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Background In Egypt, the characterization of Neuromyelitis Optica Spectrum Disorder (NMOSD) is lacking. Objectives To determine the demographics, clinical features, aquaporin4 antibodies (AQP4-IgG) status, and neuroimaging of Egyptian NMOSD patients. Methods Retrospective analysis of 70 NMOSD patients’ records from the MS clinic, Kasr Alainy hospital, between January 2013 and June 2018. Results Patients’ mean age was 34.9 ± 9.2 years, and the mean at disease onset was 28.9 ± 10.5 years. Fifty-nine patients had an initial monosymptomatic presentation. AQP4-IgG was measured using either enzyme-linked immunosorbent assay (ELISA) (22 patients) or cell-based assay (CBA) (34 patients). Six and 29 patients had positive results, respectively (p < 0.001). 84% had typical NMOSD brain lesions. Longitudinally extensive myelitis was detected in 49 patients, and 9 had either short segments or normal cords. Treatment failure was higher in seropositive patients. Rituximab significantly reduced the annualized relapse rate (ARR) compared to Azathioprine with a percentage reduction of (76.47 ± 13.28) and (10.21 ± 96.07), respectively (p = 0.04). Age at disease onset was the only independent predictor for disability (p < 0.01). Conclusion Treatment failure was higher in seropositive patients. However, there was no difference in clinical or radiological parameters between seropositive and seronegative patients. Patients, who are polysymptomatic or with older age of onset, are predicted to have higher future disability regardless of the AQP4-IgG status.

Guillain-Barre syndrome (GBS) and multiple sclerosis (MS) are autoimmune demyelinating disorders of the peripheral and central nervous systems, respectively. The co-occurrence of these 2 conditions is rare in the literature. Herein, we present a rare case of GBS and MS in a 19-year-old female who presented initially with GBS followed by MS, and we provide a literature review. Despite being rare, it should be kept in mind in the differential diagnosis of patients with atypical and usual presentation of both diseases.

The ongoing coronavirus (COVID-19) pandemic is a global health emergency of international concern and has affected management plans of many autoimmune disorders. Immunosuppressive and immunomodulatory therapies are pivotal in the management of neuromyelitis optica spectrum disorder (NMOSD), potentially placing patients at an increased risk of contracting infections such as COVID-19. The optimal management strategy of NMOSD during the COVID-19 era remains unclear. Here, however, we examined the evidence of NMOSD disease-modifying therapies (DMTs) use during the present period and highlighted different scenarios including treatment of relapses as well as initiation and maintenance of DMTs in order to optimize care of NMOSD patients in the COVID-19 era.

The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient’s immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.

Two field experiments were carried out at Mallawi requirements research station El-Minia Governorate, Egypt; Water Management Research Institute – National Water Research Center during 2012 and 2013 seasons. The aim of this investigation is to evaluate the effect of the different irrigation regimes and potassium fertilization rates on crop coefficient of potato. Also it evaluate and compare the potential evapotranspiration (ETp) with actual water requirement under El-Minia Governorate conditions. The experiment included five treatments of irrigation regimes (A) and four treatments of potassium fertilization (B) with three replicates so that the experiment was arranged in a split plot design. The irrigation regime treatments were treationial irrigation (the farmers practes, 100%, 90%, 80% and 70% of field capcity). Potassium rates was applied in a form of potassium sulphate (48%K2O) at rate 200 kg/fed. (b1), 100 kg K2O/fed. + potasine (Biofertilizer) at rate 6 liters/fed (b2), 100 kg/fed. + potasine (Biofertilizer) at rat 6 liters/fed. + potassium foliar (36% K2O) at rate 2 liters/fed. (b3) and Potassium (biofertilizer) at rate 6 liters/fed (b4). These results indicated that the first irrigation treatment where plants irrigated with conventinal irrigation had the highest value of actual consumptive use (daily and seasonal). This was due to the decrease in the value of tension moisture of the first treatment which led to increasing the water actual consumptive use. While, the fifth irrigation treatment for plants irrigated until 70% of field capacity had the lowest value of actual consumptive use (daily and seasonal). The application of Potassium fertilization caused a slight decrease in daily, monthly and seasonal actual evapotranspiration(ETa), in both seasons. Modified Penman and modified Blaney & Criddle gave high average values for potential evapotranspiration (ETp) (63.24 and 56.50 cm/season) while radation method and pan method gave less average values (53.99 and 49.11 cm/season) for the two studied seasons respectively. The actual values of evapotranspiration were less than those computed by climatological equations. This is due to the estimated factors in these equations. The average values of potential evapotranspiration (ETp) for the two studied seasons, by modified Blaney & Criddle and radation method were the nearest values to general average (+1.41 and -3.09% respectively). While, the farthest values to general average were obtained by modified Penman and Pan method (+13.52 and -11.85% respectively). Kc average were 0.76, 0.72, 0.71, 0.70 and 0.68 for A1, A2, A3, A4 and A5 under all sub-treatments respectively. Modified Blaney & Criddle was the nearest to the actual consumptive use. Therefore, recommended for calculating the potential evapotranspiration using modified Blaney & Criddle or radiation method for potato plants which grow under El–Minia conditions and other corresponding conditions.

Single-nucleotide polymorphisms (SNPs) in microRNA-146a (miRNA-146a) can be associated with the development of immune-system dysfunctions.The aim of this work is to correlate SNPs of miRNA-146a and its target gene, IRAK1, with susceptibility, clinical manifestations, and diseases progression in patients with systemic lupus erythematous (SLE) and multiple sclerosis (MS). Genotyping for miRNA-146a (rs2910164) and its target gene IRAK1 (rs3027898) was performed using real-time polymerase chain reaction (RT-PCR) in 80 patients with SLE and 70 patients with MS, as well as 120 healthy control individuals. A statistically significant difference was found between the frequencies of the genotypes and alleles of miRNA-146a (rs2910164) and IRAK1 (rs3027898), compared with the control group. Also, whereas the mutant allele G of miRNA-146a may be a factor in the pathogenesis of lupus nephritis, the mutant allele C of IRAK1 may play a role in lupus arthritis. Both genes may contribute to the susceptibility of patients to SLE and MS.

Hatem S Shehata,1 Hadeer Mahmoud AbdelGhaffar,2 Mohammed Nasreldin,3 Alaa Elmazny,1 Ahmed Abdelalim,1 Asmaa Sabbah,1 Nevin M Shalaby1 1Department of Neurology, Cairo University, Giza, 2Department of Paediatrics, Fayoum University, Fayoum, 3Department of Psychiatrics, Cairo University, Giza, Egypt Introduction: Refractory epilepsy is a common clinical manifestation in patients with tuberous sclerosis complex (TSC), which can be complicated by many life-threatening conditions, such as status epilepticus (SE). However, very few reports mention the patterns and semiology of SE in those patients.Objective: To study the clinical characteristics and outcomes of SE in TSC patients.Materials and methods: This observational, prospective study was carried out on 36Egyptian children with definite TSC. Clinical history, general and neurological examination and psychometric evaluation by standard questionnaires were used to explore characteristics of epileptic manifestations and clinical patterns of SE. All included patients were required to have long-term video electroencephalograms (EEGs) and brain MRI performed.Results: A total of 32 attacks of SE were recorded in 21 patients (58.3%) in our cohort during a follow-up period of 2.8±1.1 years; of those patients, 15 had convulsive status, 7 had non-convulsive SE, 6 had refractory/super-refractory SE and 14 patients had a history of infantile spasms (epileptic spasms). The duration of status ranged from 40 to 150 min (mean ± standard deviation: 90±15). Fourteen patients with SE had severe mental retardation, 9 had autistic spectrum disorder and 22 had severe epileptogenic EEG findings. Patients with SE had higher tuber numbers (mean: 9.6), 5patients had subependymal giant cell astrocytomas and 2 patients had their SE after receiving everolimus.Conclusions: The incidence of SE in our patient sample is high (>50%); severe mental retardation, autistic features, history of infantile spasm (epileptic spasms) and high tuber burden are risk factors for developing SE. Keywords:Egyptian children, tuberous sclerosis, status epilepticus, infantile spasms, autistic spectrum

Naglaa A El-Sherbiny,1 Hatem Samir Shehata,2 Hanan Amer,2 Alaa Elmazny,2 Mohamed Masoud,1 Hanan Helmy,2 Nevin M Shalaby2 1Faculty of Medicine, Fayoum University, Faiyum, Egypt; 2Faculty of Medicine, Cairo University, Cairo, Egypt Background: The reported prevalence of headache disorders in Arab regions varies considerably between countries. This may be due to a lack of standardized survey instruments that capture the prevalence. Purpose of the study: Our goal was to construct and validate a structured headache questionnaire for Arabic-speaking headache patients to be used as an epidemiological survey instrument. Methods: We developed a culturally adapted interviewer-administered questionnaire in Arabic language comprising two sets of questions. The first set included personal and sociodemographic data together with a screening question regarding the presence of headaches over the last year. The second set was designed to define the type and pattern of headaches according to the International Classification of Headache Disorders criteria (for subjects with “yes” answers on the screening question). Validation process took place in two phases through probability random sampling selected from 1,221 headache subjects collected in an epidemiological survey 3 (n=70) and 6 months (n=232) later. A detailed assessment of patients’ headaches was performed by neurologists (blinded from the questionnaire diagnosis) who clinically assessed the patients’ headache. Results: The validity of the questionnaire was tested in 232 subjects with a mean age of 41.2±10.9 years, 72.8% of whom were females. The mean time to complete the questionnaire was 8.4±1.7 minutes. The intraclass correlation coefficient was 0.903 (95% confidence interval: 0.875–0.925), the Cronbach κ coefficient was 0.775 (95% confidence interval: 0.682–0.837), and the percentage of agreement was 84.5%.Conclusion: Our results support the use of this comprehensive questionnaire as a valid tool for headache assessment among Arabic-speaking patients. Keywords: Arabic, Egypt, headache, questionnaire, validation&nbsp

Background Chronic migraine is a prevalent disabling disease, with major health-related burden and poor quality of life. Long-term use of preventive medications carries risk of side effects. Objectives The aim of this study was to compare repetitive transcranial magnetic stimulation (rTMS) to botulinum toxin-A (BTX-A) injection as preventive therapies for chronic migraine. Methods A pilot, randomized study was conducted on a small-scale sample of 29 Egyptian patients with chronic migraine, recruited from Kasr Al-Aini teaching hospital outpatient clinic and diagnosed according to ICHD-III (beta version). Patients were randomly assigned into two groups; 15 patients received BTX-A injection following the Phase III Research Evaluating Migraine Prophylaxis Therapy injection paradigm and 14 patients were subjected to 12 rTMS sessions delivered at high frequency (10 Hz) over the left motor cortex (MC, M1). All the patients were requested to have their 1-month headache calendar, and they were subjected to a baseline 25-item (beta version) Henry Ford Hospital Headache Disability Inventory (HDI), Headache Impact Test (HIT-6), and visual analogue scale assessment of headache intensity. The primary efficacy measures were headache frequency and severity; secondary measures were 25-item HDI, HIT-6, and number of acute medications. Follow-up visits were scheduled at weeks 4, 6, 8, 10, and 12 after baseline visit. Results A reduction in all outcome measures was achieved in both the groups. However, this improvement was more sustained in the BTX-A group, and both the therapies were well tolerated. Conclusion BTX-A injection and rTMS have favorable efficacy and safety profiles in chronic migraineurs. rTMS is of comparable efficacy to BTX-A injection in chronic migraine therapy, but with less sustained effect.

Antiepileptic drugs (AEDs) are commonly incriminated for vitamin D deficiency in children with epilepsy. The aim of this study was to examine 25(OH) vitamin D status among children and adolescents with genetic generalized epilepsy (GGE) who had never received AEDs and its relation to seizure frequency and epilepsy duration.This case-control study was conducted on 42 recently diagnosed patients with GGE, aged ≤18 years and 40 age- and gender-matched controls. Serum 25(OH) vitamin D level was performed for all participants.Serum 25(OH) vitamin D level was significantly lower in patients (median = 22 ng/ml, interquartile range (IQR) = 16.6-28.6) compared with controls (median = 58.4 ng/ml, IQR = 53-68), (P-value 0.001). Patients with ≥4 seizures per month had a significantly lower level of serum 25(OH) vitamin D (median = 17.7 ng/ml, IQR = 16-24) than patients with lower seizure frequency (median = 28.3 ng/ml, IQR = 24.2-40.2), (P-value = 0.004). Also, there was a statistically significant negative correlation between the duration of epilepsy and serum 25(OH) vitamin D level (r = -0.309, P-value = 0.046). The receiver operating characteristic curve analysis showed that serum 25(OH) vitamin D level with a cutoff value of 23.9 distinguished patients with low seizure frequency (five or less per year) from patients with higher seizure frequency with a sensitivity and specificity of 80% and 74%, respectively (area under the curve (AUC) = 0.798).Vitamin D deficiency is found in treatment-naive children with epilepsy and adolescents with GGE, and it is associated with higher seizure frequency, longer disease duration, and younger age at onset.

Sherif M Hamdy,1 Maged Abdel-Naseer,1 Nevin M Shalaby,1 Alaa Elmazny,1 Marian Girgis,2 Mona A Nada,1 Amr Hassan,1 Husam S Mourad,1 Mohamed I Hegazy,1 Ahmed Abdelalim,1 Nirmeen A Kishk,1 Noha T Abokrysha,1 Shaimaa A Genedy,1 Ehab A Essawy,3 Hatem S Shehata1 1Neurology Department, Cairo University, Cairo, Egypt; 2Pediatric Department, Cairo University, Cairo, Egypt; 3Division of Biochemistry, Chemistry Department, Faculty of Science, Helwan University, Helwan, Egypt Introduction: Although the frequency of pediatric-onset multiple sclerosis (POMS) has increased in recent decades, it is still highly uncommon, which creates a need for the involvement of more registries from various clinical centers.Objective: To characterize the demographic, clinical, and paraclinical features of Egyptian patients with POMS.Patients and methods: A retrospective chart review study was undertaken on 237 Egyptian patients with demyelinating events which started before the age of 18 years who attended one of five tertiary referral centers in Cairo, Egypt.Results: Multiple sclerosis was diagnosed in 186 patients, 47 (25.27%) patients had disease onset before the age of 12 years; “early-onset pediatric multiple sclerosis (EOPMS)”. The mean age of disease onset was (14.13±2.49years), with a female:male ratio of 1.62:1, none of the enrolled patients had a primary progressive course (PPMS), whereas 10 patients (5.38%) had a secondary progressive form. Approximately two-thirds of the patients had monofocal disease onset, and less than 10% presented with encephalopathy; most of them had EOPMS. Motor weakness was the presenting symptom in half of the patients, whereas cerebellar presentation was detected in 34.95%, mainly in EOPMS. Seizures (not related to encephalopathy) were more frequent in those with EOPMS. Initial brain magnetic resonance images were positive in all patients, with detected atypical lesions in 29.03%, enhanced lesions in 35.48%, black holes in 13.98%, and infratentorial in 34.41%. Cervical cord involvement was found in 68.28%. More than two-thirds of the patients received either immunomodulatory or immunosuppressant (IS) treatment throughout their disease course, and about half of them received their treatment within the first year from symptoms onset, with a more favorable outcome, and patients with highly active disease received natalizumab, fingolimod, or other IS.Conclusion: The results from this registry – the largest for MS in the Arab region to date – are comparable to other registries. Immunomodulatory therapies in POMS are well tolerated and efficacious and they can improve the long-term outcome in children. Keywords: multiple sclerosis, pediatric onset, early onset, registry, Egypt&nbsp

Sherif M Hamdy,1 Maged Abdel-Naseer,1 Nevin M Shalaby,1 Alaa N Elmazny,1 Ahmed A Nemr,2 Amr Hassan,1 Mohamed I Hegazy,1 Husam S Mourad,1 Nirmeen A Kishk,1 Mona A Nada,1 Ahmed Abdelalim,1 Amr M Fouad,1 Hatem S Shehata1 1Neurology Department, Cairo University, 2Neurology Department, Maadi Military Hospital, Cairo, Egypt Background: Multiple sclerosis (MS) is a complex autoimmune disease with a heterogeneous presentation and diverse disease course. Recent studies indicate a rising prevalence of MS in the Middle East.Objective: To characterize the demographics and disease features of Egyptian patients attending four tertiary referral MS centers in Cairo.Materials and methods: This was a retrospective, observational study on 1,581 patients between 2001 and 2015. Medical records were reviewed and data were identified and extracted in a standardized electronic registry.Results: The mean age of disease onset was 26.6±7.8 years, with the majority being female (2.11:1). Relapsing–remitting MS was the most common type (75.1%). The main presenting symptom was motor weakness (43.9%), which was also the most frequent symptom during the disease course. Family history of MS was found in 2.28%. Higher initial Expanded Disability Status Scale score, black holes, and infratentorial lesions on initial magnetic resonance imaging were independent factors for disease progression by univariate analysis (OR 3.87 [95% CI 1.84–6.51], 4.14 [95% CI 3.08–5.58], 4.07 [95% CI 3.21–4.99], respectively); however, in multivariate analysis, only infratentorial lesions were an independent risk for disease progression (OR 6, 95% CI 2.99–12.02; P=0.0005).Conclusion: The results from this registry – the largest for MS in the Arab region to date – are comparable to other registries with slight differences. Keywords: multiple sclerosis, MS registry, epidemiology, Middle East, North Africa, Egypt&nbsp