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Tuberculosis (TB) may affect the nervous system in many ways. We describe an immunocompetent teenage girl with lymph node TB who had first presented with bilateral optic neuritis. Detailed history identified features inconsistent with immune-mediated optic neuritis. Several unusual features prompted further investigation, including transient visual obscurations without raised intracranial pressure, prominent disc swelling and absence of laboratory findings to support an immune-mediated cause. Whole body PET/MR imaging identified widespread mediastinal and supraclavicular lymphadenopathy. Despite no known TB contacts, a negative interferon gamma release assay and a normal chest X-ray, a targeted lymph node biopsy confirmed TB.

IntroductionFeedback from core medical trainees and trust-grade doctors at the National Hospital for Neurology and Neurosurgery highlighted areas for improvement including induction, curriculum coverage and educational governance. A rolling programme of improvements since August 2017, facilitated by a consultant-appointed CMT Lead, was implemented in response to feedback.MethodsSpecific improvements included a paired colleague system to facilitate leave, dedicated firm timetables with clinic and acute neurology allowances, a new junior doctor handbook, overhaul of the induction programme, the appointment of clinical support workers and physician associates, daily safety huddles, regular team-building events and a case presentation competition.ResultsWe evaluated doctor satisfaction on a 6-monthly basis using an internal survey, from August 2017 to December 2019. Measures that demonstrated clear improvement included the proportion of doctors rating induction as good (14% to 83%), feeling valued as a team member (34 to 75%), deeming the job valuable for training (67% to 100%), attending teaching (39% to 50%), and those that were able to present to a consultant (41% to 58%).DiscussionThrough rolling improvements and regular feedback, job satisfaction has improved. More work remains to be done, in particular to improve attendance at protected teaching and facilitate contact with consultants.bryan.ceronie@gmail.com

General neurologists and stroke specialists are regularly referred cases of visual disturbance by general practitioners, emergency doctors and even ophthalmologists. Particularly when the referral comes from ophthalmologists, our assessment tends to focus on the optic nerve; however, retinal conditions may mimic optic neuropathy and are easily missed. Their diagnosis requires specific investigations that are rarely available in a neurology clinic. This article focuses on how a general neurologist can identify retinal problems from the clinical assessment and how to proceed with initial investigations. The following cases were all referred to a consultant neurologist (GTP) from ophthalmology services as optic neuropathies or other neurological disorders. Part A of the summary describes the presentation and findings in the neurology clinic; part B describes the subsequent specialist assessment in the neuro-ophthalmology/eye clinic.

ObjectivesTo re-evaluate serum samples from our 2007 cohort of patients with single-episode isolated ON (SION), recurrent isolated ON (RION), chronic relapsing inflammatory optic neuropathy (CRION), multiple sclerosis-associated ON (MSON) and neuromyelitis optica (NMO).MethodsWe re-screened 103/114 patients with available serum on live cell-based assays (CBA) for aquaporin-4 (AQP4)-M23-IgG and myelin-oligodendrocyte glycoprotein (MOG)-α1-IgG. Further testing included oligoclonal bands, serum levels of glial fibrillar acidic and neurofilament proteins and S100B. We show the impact of updated serology on these patients.ResultsReanalysis of our original cohort revealed that AQP4-IgG seropositivity increased from 56% to 75% for NMO, 5% to 22% for CRION, 6% to 7% for RION, 0% to 7% for MSON and 5% to 6% for SION. MOG-IgG1 was identified in 25% of RION, 25% of CRION, 10% of SION, 0% of MSON and 0% of NMO. As a result, patients have been reclassified incorporating their autoantibody status. Presenting visual acuity was significantly worse in patients who were AQP4-IgG seropositive (p=0.034), but there was no relationship between antibody seropositivity and either ON relapse rate or visual acuity outcome.ConclusionsThe number of patients with seronegative CRION and RION has decreased due to improved detection of autoantibodies over the past decade. It remains essential that the clinical phenotype guides both antibody testing and clinical management. Careful monitoring of the disease course is key when considering whether to treat with prophylactic immune suppression.

Supplemental material, MSJ831400-Supp-Methods for Clinical relevance of cortical network dynamics in early primary progressive MS by Carmen Tur, Baris Kanber, Arman Eshaghi, Dan R Altmann, Zhaleh Khaleeli, Ferran Prados, Sebastian Ourselin, Alan J Thompson, Claudia AM Gandini Wheeler-Kingshott, Ahmed T Toosy and Olga Ciccarelli in Multiple Sclerosis Journal

Evidence suggests that Epstein-Barr virus (EBV) plays a role in triggering or perpetuating disease activity in multiple sclerosis (MS).We investigated 100 subjects (50 clinically isolated syndrome [CIS], 25 relapsing-remitting [RR] MS, 25 primary progressive [PP] MS) for 1) evidence of EBV reactivation and 2) disease activity as indicated by serial gadolinium (Gd)-enhanced MRIs over a 5-year period. EBV DNA in blood was quantified by real-time quantitative PCR and EBV serology for anti-Epstein-Barr virus nuclear antigen 1 (EBNA-1) immunoglobulin G (IgG), anti-viral capsid antigen (VCA) IgG, and anti-EBV IgM. Data were analyzed using repeated measures analysis, analysis of variance, and logistic regression analysis.All subjects had serologic evidence of previous EBV infection, but no lytic reactivation was detected. Significant differences in EBNA-1 IgG titers were found between subgroups, highest in the RRMS cohort compared with PPMS (p0.001) and CIS (p0.001). Gd-enhancing lesions on MRI correlated with EBNA-1 IgG (r = 0.33, p0.001) and EBNA-1:VCA IgG ratio (r = 0.36, p0.001). EBNA-1 IgG also correlated with change in T2 lesion volume (r = 0.27, p = 0.044) and Expanded Disability Status Scale score (r = 0.3, p = 0.035).The correlation between elevated Epstein-Barr virus nuclear antigen 1 (EBNA-1) immunoglobulin G (IgG) and gadolinium-enhancing lesions suggests an association between Epstein-Barr virus (EBV) infection and multiple sclerosis (MS) disease activity. The heightened immune response to EBV in MS is specifically related to EBNA-1 IgG, a marker of the latent phase of the virus. The lack of association between acute viral reactivation in the peripheral blood and Gd(+) lesions suggests a limited role of the former in driving disease activity.

­­Copper deficiency often goes undiagnosed Patients presenting with a neurological syndrome typical of B-12 deficiency may actually be manifesting symptoms of copper deficiency, as has been recognised over the past decade.1 Most commonly, they have a progressive spinal cord syndrome resulting in poor balance due to loss of proprioception. The cases we report show that copper deficiency, which has various causes, is more common than previously realised and often goes undiagnosed. Increased awareness of this condition is vital because early diagnosis and treatment can prevent severe disability. A 65 year old man presented in 2006, having fallen in the shower on closing his eyes; he had burning and tightness affecting his feet and had recently lost weight. Over six months he became bedbound due to poor balance. He had undergone partial gastrectomy in 1973 for a duodenal ulcer. Three years before the neurological symptoms developed, he was diagnosed with asymptomatic B-12 deficiency, which was successfully treated. Initial examination showed a positive Romberg test and an inability to walk heel-to-toe. Cranial nerve examination was unremarkable. Tone and power were normal, ankle jerks were depressed, and one plantar reflex was extensor. Over six months he developed spastic weakness in his legs (hip flexion MRC grade 4), hyper-reflexia, and bilateral extensor plantar reflexes. Sensory disturbance suggested greater abnormality in the posterior columns; vibration sense was reduced to the costal margins, proprioception to the ankle, and pinprick to mid-foot level. Magnetic resonance imaging showed T2 signal abnormality in the posterior cervical cord at C2-4 (figure ⇓). Electrophysiology found lower limb motor abnormalities consistent with a motor neuronopathy, but sensory nerve action potentials were normal. Central motor conduction to the limbs (a method for examining the central motor pathways, in which the difference between the latency of motor evoked potentials …

Did these “good old days” of the NHS ever really exist? If so, it seems there is a chasm between the experience of juniors today and that of older consultants. While juniors fill in their duty diaries, dread their on-calls, and are cosseted endlessly to maximise their training and minimise their discomfort, they encounter consultants who have not only poured their entire lives into the NHS but apparently thrived on it. In my opinion, today's juniors are no less dedicated, but they are more cynical. NHS doctors have always worked long hours under adverse conditions. So why are there now so many reports of low morale within the service and of large numbers leaving? The working environment seems to have altered so much that it has deeply affected doctors' satisfaction with their work. To find out some answers, I asked two old time consultants about their different experience at the beginning of their careers. Although not rigorous scientific evidence, their thoughts and memories give some useful insights. The …

There are few things less reassuring during revision than someone who hardly knows you saying, “you'll be fine,” “they want you to pass,” and “it's just like a driving test.” The last comment was particularly alarming to me as I failed my driving test four times. And yet, horribly, in a year's time you yourself will change into someone who blithely chants “it's really hard to fail.” What gives a house officer this new found assurance is not only the knowledge that general expectation of their talents has returned to zero. It's also the certainty of survival. A large amount of time at medical school does seem to be specifically and cruelly designed to cause maximum stress, and this is often justified by the fact that you are being prepared for a …