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Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by autonomic and inflammatory features. There is paucity of data regarding sustained benefits of any treatment modality. We aimed to document the effect of steroids in CRPS on long-term basis.We came across five patients of CRPS in Out Patient clinics of super-speciality Institutes in North India. All five cases fulfilled the Budapest criteria for the diagnosis of CRPS. All of them received prednisolone and were prospectively followed up for 2 years. Treatment outcome was carefully recorded in all affected modalities.All five cases were found to have excruciating neuropathic pain in defined regions along with cutaneous manifestations. Osseous changes in the form of surface erosion of underlying bones in four cases and marked marrow edema leading to considerable increase in bone thickness in one case were noted. All these features improved considerably following steroid therapy. Bone marrow edema and bone resorption showed improvement on serial imaging.Apart from pain relief, steroids therapy is capable of reversing the osteo-cutaneous autonomic changes of CRPS type I.

Even though infection with SARS-CoV-2 presents primarily with respiratory symptoms, unusual clinical manifestations have also been reported during the current pandemic. In May 2020, a middle-aged man presented to us with three episodes of impaired consciousness, which clinically appeared to be syncopal episodes. Patient had history of a single episode of mild fever 6 days prior to presentation, not accompanied by any respiratory symptoms. As a routine, swab for SARS-CoV-2 was sent and he tested positive. Holter recording was able to record sinus bradycardia followed by junctional escape during one such episode. Patient was managed symptomatically and there was no further recurrence of syncope.

Background As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. Aims The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. Methods The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. Results A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. Conclusions Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Movement disorders classically have an insidious onset and slow progression and are usually not associated with emergency situations. Infrequently, there do arise rapidly evolving movement disorders or acute complications of existing movement disorders that need immediate attention and rapid management which can be life-saving [1, 2]. This chapter deals with the clinical presentation, diagnosis and management of some common movement disorders presenting to the emergency department (ED).

In amyotrophic lateral sclerosis (ALS), death wish is expressed in a varying proportion of patients in different countries. In this first study from India, influence of belief system of religion/spirituality and attitude towards death, widely prevalent in the country, in decision making, was evaluated.Twenty ALS patients were assessed using 'Wish-to-Die Questionnaire' (WDQ) developed to reflect seven domains, namely religion/spirituality, belief in karma, meaning of life, hope, family support, financial support and death wish. Functional impairment, depression, hopelessness and suicidal ideation were assessed by ALS Functional Rating Scale, Beck's Depression Inventory, Beck Hopelessness Scale and The Scale of Suicidal Ideation, respectively.On WDQ, all the 20 patients had belief in religion/spirituality, had hope and family support. Nineteen patients (95%) believed in karma, 16 (80%) still found life meaningful and 15 (75%) had financial support. Six patients (30%) had mild to moderate depression; hopelessness was present in 6 (30%) and suicidal ideation was present in one (5%). The 5 (25%) patients who expressed death wish did not significantly differ from others in 6 domains (religion/spirituality, belief in karma, meaning of life, hope, family support, financial support) of WDQ. The main reason in 3 patients who expressed death wish was lack of financial support. The fourth patient could not find meaning of life after the onset of illness, and the fifth wished to end his life since he had satisfactorily fulfilled all his responsibilities.Smaller proportion of patients of ALS expressed death wish in India compared to the Western countries. This may be attributed to belief in religion/spirituality and karma, having meaning of life and family support. As this is the first report from India, useful information may be obtained if similar studies are done on a larger sample.

Wilson's disease is a rare autosomal recessive disorder of copper transport due to mutations in the ATP7B gene, responsible for transport of copper into bile from hepatocytes and its incorporation into apoceruloplasmin to form ceruloplasmin resulting in excessive accumulation of copper in the liver and extrahepatic tissues. Clinical features of WD result from toxic accumulation of copper in liver, brain and kidney. Early diagnosis is mandatory to initiate early treatment to prevent morbidity and mortality. More than 400 mutations have been reported, some of which are rather characteristic of geographical regions and ethnic population. Genetic testing is not useful as a routine procedure, but has its role in at risk individuals such as siblings and children of probands and in individuals with suggestive symptoms but where other tests are contradictory.

Diamond-Gardner Syndrome or autoerythocyte sensitization is a rare syndrome characterized by spontaneous development of painful edematous skin lesions progressing to ecchymoses over the next 24 hours. Severe stress and emotional trauma always precede the skin lesion. We present here a case of 15 years old girl who presented with multiple ecchymotic patches over the body with conversion disorder. Baseline biochemical, hematological and immunological investigations were normal. Skin biopsy showed no evidence of vasculitis. All routine coagulation investigations were normal. Therefore the diagnosis of Gardner-Diamond Syndrome was made on purely clinical grounds. It was therefore a diagnosis of exclusion. A high index of suspicion and Psychiatric evaluation were necessary to make the diagnosis.

Patients with tuberculous meningitis (TBM) have been frequently observed to have excessive sleep during the day and frequent awakenings during night. We undertook this study to evaluate sleep related abnormalities in patients with TBM since there is no published literature pertaining to the same.To study sleep wake cycles in patients with tuberculous meningitis by actigraphy and sleep logs and compare these with age and sex matched controls.Consecutive patients admitted with tuberculous meningitis were studied clinically and with three days of continuous wrist actigraphy and sleep/wake parameters were compared to those of age and gender matched normal healthy controls.Forty three patients with tuberculous meningitis were enrolled in the study. Of these, twenty-eight patients (15 females, 13 males; mean age 31.64 years) who were able to complete adequate actigraphy were compared with an equal number of controls (15 females, 13 males; mean age 30.93 years). Patients were found to have greater sleep time (p0.0005) and more sleep episodes (p0.0005) during the day while during the night they had less sleep (p0.0005) with more frequent (p=0.019) and longer (p0.0005) awakenings as compared to normal controls. Majority of the patients had reversal of sleep/wake cycles. There was poor co-relation between sleep parameters measured by actigraphy and sleep logs.Tuberculous meningitis is associated with significant alteration of sleep-wake circadian cycles. This needs to be further characterized through studies involving polysomnography. There is a need to address these specific sleep difficulties to improve the quality of life of the patient as well as the care-giver.