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A 17-year-old Pakistani female patient presented with acute onset flaccid quadriparesis with nerve conduction studies showing demyelinating polyneuropathy consistent with Guillain-Barre' syndrome. She was treated with 4 plasmapheresis sessions. She developed raised blood pressure, headache, visual loss and generalised seizures on the 13th day of admission. MRI of the brain on contrast showed findings of altered signals low on T1-weighted image, high on T2-weighted image and fluid-attenuated inversion recovery in the white matter of bilateral occipital, parietal and right frontal lobe consistent with posterior reversible encephalopathy syndrome. The patient was administered antiepileptic and antihypertensive drugs to control seizures and blood pressure. She was discharged in a stable state. On follow-up her visual loss had recovered completely and she had regained full motor strength in all four extremities after 6 weeks. Fresh MRI of the brain revealed complete resolution of lesions. Antihypertensive and antiepileptic medication was discontinued. She is independent in all her daily activities.

Central nervous system (CNS) involvement in SARS-CoV-2 is now a known fact, likely due to viral transmission through the olfactory nerve and high brainstem viral load, which also suggests dissemination in the ambiguus and solitary nuclei from the respiratory tract via the vagus nerve. 1 Anosmia and ageusia findings are justified by a potential large cohort study. It may only be an interesting coincidence that hyposmia disorders are normal in premature Parkinson's disease (usually only in the prodromal phase) and the olfactory system is an early favored site for alpha-synuclein linked diseases. 2 Chorea is a hyperkinetic movement disorder characterized by involuntary brief, sudden and irregular movements. 3 Chorea patients may not recognize irregular movements immediately since they are discreet, and some gestures can be temporarily blocked by parakinesia. The inability to maintain voluntary contraction, as observed during the milkmaid grip test and in individuals with persistent tongue protrusion, is a characteristic of chorea. Chorea can cause irritability and gaucheness. Chorea can be hereditary or acquired, generalized or localized and can have several etiologies, such as viral infection and acute stroke. A 58-year-old male, with known hypertension and no travel history, was brought to the emergency room (ER) at 1:00 pm with complaints of abnormal movements of the hands and feet with an inability to talk properly. The patient was very irritable during the initial ER visit, and intravenous (IV) midazolam was given to control movements. Consultation with the neurology department was requested (Supplementary Video 1 in the online-only Data Supplement). The neurology resident on duty re

ContextThe role of glycated haemoglobin (HbA1c) in the prediction of ischaemic stroke in individuals without diabetes is underestimated.AimsWe performed a study to analyse the role of HbA1c in the risk prediction of ischaemic stroke in Pakistani population without diabetes. We further studied the difference between HbA1c values of individuals with diabetes and without diabetes with stroke.Settings and designSingle centre, case–control.Materials and methodsIn phase I, a total of 233 patients without diabetes with ischaemic stroke and 245 as controls were enrolled. Association of HbA1c levels, lipid profiles and blood pressure recordings with ischaemic stroke was analysed. In phase II, comparison was done between diabetics and non-diabetics with stroke.Statistical analysisComparison of the mean variables was performed with Student's t-tests. Logistic regression analysis with ischaemic stroke as the dependent variable was performed for phase I.ResultsIn phase I, the ischaemic stroke group had significantly higher HbA1c levels (5.9±2.9% vs 5.5±1.6%) compared with controls (p<0.05). Triglyceride cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, diastolic blood pressure and HbA1c were the significant determinants of stroke (p<0.05). In phase II, mean HbA1c values were significantly higher in the diabetes group (7.6±2.1 vs 6.1±2.3) (p<0.05) but other parameters were not statistically significantly different (p>0.05).ConclusionsHigher HbA1c indicated a significantly increased risk for ischaemic stroke. An HbA1c value above 5.6% (prediabetic range) predicted future risk of stroke and efforts to maintain glucose level within the normal range (≤5.6%) in individuals with high cardiovascular risk are important.

Mononeuritis multiplex (MM) is a common variant of a peripheral neuropathy which is characterized by neurological discrepancies that afflict two noncontiguous nerve systems. It is mostly associated with systemic illnesses such as diabetes mellitus, vasculitis, systemic lupus erythematosus (SLE), viral infections including human immunodeficiency virus (HIV) and paraneoplastic syndromes. Lymphoma is a common antecedent to paraneoplastic syndromes that cause peripheral neuropathies but a specific presentation of MM is a rare predicament per our literature analysis.