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Letters to the Editor

intervention. When the biopsy report came in, it was clear that something had gone wrong. And when her symptoms recurred, it was obvious that the diagnosis was off the mark. The second brain imaging suggested a clue to the diagnosis. CSF analysis was the answer. With a mass lesion and papilledema there was a risk of death with the procedure. However, the progressive nature of the disease demanded a calculated risk. A guarded lumbar puncture was performed and the procedure was uneventful. In view of the patient’s diabetic[1] status, in addition to routine CSF analysis, a Cryptococcal antigen test was also ordered. This clinched the diagnosis and saved the patient. There have been several cases reported with Cryptococcal[2] and pneumococcal[3] meningitis masquerading as hemorrhage. The presenting features may be identical. Diabetes mellitus is a risk factor for both meningeal infections and cerebrovascular events. The one may be differentiated from the other by a guarded lumbar puncture for CSF analysis.[4] The case is quite instructive and humbling at the same time. It highlights the need for careful pre‑operative assessment and the importance of differential diagnosis in apparently straight forward presentations. It stresses the need for re‑evaluation and logical investigation even in post‑operative patients.

N. V. Sundarachary, A. Sridhar1 Departments of Neurology and 1General Medicine, Guntur Medical College, Guntur, Andhra Pradesh, India For correspondence: Dr. A. Sridhar, PG Hostel, Government General Hospital,

Guntur, Andhra Pradesh, India. E‑mail: [email protected]

References

Kushawaha A, Mobarakai N, Parikh N, Beylinson A. Cryptococcus neoformans meningitis in a diabetic patient – The perils of an overzealous immune response: A case report. Cases J 2009;2:209. 2. Hoque R, Gonzalez‑Toledo E, Jaffe SL. Cryptococcal meningitis presenting as pseudosubarachnoid hemorrhage. South Med J 2008;101:1255‑7. 3. Morgan LK. Pneumococcal meningitis masquerading as subarachnoid haemorrhage. Med J Aust 2003;179:559‑60;560. 4. Given CA 2 nd , Burdette JH, Elster AD, Williams DW 3 rd . Pseudo‑subarachnoid hemorrhage: A potential imaging pitfall associated with diffuse cerebral edema. AJNR Am J Neuroradiol 2003;24:254‑6. 1.

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Acknowledgments

Website: www.annalsofian.org

DOI: 10.4103/0972-2327.120444

The authors would like to thank the Department of Radiology, Guntur Medical College.

Magnetic resonance imaging and computed tomography scan findings in methanol poisoning Sir, I enjoyed reading the article titled “A rare presentation of methanol toxicity” that was published in your journal.[1] The authors mention that brain lesions typically described in methanol poisoning are in the form of hemorrhagic and non‑hemorrhagic necrosis of the basal ganglia and sub‑cortical white matter and to their knowledge, lesions in the parietal, temporal, or frontal areas of cerebrum and cerebellar hemispheres have rarely been reported in these patients to date. Therefore, after the presentation of the magnetic resonance imaging (MRI) findings in their patient’s brain, the authors state that their case is a rare presentation of infarct in bilateral parasagittal, parieto‑occipital and cerebellar regions of the brain. It should be noted that a previously published article, [2] however, gave information about 42 patients with acute methanol poisoning. Of them, 28  (66.6%) had a total of 55 pathological findings on their brain computed tomography (CT) scans, 5 (17.9%) and 7 (25%) of which were bilateral parasagittal hypodense white matter lesions in the occipital and frontal lobes, respectively. In addition, other

authors had not only previously reported the same lesions as that of the present Gupta’s case but also lesions in the frontal and temporal lobes in the brain CT and MRI of the methanol‑poisoned patients.[3‑13] This shows that the uni- or bilateral parasagittal, parietal, frontal, temporal, occipital, and cerebellar lesions seen on CT scan and MRI of the brain are documented and not rare complications of methanol poisoning although all these lesions may not concomitantly be present in a single case. If the authors had performed a simple search using PubMed, Google Scholar or SCOPUS, they could easily have retrieved the above‑mentioned studies. I suggest the authors to perform an accurate search for their review of the literature.

Hossein Sanaei‑Zadeh Emergency Room/Division of Medical Toxicology, Hazrat Ali‑Asghar (p) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

Annals of Indian Academy of Neurology, October-December 2013, Vol 16, Issue 4



Letters to the Editor Address for correspondence:

Dr. Hossein Sanaei‑Zadeh, Division of Medical Toxicology,

Emergency Room, Hazrat Ali‑Asghar (p) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran. E‑mail: h‑[email protected]

References 1. 2. 3. 4. 5. 6. 7.

Gupta N, Sonambekar AA, Daksh SK, Tomar L. A rare presentation of methanol toxicity. Ann Indian Acad Neurol 2013;16:249‑51. Taheri MS, Moghaddam HH, Moharamzad Y, Dadgari S, Nahvi V. The value of brain CT findings in acute methanol toxicity. Eur J Radiol 2010;73:211‑4. Lin SH, Tseng GF, Liang CC, Hung YC. Methanol intoxication with bilateral putaminal and occipital necrosis. Tzu Chi Med J 2010;22:160‑3. Askar A, Al‑Suwaida A. Methanol intoxication with brain hemorrhage: Catastrophic outcome of late presentation. Saudi J Kidney Dis Transpl 2007;18:117‑22. Sefidbakht S, Rasekhi AR, Kamali K, Borhani Haghighi A, Salooti A, Meshksar A, et al. Methanol poisoning: Acute MR and CT findings in nine patients. Neuroradiology 2007;49:427‑35. Chen JC, Schneiderman JF, Wortzman G. Methanol poisoning: Bilateral putaminal and cerebellar cortical lesions on CT and MR. J Comput Assist Tomogr 1991;15:522‑4. Gaul HP, Wallace CJ, Auer RN, Fong TC. MR findings in methanol intoxication. AJNR Am J Neuroradiol 1995;16:1783‑6.

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8. Rubinstein D, Escott E, Kelly JP. Methanol intoxication with putaminal and white matter necrosis: MR and CT findings. AJNR Am J Neuroradiol 1995;16:1492‑4. 9. Yun CB, Kim MK, Kang SS, Park HM, Jeong HM, Shin DJ. A case of methanol intoxication with multifocal enhancing lesions in brain magnetic resonance imaging. J Korean Neurol Assoc 2000;18:330‑332. [article in Korean] 10. Nagasawa H, Wada M, Koyama S, Kawanami T, Kurita K, Kato T. A case of methanol intoxication with optic neuropathy visualized on STIR sequence of MR images. Rinsho Shinkeigaku 2005;45:527‑30. [article in Japanese] 11. Vyas S, Kaur N, Sharma N, Singh P, Khandelwal N. Methanol poisoning. Neurol India 2009;57:835‑6. 12. Tunçyürek Ö, Tarhan  S, Örgüç Ş, Atalar  M, Nuri Şener R. Computed tomographic reversal sign in an adult with methanol intoxication. J Clin Anal Med 2012;3:359‑60. 13. Glazer M, Dross P. Necrosis of the putamen caused by methanol intoxication: MR findings. AJR Am J Roentgenol 1993;160:1105‑6. Access this article online Quick Response Code:

Website: www.annalsofian.org

DOI: 10.4103/0972-2327.120446

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Annals of Indian Academy of Neurology, October-December 2013, Vol 16, Issue 4

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