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the anatomy of the aneurysm, associated vascular anomalies and patient preferences. After explaining all the options available, our patient elected to undergo clipping. Post-surgery patient had an uneventful recovery and post-operative check CT angiogram showed obliteration of the aneurysm with good flow in both the distal A2.

Ananthan Raghothaman, Lekha Pandit1 Departments of Neurosurgery, and 1Neurology, K S Hegde Medical Academy, Mangalore, Karnataka, India E-mail: [email protected]

References 1. 2. 3. 4.

Gewirtz RJ, Awad IA. Giant aneurysms of the proximal anterior cerebral artery: Report of three cases. Neurosurgery 1993;33:120-4. Dashti R, Hernesniemi J, Lehto H, Niemelä M, Lehecka M, Rinne J, et al. Microneurosurgical management of proximal anterior cerebral artery aneurysms. Surg Neurol 2007;68:366-77. Suzuki M, Onuma T, Sakurai Y, Mizoi K, Ogawa A, Yoshimoto T. Aneurysms arising from the proximal (A1) segment of the anterior cerebral artery. A study of 38 cases. J Neurosurg 1992;76:455-8. Wanibuchi M, Kurokawa Y, Ishiguro M, Fujishige M, Inaba K. Characteristics of aneurysms arising from the horizontal portion of the anterior cerebral artery. Surg Neurol 2001;55:148-54. Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128339

Received: 09-12-2013 Review completed: 19-12-13 Accepted: 26-01-2014

A rare case of Guillain-Barre syndrome following scrub typhus Sir, Scrub typhus is an acute febrile disease caused by Rickettsia. The neurological complications of s c r u b t y p h u s i n c l u d e a s e p t i c m e n i n g i t i s , [1] meningoencephalitis,[2] seizures, delirium, hearing loss, cerebellitis, myelitis. Very few cases of Guillain-Barre syndrome (GBS) have been reported. [3-5] We report probably the first case of GBS from India. Here, we report the first case of GBS following scrub typhus from India.


Figure 1: Scrotal eschar after scab has fallen

Table 1: Electrodiagnostic studies

Nerve Motor Left femoral Left median Left peroneal Left tibial Left ulnar Right femoral Right median Sensory Right median

Latency (ms)


Nerve conduction velocity (m/s)

10.42 7.71 15.10 11.15 5.00 8.23 12.19

0.8 4.0 0.5 7.3 5.3 1.6 0.9

25.91 21.90 22.63 41.09 47.10 32.81 32.89




CMAP = Compound motor action potentials

A 41-year-old male farmer by occupation presented with moderate to high grade fever of 7 days duration and brick red rashes on the anterior chest with tender and enlarged lymph nodes of 2-3 cm in both inguinal region. A painless, non-itchy ulcerated lesion of 1 cm × 2 cm with an erythematous halo in the lower part of the scrotum was present [Figure 1]. Investigation work-up including complete blood picture, biochemistry, Widal test, and test for malaria parasite was normal. Serological tests for hepatitis B, hepatits C, human immunodeficiency virus 1 and 2, cytomegalovirus, Ebstein-Barr virus, Leptospira, and herpes simplex virus was negative. Scrub typhus antibody was positive (solid phase immunochromatographic assay). Lymph node biopsy of inguinal region revealed reactive lymphadenitis. Patient improved with doxycycline and discharged on 4th day. The patient was readmitted after 4 days of discharge with an acute onset flaccid quadriparesis, first involving lower limbs and evolving over the next 24 h to involve both upper limbs. Examination revealed left lower motor neuron type of facial paresis and hypotonia of all the four limbs with

Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1

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motor power of 2/5. The anterior abdominal muscles and paraspinal muscles showed marked weakness and patient could not support self in sitting position. Deep tendon reflexes were not electable and plantar responses were flexor. Cerebrospinal fluid (CSF) analysis showed albuminocytologic dissociation (protein 196, cell count-02). Electrodiagnostic studies were suggestive of demyelinating neuropathy [Table 1]. F-Waves were absent in all tested nerves. With the diagnosis of GBS, patient was treated with five cycles of plasmapheresis. Over a period of 2 weeks there was gradual improvement in motor power to 4/5 and he was discharged after 4 weeks. In this patient serology for viral infections that predispose to GBS was negative. In this patient, there was a clear temporal relationship between scrub typhus infection and the onset of flaccid weakness. Electrodiagnostic studies and CSF studies showing albino-cytological dissociation were suggestive of acute inflammatory demyelinating polyradiculoneuropathy, a type of GBS.

M. Sawale Vishal, Sanjay Upreti, Th. Suraj Singh, N. Biplab Singh, Th. Bhimo Singh Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India E-mail: [email protected]

References 1. 2. 3. 4. 5.

Silpapojakul K, Ukkachoke C, Krisanapan S, Silpapojakul K. Rickettsial meningitis and encephalitis. Arch Intern Med 1991;151:1753-7. Kim DE, Lee SH, Park KI, Chang KH, Roh JK. Scrub typhus encephalomyelitis with prominent focal neurologic signs. Arch Neurol 2000;57:1770-2. Lee MS, Lee JH, Lee HS, Chang H, Kim YS, Cho KH, et al. Scrub typhus as a possible aetiology of Guillain-Barré syndrome: Two cases. Ir J Med Sci 2009;178:347-50. Ju IN, Lee JW, Cho SY, Ryu SJ, Kim YJ, Kim SI, et al. Two cases of scrub typhus presenting with Guillain-Barré syndrome with respiratory failure. Korean J Intern Med 2011;26:474-6. Lee SH, Jung SI, Park KH, Choi SM, Park MS, Kim BC, et al. Guillain-Barré syndrome associated with scrub typhus. Scand J Infect Dis 2007;39:826-8. Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.128340

Received: 10-12-2013 Review completed: 29-01-2014 Accepted: 26-01-2014

Neurology India | Jan-Feb 2014 | Vol 62 | Issue 1

Peripheral nerves and muscles involvement by nonHodgkin’s lymphoma seen on FDG PET/CT scan Sir, Neuromuscular involvement by lymphoma is rare and unique entity. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is useful diagnostic modality in its evaluation. Here, we present a case of non-Hodgkin’s lymphoma involving muscles and peripheral nerves. A 60-year-old female had non-Hodgkin’s lymphoma of sacral nerve roots. She had received chemotherapy and radiotherapy for the same. Later, she presented with foot drop and recurrence was suspected. She underwent whole body FDG PET/CT for evaluation of her disease status. Whole body maximum intensity projection PET image [Figure 1] shows increased FDG uptake in subcutaneous soft-tissue density lesions in the right axillary region, pericardial soft-tissue deposit, enlarged sciatic nerves; the fused PET/CT image shows increased FDG uptake in fusiform enlargement of sciatic nerves [Figures 2 and 3]. Increased FDG uptake is also seen in left tibial and peroneal nerves, left soleus [Figure 4] and plantar muscles [Figure 5]. These findings, in view of known history of lymphoma, are suggestive of recurrence of the disease with predominant neuromuscular involvement. Involvement of peripheral nervous system by lymphoma is termed as “Neurolymphomatosis”, the term coined by Lhermitte and Trelles.[1] According to International Primary Central Nervous System (CNS) Lymphoma Collaborative Group who retrospectively analyzed 50 patients, the affected neural structures included peripheral nerves in 60%, spinal nerve roots in 48%, cranial nerves in 46% and plexus in 40% and multiple site involvement in 58%.[2] Nerve involvement in lymphoma is due to direct infiltration of peripheral nerves by lymphomatous cells and neurological complications occur due to direct axonal damage.[3] Four different clinical presentations have been mentioned – painful infiltration of nerves or roots, painful or painless cranial neuropathy, painless involvement of peripheral nerves and painful or painless involvement of a single peripheral nerve.[4] Peripheral neuropathy can also occur as paraneoplastic symptom in some form of lymphoma due to various antibodies.[5,6]


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A rare case of Guillain-Barre syndrome following scrub typhus.

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