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Thymectomy is a common procedure performed in cases of myasthenia gravis (MG) with a thymoma or general MG that does not improve with medical therapy. This procedure is usually preceded by plasmapheresis to prevent the occurrence of myasthenic crisis and improve clinical outcome after thymectomy. Early-onset MG has a different phenotype than late-onset MG. So far, the effectiveness of plasmapheresis followed by thymectomy in early-onset MG remains unclear because of the conflicting results of previous studies. We present 5 early-onset MG patients who underwent plasmapheresis followed by thymectomy in the 2007–2020 period. Follow-up was done 1 year after thymectomy. We describe clinical features and postoperative data and evaluate the clinical outcome after thymectomy. Muscle strength was assessed by the Medical Research Council scale. Evaluation of clinical stage before and after thymectomy were carried out with the modified Osserman classification. All patients showed improvement (100%) in the clinical grade of the modified Osserman classification: 3 patients were in the complete remission category and 2 patients were in the improved category. All patients with general weakness experienced improvement in muscle strength at the 1-year evaluation.

Pronator teres syndrome (PTS) is a rare peripheral neuropathy of the proximal median nerve that occurs due to compression of the pronator teres muscle or its surrounding anatomical structures. Treatment options in cases of pronator syndrome include conservative therapy (oral, physical, intervention) to surgical therapy. Dextrose hydrodissection with ultrasound guided is an interventional therapy option in cases of peripheral neuropathy. This study presented a case of 50 year old female with chronic pronator teres syndrome who received ultrasound-guided 5% dextrose hydrodissection therapy and experienced satisfactory resolution within 6 months of post injection evaluation.

Background Patients with epilepsy experience seizures, which have been reported to increase and worsen during the coronavirus disease (COVID-19) pandemic. However, the association between epilepsy and COVID-19 outcomes remains unclear. The aim of this study was to analyze whether patients with epilepsy have an increased risk of having poor COVID-19 outcomes. Methods We comprehensively evaluated potential articles extracted from the medRxiv, Europe PMC, and PubMed databases until June 30, 2021, using selected keywords. All published studies on epilepsy and COVID-19 were selected. We used the Review Manager 5.4 and Comprehensive Meta-Analysis 3 software for statistical analysis. Results Thirteen studies with 67,131 patients with COVID-19 were included in the analysis. Evaluation of the collated data revealed an association between epilepsy and increased severity of COVID-19 (OR, 1.69; 95%CI: 1.11–2.59; p = 0.010; I2 = 29%; random-effect modeling) and mortality from COVID-19 (OR, 1.71; 95%CI: 1.14–2.56; p = 0.010; I2 = 53%; random-effect modeling). The results also showed that the association between epilepsy and increased risk of developing severe COVID-19 is influenced by sex and neurodegenerative disease. Conclusions The findings of this study suggest that patients with epilepsy are at risk of having poor COVID-19 outcomes. Patients with epilepsy need special attention and should be prioritized for administration of the COVID-19 vaccine. Registration details: PROSPERO (CRD42021264979).

Background: Piriformis syndrome (PS) is a neuromuscular condition caused by the entrapment of the sciatic nerve at the level of the piriformis muscle (PM). Diagnosing PS remains challenging despite recent invasive and non-invasive diagnostic methods. Response to invasive nerve block is still one of the most reliable diagnostic modalities because there is no gold standard test for PS. As early diagnosis may prevent delayed diagnosis that results in chronic somatic dysfunction and muscle weakness, a screening test with high sensitivity could guide clinicians in performing the next appropriate step in diagnosing PS.Aim: The purpose of this study is to determine the sensitivity, specificity, and best cut-off point of ultrasound-guided PM thickness in PS.Method: This case-control study was conducted in a general hospital in Tangerang during a 3-month period. We recruited 58 patients clinically diagnosed with PS and 58 healthy patients (without a history of hip and buttock pain) during their visits to the outpatient clinic. All patients underwent ultrasound assessment to measure bilateral PM thickness. Sex, age, body mass index, history of micro-/macro-trauma, and prolonged sitting duration were recorded. Statistical analyses were performed using the Statistical Package for the Social Sciences version 25.Result: The PS and control groups predominantly comprised female subjects, with mean ages of 51.79 ± 14.10 and 50.09 ± 13.26 years on PS and healthy subjects, respectively. The mean ultrasound-guided PM thickness was higher in PS subjects compared to healthy subjects with mean thicknesses of 1.16 ± 0.13 and 0.85 ± 0.11 cm, respectively (p < 0.05). The area under the receiver operating characteristic curve of the PM was 0.970 (95% confidence interval 0.943–0.998, p < 0.05). The best cut-off point defined by Youden's J index was 0.9950 cm for all PS subjects.Conclusion: We propose 0.9950 cm as the cut-off point for diagnosing PS by ultrasound, which has the sensitivity and specificity of 94.8 and 87.9%, respectively.

Background: Piriformis syndrome is a neuromuscular condition characterized by hip and gluteal pain caused by abnormality of piriformis muscle. In clinical practice, this syndrome is usually misdiagnosed with other spinal disorders. There is no specific test in diagnosing piriformis syndrome, therefore by understanding the characteristics and predisposing factors, clinicians may be more aware in diagnosing this syndrome. Objective: To investigate the characteristics and predisposing factors of piriformis syndrome. Methods: A descriptive study was conducted on patients with gluteal pain in a referral hospital. Diagnosis was established by block injection on piriformis muscle and showed clinical improvement afterwards. Demographic characteristics, predisposing factors, and physical examination were analyzed. The data is collected and processed by SPSS 20.0. Results: The total of 65 patients were evaluated, with a male to female ratio 1:3. As much as 47.7% of patients were > 60 years old. Average weight was 60 kg and BMI (Body Mass Index) was within normal range (58.9%). Most subjects were housewives (55.4%) and the majority of subjects had history of microtrauma such as sitting on rigid surfaces (36.9%), walking or running long distances (18.5%), and cross-legged sitting (10.8%). Average sitting per day was approximately 5 hours. In 56.9% of subjects, exercises were conducted. There was no history of back pain in 81.5% of subjects. Conclusion: Our study showed age and housewives characteristics differ with other studies. The most predisposing factors were history of microtrauma, female, age, and normal BMI.

Sindrom piriformis (SP) merupakan sindrom klinis dengan keluhan nyeri pantat menjalar ke tungkai sisi unilateral yang disebabkan penekanan saraf skiatik oleh otot piriformis. Beberapa modalitas terapi SP antaralain terapi oral, fisik, intervensi hingga pembedahan. Terapi injeksi intramuskular merupakan terapi intervensi bagi pasien yang mengalami nyeri hebat atau mengalami kegagalan terapi oral dan/atau terapi fisik. Terapi injeksi intramuskular umumnya berupa penggunaan anestesi lokal, kortikosteroid maupun toksin Botulinum A. Studi ini mewakili lima kasus SP yang mengalami kekambuhan dalam periode singkat pada 4 perempuan dan 1 laki-laki dengan variasi usia 32-43 tahun. Keseluruhan kasus mengeluhkan gejala klasik dengan onset subakut-kronik juga riwayat pengobatan konservatif dan intervensi. Perbaikan jangka panjang (>9 bulan) dialami pascainjeksi toksin-botulinum-A dengan panduan ultrasonografi. Kata Kunci: Sindrom piriformis, terapi injeksi, toksin botulinum

Introduction. Parsonage Turner Syndrome (PTS) is a rare syndrome that may occur in healthy subjects. The clinical presentation might not be typical and risk factors attributed to the development of disease may not be easily depicted. We present a case of abrupt onset of unilateral shoulder pain, followed by progressive neurologic weakness. Result. A 54-year-old male presented with abrupt onset of shoulder pain mainly on the right side. Pain was felt in both shoulder and thigh which progressed to weakness, dysesthesia, and numbness in the right upper arm. In 4 days, he could barely lift his right upper arm. There was no history of trauma nor infection on the affected area. On physical examination, there were limitation of shoulder abduction and external rotation. His right arm strength from proximal to distal was 1344. Other extremities showed no significant weakness. Sensory involvement did not match dermatomal and peripheral sensory distribution. Nerve Conduction Velocity (NCV) showed axonal motor neuropathy of right axillary nerve. Electromyography (EMG) showed no Motor Unit Action Potential (MUAP) on deltoid muscle. His CK was 457, and there was an increase in LDH and CRP. Cervical MRI was unremarkable. Steroids were immediately given, and the response was fast and satisfactory. After 1 day, his motor strength increased, and the pain subsided. EMG showed single MUAP on deltoid. After 10 days, his motor strength returned to near normal. NCV study showed decreased amplitude of right axillary nerve, and recruitment was slightly decreased on right deltoid muscle. He underwent physical therapy and was making marked progress. Conclusion. PTS generally involves one upper limb, and axillary nerve is one the most commonly involved. PTS should be considered as a differential diagnosis in cases of shoulder pain and arm weakness without any clear etiology.

Introduction. The axillary nerve is a terminal branch of the posterior cord of the brachial plexus and derives from the ventral rami of the fifth and sixth cranial nerves. Its injury is infrequently diagnosed and a rare occurence. It generally appears secondary to the trauma and characterized by severe shoulder pain at night with limitation of the shoulder movements followed by shoulder atrophy in the following weeks. Case Illustration: A 22-year-old male was admitted with decreased of consciousness, headache, neck stiffness, subconjunctival hemorrhage, and decreased left arm strength along with range of movement, especially left shoulder abduction and left arm pronator after a motorcycle accident. Vital signs were unremarkable. Head CT scan showed minimal subarachnoid hemorrhage (SAH) at anterior interhemisphere falx, and tripod fracture at left zygomatic bone. Hand, humeral and antebrachii X-ray showed no fracture nor dislocation. Electromyography (EMG) test showed no nerve conduction velocity of left axillary nerve injury. Patient underwent physiotherapy and given neuroprotectors. After 7 days, there was a significant improvement in shoulder abduction and left arm pronation. Patient was then discharged and scheduled for further physiotherapy. Discussion. Isolated lesions of the axillary nerve occur most commonly after a fracture or dislocation around the shoulder. Most recover spontaneously. In this case, patient had a speed recovery a week after the injury. Electrodiagnostic study shows a physiologic block of nerve conduction in the axillary nerve. At the end of the week, patient showed significant strength. This might be due to temporary interruption of conduction without loss of axonal continuity (neuropraxia). Conclusion. Isolated axillary nerve injury is often a low-grade injury which progresses to full recovery without intervention. Electrodiagnostic study might reveal no nerve conduction. However, recovery of nerve conduction deficit is full, and requires days to weeks.

Wernicke’s encephalopathy is a rare occurrence in Indonesia because alcohol consumption is very low. However, in Indonesia, Wernicke’s encephalopathy could be triggered by an inadequate intake of thiamine (vitamin B1) due to an extreme diet for several months. It is a case of a 31-year-old male, who presented to the emergency room with a decreased level of consciousness. According to the family, for the last few weeks, he has become less responsive and less attentive. Fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) revealed a unique picture with symmetrical lesions in the bilateral medial thalamus, mammillary bodies, periaqueductal gray matter, and the dorsal surface of the medulla oblongata. Clinically, there is no neck stiffness and no fever. The laboratory results from the blood and cerebrospinal fluid have ruled out meningitis. Treatment with thiamine 200 mg t.i.d. has shown an excellent response and significant clinical improvement. The earlier thiamine substitution treatment is started, the better the outcome because thiamine will prevent further injury to the brain and enhance recovery.

Background Piriformis syndrome (PS) is one causes of buttock and hip pain which is caused by pressure of sciatic nerves on piriformis muscle. PS is sometime misdiagnosed because of similar clinical signs and symptoms with other lower back pain diagnosis such as Hernia Nucleus Pulposus (HNP), Sacroiliac joint pain, facet joint pain. Gold standard diagnosis of PS is diagnostic block injection. However, provocative test and prolonged H reflex on EMG might be also standard diagnostic of PS.Aim Understand the sensitivity and specificity of provocative test and prolonged H reflex to diagnose PS.Method 72 patients with suspected PS who came to Neurology OPD in period of August- December 2017 were testing with physical examination (provocative test) and Electromyography test of H reflex. PS is diagnosed by positive diagnostic block injection. Data was proceeded with SPSS 20 version.Result 72 patients with buttock pain which diagnosed with PS were dominated by female gender than male with ratio 1:3 with housewives as majority of work. Most age groups were 48.6% elderly (age more than 60 years old). Provocative tests result of Freiberg, FAIR, Beatty, Pace Sign, Hip Abduction sensitivity were 52.30; 66.15; 53.84; 46.15; 55.32 and specificity were 100; 42.85; 71.42; 71.42; 57.14. While sensitivity and specificity of prolonged H reflex more than 1.86 msec were 69.23 and 28.59. Combination of 3 provocative tests (FAIR, Freiberg and Beatty) resulted highest sensitivity and specificity in this study as 71.42 and 100.Conclusion Provocative test and prolong H reflex can be supported diagnosis of PS. However both tests might not be comparable yet than diagnostic block injection as gold standard of PS. Combination of provocative test increased the sensitivity and specificity of provocative test than single test only.

NMO is one the disease in Asia which has not been well understood and studied in Asia, particularly Indonesia. Lesions in optic nerve combined with longitudinal lesion that involved more than three segments of spinal cord have become the hallmark of NMO diagnosis besides antibody of aquaporin 4 examination. Lesion presents at brain MRI usually exclude the diagnosis, shifting it to Multiple Sclerosis (MS). Failure to distinguish NMO from MS can be proven to be catastrophic as treatment of MS may not only inefficacious but also exacerbate the relapse rate of NMO.

Background Conventional contact investigation and molecular fingerprinting of Mycobacterium tuberculosis isolates in tuberculosis (TB) outbreaks have facilitated recognition as well as application of public health control activities. Singing in a choir as an activity that promotes TB transmission has been occasionally recognized. Such avocational transmission in a middle class community can occur with attendant difficulties encountered in contact investigation. Methods Five cases of TB (one index case; three secondary cases; one unassociated case) were identified among members of a famous church gospel choir in Newark, NJ. DNA fingerprinting and susceptibility testing were done on all retrieved strains. Of 306 choir members who had tuberculin tests, 19% were reactors. The presumed outbreak site was investigated. Results Four of the five patients were tenors, and one was an alto. Tenors were approximately twice as likely to be tuberculin reactors than subjects with other vocal ranges combined (relative risk, 2.04; 95% confidence interval, 1.17 to 3.56). An air ventilation outlet was directly in front of the tenor section. Some limited extra-church activity between choir members may have contributed to transmission. Conclusion Conventional contact investigation must be supplemented by newer techniques, such as DNA figerprinting, in identifying possible outbreak transmission. Singing, location of a ventilation outlet, and exposure time may have contributed to TB transmission in this outbreak. Transmission need not only be in congregate settings among well-defined socioeconomic groups but may occur unexpectedly in middle class communities.

Twenty patients with mild to severe essential hypertension completed a 12-week open crossover study to compare the effectiveness and tolerance of two beta-blocker/diuretic combinations. Patients were allocated at random to receive treatment for 6 weeks with either 40 mg propranolol plus 12.5 mg hydrochlorothiazide twice daily or 400 mg acebutolol plus 25 mg hydrochlorothiazide once daily. They were then crossed over to the alternative medication for a further 6 weeks. Blood pressures and pulse rate were monitored in the supine and erect positions at regular intervals, as were side-effects, laboratory variables and ECG. The results showed that both combinations produced significant reductions from baseline in systolic and diastolic blood pressures but that the acebutolol combination produced a significantly greater reduction in diastolic blood pressure. There was no evidence of a treatment sequence effect. The two drug treatments were reasonably well tolerated, with a trend in favour of the acebutolol combination. No clinically significant changes were observed in any of the laboratory parameters investigated and there were no ECG abnormalities.