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Rabies is an almost always fatal disease that physicians and patients dread due to its dismal prognosis and limited treatment options. Transmission of this disease occurs through the bite of dogs and wild animals (like jackal in our case). Other rare forms of transmission may be through inhalation in bat-infested caves and human-to-human transmission by infected corneal transplants, solid organ and tissue transplantation, and sometimes in laboratory settings. Its diagnosis is usually clinical in the absence of availability of special laboratory investigations at the point-of-care facility. Few people have described the role of imaging in diagnosis. We hereby report a patient with rabies encephalitis, having a history of jackal bite and classical MRI findings that we can use for early diagnosis in the absence of typical clinical features and specialised diagnostic testing.

Introduction: This study tried to find out type of lobar features found in patients with progressive supranuclear palsy (PSP) and whether they differ from those of frontotemporal dementia (FTD) as both of these are tauopathies. Methods: We studied lobar functions of 45 patients with PSP. Results: Five (11.1%) patients had no lobar feature; 11 (24.4%) had PSP-like features like apathy, frontal release signs, impaired motor Luria written sequences, and fist-edge-palm test; and 29 (64.4%) patients had FTD-like lobar features like disinhibition, poor naming, and word finding difficulty. Among features resembling FTD, behavioural variant type occurred in 31.1%, primary progressive aphasia type occurred in 58.6%, 3.4% patients had semantic dementia type features, and 6.9% were unclassified. Conclusions: Hence, patients with PSP with lobar features may fall in the middle of PSP-FTD spectrum with frontal lobe features typical of PSP (PSP-frontal like) and those with frontal lobe features resembling FTD (PSP-FTD complex) in between.

'Locked-in syndrome (LIS)' is a neurological disorder, often missed initially and can have grave consequences. A rare case of LIS caused due to folic acid deficiency-induced hyperhomocysteinemia is being described here. A 16-year-old boy presented with complaints of sudden onset weakness of all the four limbs with loss of voice for one day. All the tendon reflexes were increased, bilateral planters were extensor and sensory system was intact. Patient was conscious and responded to verbal commands by ocular movements in vertical direction. Hence, a diagnosis of LIS was made. Magnetic resonance imaging of the head revealed an acute infarct in ventral pons. Serum homocysteine level was elevated (20.65 μmol/l) and folic acid level was severely low (1.7 nmol/ml). Cause of LIS was found to be hyperhomocysteinemia induced stroke in the pons, related to folic acid deficiency. The patient was managed with antiplatelet agents and folic acid supplementation and was discharged subsequently. Recognition of LIS is important as casual remarks at bedside can severely traumatize an already paralyzed but conscious and awake patient. Folic acid deficiency can lead to hyperhomocysteinemia, which can cause strokes and even LIS. Prevention of hyperhomocysteinemia may possibly prevent such neurological disasters.

HIV Associated Neurocognitive Disorder (HAND) is still prevalent even in the ART (Anti-Retroviral Therapy) era. It may have some association with CD4 counts and Anti-Retroviral Therapy. The prevalence of HAND in HIV-patients, was, therefore studied in the context of ART and CD4 counts.Modified Mini Mental State Examination scores of 200 (65% males) HIV-positive patients and 200 controls were analyzed in the context of ART and CD4 counts.Maximum number of participants were educated between 8th-12th class (89.5%), aged between 25-50 years (81.5%) and a higher proportion of males had a CD4 count500 (69.2%) (p=0.007). Using 3MS, 21% patients (mean 76.24±1.51) and none of the controls were found to be neurocognitively impaired. Mean scores of patients with CD4 counts500(82.54±5.58) were lesser in comparison to those of patients with CD4 counts500 (p0.001). Those with an ART duration of48 months had a lower score in comparison to those with an ART duration of72 months (p=0.005).Most decrease from maximum value was seen in similarities (48.3 %), second recall (36.1 %), repetition (33.4 %), copying two pentagons (28.3 %), read and obey (24.0 %), mental reversal (22.7 %) and first recall (21.3%) parameters of Modified Mini Mental State Examination.HAND was less prevalent in the present study in comparison to past literature. CD4 counts and ART duration had an inverse association with the degree of cognitive impairment. The parameters of Modified Mini Mental State Examination showing maximum impairment may be compiled to form a short screening questionnaire.

Electromagnetic fields (EMFs) emitted by cellular telephones may cause neurological ill effects like cognitive dysfunction, emotional instability, and even brain tumors. Slowing of brain activity on electroencephalography (EEG) has been shown. However, these findings need further validation.EEG changes and adverse effects experienced following cell-phone use were studied.The study was conducted in the Department of Neurology of a tertiary care university hospital in India on North Indian students of the University, from August 2017 to October 2017.Twenty-one students underwent video-EEG recording before and after application of Samsung GT-56312 dual SIM smart phone in switched off, switched on, and switched on mode with conversation.Average EEG frequencies and amplitudes were calculated for different brain regions. Chi-square tests and t-tests were used for comparison between variables.The mean age of 7 (33.3%) male and 14 (66.7%) female subjects was 20.76 ± 1.48 years. The average EEG frequencies following mobile phone application with conversation were higher and the amplitudes lower than the baseline values. Frequencies were greater on the right side. Slow waves were detected in the frontal region in 38.1%, in the parietal region in 33.3%, in the occipital and temporal region in 19.1%; and, generalized slow waves were seen in 9.5% students. During the experiment, 23.8% experienced headache, 19% experienced irritation, and 9.5% felt drowsy. Headache and loss of concentration (33.3%), sleep disturbances (28.6%), and fatigue (19%) were frequent in daily life.Experimental application of mobile phones may lead to some EEG changes and certain ill effects on the well-being. Hence, prolonged use of these gadgets warrants caution.

N-hexane neuropathy is an occupational disease caused by exposure to n-hexane, which is used as a solvent in silk screen printing. Here, we describe a 35-year-old man, a silk screen printer by profession, who presented with dizziness, distal swelling of both lower limbs for 10 months and tingling and burning sensation in both feet for 9.5 months along with cold allodynia. The patient had normal results of a motor and sensory system examination, apart from an impaired temperature sense. Nerve conduction tests showed a conduction block in bilateral common peroneal nerves and absence of conduction in bilateral sural nerves. These symptoms resolved when further exposure to n-hexane was ceased but cold allodynia remained. Thus, cold allodynia and impaired temperature sense can be a manifestation of n-hexane neuropathy. Hence, abnormalities on nerve conduction studies can be detected in n-hexane neuropathy patients, even before clinical examination detects any such abnormalities. In the case of the patients presenting with sensory motor neuropathy, history of occupational exposure to n-hexane becomes important, as the sooner the disease is detected, the better the chances of recovery.

Objectives Autonomic dysfunction is often a late feature of multiple system atrophy (MSA). Based on early features, MSAp (Parkinsonian) and MSAc (cerebellar) variants are known. We studied the severity of autonomic dysfunction at first examination in MSA patient that may have relevance in its early diagnosis. Methods Clinical (including autonomic), radiological and lab features of 53 MSA patients were analyzed in the context of MSAp (16 patients) and MSAc (37 patients). Results Most frequent autonomic symptoms were erectile dysfunction in 30 out of 38 males (78.9%), bladder symptoms in 35 (66%), followed by blackouts/fainting attacks in 33 (62.3%). Autonomic abnormalities were detected in hand grip test (86.8%), deep breathing test (79.2%), cold pressor test (71.7%), Valsalva maneuver (75.5%), heart rate variability at 30:15 beats after standing (50.9%) and systolic BP on standing (41.5%). Six (16.2%) MSAp and 1 (6.3%) MSAc patients continued to have autonomic symptoms for several months (38.7 ± 26.11, median 36 months) before the appearance of cerebellar (1 patient) or Parkinsonian (6 patients) features. Conclusion Autonomic dysfunction may be the only presenting feature in some patients with MSA. Routine autonomic testing may help in the early diagnosis of MSA in patients presenting with Parkinsonian or cerebellar features.

Objectives Rarity of specific MRI features like ‘hot-cross bun’ sign and ‘hyperintense putamen rim’ reduce diagnostic utility of MRI in MSA. We therefore, studied some non-specific MRI features in addition to the specific ones, to find their diagnostic utility. Patients and methods Clinical and MRI features of 53 indoor and outdoor patients with MSA were analyzed in the context of its Parkinsonian (MSA-P) and cerebellar (MSA-C) variants. Results Of 53 cases (mean age: 59.53 ± 9.74 years), 16 (30.2%) had MSA-C and 37 (69.8%) had MSA-P. Midbrain atrophy was found in 37 (69.8%) MSA patients (70.3% of MSA-P and 68.8% of MSA-C), cerebellar atrophy in 45 (84.9%) MSA patients (81.1% of MSA-P and 93.8% of MSA-C), ‘hot-cross bun’ sign in 13 (24.5%) MSA patients (27% of MSA-P and 18.8% of MSA-C), hyperintense putamen rim in 19 (35.8%) MSA patients (37.8% of MSA-P and 31.3% of MSA-C) and corpus callosal atrophy in 39 (73.6%) MSA patients (75.7% of MSA-P and 68.8% MSA-C). The midbrain atrophy was mainly lateral tegmental and resembled a positive ‘Morning glory’ sign in 16 (30.2%). Conclusion “Hot cross bun” sign and “hyperintense putamen rim” sign were rarely seen in MSA. Combination of mid brain atrophy, corpus callosum atrophy and cerebellar atrophy was more commonly observed in both MSA-C and MSA-P and may be taken as of diagnostic significance.

Cannabis, an illicit recreational substance, is considered to be relatively safe by the public.1 However, potential health risks, particularly cardiovascular risks, are a cause of concern.2 Ischaemic and rarely haemorrhagic strokes may occur with cannabis use.2–4 Stroke usually ensues following chronic cannabis use or with concomitant use of tobacco and cannabis.2 3 A 23-year-old man, brought in an unconscious state with suspected poisoning had …

Objectives Cardinal extrapyramidal features of progressive supranuclear palsy (PSP) help in clinically differentiating this condition from Parkinson's disease and other Parkinsonian syndromes. However, not all extrapyramidal features may be initially present, thus posing a difficulty in early diagnosis. We studied their frequency at the time of first presentation. Methods Patients diagnosed clinically with PSP using the National Institute for Neurological Disorders and Society for PSP (NINDS/SPSP) criteria and seen between August 2010 and April 2013 were examined for the presence, ‘presence with deviation’ or absence of six extrapyramidal features: axial rigidity, symmetry, extended posture, backward falls, absence of tremors and lack of levodopa response. Results Twenty-eight patients (mean (SD) age 64.86 (9.72) years; 16 (57%) men) met the inclusion criteria. Of these, 14% had all six extrapyramidal features associated with PSP, 39% had five, 29% had four, 14% had three and 4% had two. The most frequent extrapyramidal sign was axial rigidity (68%). Axial plus peripheral rigidity was found in 18% of patients and peripheral rigidity alone in 14%. Extrapyramidal features were symmetrical in 29% and asymmetrical beyond 1 year in 29%. Body posture was extended in 46% and flexed in 21%. Backward falls were found in 50% and forward falls in 11%. Pill-rolling tremors were observed in 29%. Response to levodopa therapy was poor in 21% and good beyond 6 months in 39%. Conclusions Only 14% of PSP patients present with all six cardinal extrapyramidal features. Also, deviations from standard descriptions are common in the initial stages of disease.

Leptospirosis is a zoonosis prevalent worldwide and is endemic in many parts of India. In early leptospiremic as well as late immune phase of the disease kidney, liver, heart, and lungs are commonly involved. Neurological manifestations are rare but may occur during immune phase in the form of aseptic meningitis, meningoencephalitis, seizures, myelitis, polyradiculoneuritis, and myalgia. In this report, we describe a rare case of leptospirosis with combined involvement of nerve, muscle, and myoneural junction in generalized fashion along with pulmonary, renal, and hepatic dysfunction.