrombolysis after full informed consent was obtained. A selective right vertebral artery catherisation was done. A 5 mg bolus of r-tPA was injected over a period of 1 min. This was followed by a slow infusion of 20 mg r-tPA. However, after an infusion of 4 mg of r-tPA after the bolus, the patient had a sudden cardiorespiratory arrest. He succumbed despite resuscitative measures.A non contrast cranial CT scan was repeated, which did not show any hemorrhagic transformation.Recent reportshave described unexpected sudden cardiorespiratory arrest in lateralmedullary infarction during convalescence after a stroke with minimal motor disability.

Background: Hyperhomocysteinemia has been proposed as an important risk factor for ischemic stroke worldwide, but data available from the Indian subcontinent is scarce. Aim: To study homocysteine levels in patients with ischemic stroke and compare it with age- and sex-matched controls. Settings and Design: Case–control prospective study. Materials and Methods: Fifty-seven patients with ischemic stroke and 30 controls were recruited for the study. They were subdivided into two subgroups ( 40 years of age) and plasma fasting total homocysteine (tHcy) levels were measured. Statistical analysis used: Student’s ‘t’ test and chisquare test. Results: The tHcy were significantly high in patients with stroke, compared to controls (9.91 ± 2.25 vs 8.00 ± 2.74 µmol/l; P < 0.001). Significantly high levels were seen in both male patients compared to controls (10.24 ± 2.34 vs 8.45 ± 2.72 µmol/l; P = 0.01) and female patients compared to controls (9.08 ± 1.81 vs 6.79 ± 2.60 µmol/l; P = 0.04). The tHcy levels were significantly high in patients with hypertension compared to normotensive patients (10.96 vs 9.49 µmol/ l; P = 0.01) and smokers compared to nonsmokers (11.17 vs 9.33 µmol/l; P = 0.01). Conclusions: Hyperhomo-cysteinemia emerged as an important independent risk factor for ischemic stroke. A strong positive correlation was also observed between hypertension, smoking, and high-tHcy levels in the present study.