A Patient with Post Infectious Immune Mediated Neuropathy (Miller Fisher Syndrome)

The Miller Fisher variant is an uncommon but well known syndrome being described as a triad of areflexia, ataxia and complex ophthalmoplegia. It is characterized by antibodies against myelin that affects peripheral nerves, extraocular muscles and Schwann cells. Anti-ganglioside antibodies have been recognized in disease pathogenesis and decreasing antibody production is the mainstay of treatment. The course is usually benign with improvement after immunomodulation. This case report describes the approach to a patient suspected of having a demyelinating disorder. It delineates the subsets of immune mediated neuropathies in evaluating the diagnosis and emphasizes the need for early therapeutic intervention in achieving a good clinical outcome.

The Epidemiology and Spatial Analysis of Stroke in Trinidad and Tobago in the First Decade of the 21^stCentury (2000-2009)

Objective: To investigate the pattern and distribution of stroke in Trinidad and Tobago from 2000-2009. To identify the prevalence of co-morbid conditions among new stroke patients during the period under surveillance. Methods: Data were collected from May 2010 to July 2010 from the clinic of 728 new persons treated stroke at one of the main treatment centers. Variables measured included age, gender ethnicity, smoking status and co-morbid conditions. SPSS (Version 17) for Windows and ARC GIS version 9.3 were used to facilitate both descriptive and inferential data analysis. Results: Of the 728 new hospital admissions for the period January 2000-December 2009 for stroke, 369 (50.7%) were males and 359 (49.3%) were females. 59.8% were South-East Asian;30.5% were African and 9.7% were mixed ethnicity. The predominant age group was 60 - 69 years (n = 215, 29.5%) while less than 1% were under 30. Ischemic stroke accounted for 352 (48.4%) of all new cases for the period;Hemorrhagic stroke accounted for 14.6% (n = 107), with 37% (n = 269) classified as other unspecified condition (including unknown). Of the 728 cases examined, 171 patients died before being discharged and 552 were treated and discharged. Information of 5 cases was not available. Using this data, the overall case fatality ratio was calculated as 23.5%, with the case fatality ratio for males being 23.2% and the equivalent ratio for females being 22.9%. Using a standard classification, the majority, (n = 389, 53.4%), of cases were classified as mild;246 (33.8%) were deemed moderate, and 93 (12.8%) were severe cases. Hypertension was clinically diagnosed in 80.9% of the cases;56.3% were diabetic, and 21.7% were classified as smokers having been either past or current smokers. Other lifestyle risk factors such as obesity and exercise were not examined due to the lack of the relevant data. The most frequent cardiovascular risk factor was chamber enlargement being present in 33.2%, while the second most frequent was left ventricular hypertrophy, 26.9%. The other cardiovascular risk factors examined included Ischemic heart disease, atrial fibrillation and previous myocardial infarction. All of which were present in less than 15% of the patients. Conclusion: The incidence of stroke in Trinidad and Tobago continues to be an important public health challenge as we complete the first decade of the 21 century. We provide important evidence on the changing epidemiological patterns of the disease, providing the first attempt to describe a possible stroke belt in the southern half of the island.

Renal Replacement Therapy in a Caribbean Population: The Impact of Biological, Sociocultural and Demographic Factors

Background: The options for renal replacement therapy for end stage renal disease include haemodialysis (HD), peritoneal dialysis (PD) and renal transplantation. In this study demographic, sociocultural and biological factors were assessed over a 1-year period for patients on renal replacement therapy. Methods: This cross-sectional study included all patients 18 years and older and on renal replacement therapy for at least 3 months in Trinidad and Tobago. Five hundred and thirty participants were recruited from our organ transplantation unit, all centres facilitating PD and a stratified random sample of all HD centres (100 T, 80 PD, 350 HD from October 2015 to October 2016. A questionnaire was administered and included demographics, knowledge and understanding and biological factors impacting on renal replacement therapy. Results: Thirty eight percent of all patients were between 56 to 65 years of age. The Indo Trinidadian population accounted for 51% of the subjects. 52.5% were male and 47.5% were female. From the data, 72% of patients were diabetic and/or hypertensive. In the transplant recipients, 39% were diabetic and/or hypertensive and 27% reported chronic glomerulonephritis as the aetiology of their kidney failure. The diagnosis of chronic kidney disease was made when patients were at end stage renal disease requiring intervention in 84.2% of persons. The employed population of patients constituted 65% of renal transplant recipients, 43.75% of peritoneal dialysis patients and 22.86% of haemodialysis patients. The patient’s physician had the greatest influence on renal replacement therapy choice (85.4% haemodialysis, 85% peritoneal dialysis, 71% transplant). Conclusions: In this cohort of 530 patients on renal replacement therapy, knowledge of therapy and physician’s influence were some of the factors that impacted on choice of therapy. Most patients were already de novo end stage renal disease when the diagnosis of kidney disease was made. Lifestyle diseases-type 2 diabetes mellitus and hypertension were the main causative diseases contributing to renal failure. This study which is the first in the Caribbean to evaluate biological, sociocultural and demographic factors in patients receiving renal replacement will better assist in prevention strategies and resource allocation.

Large Vessel Vasculitis in a Patient with Systemic Lupus Erythematosus Presenting as Takayasu’s Pulseless Arteritis

Systemic lupus erythematosus (SLE) with an associated aortoarteritis presenting as an ischemic stroke is a rarity in the medical literature. We report the case of an 11-year-old male presenting with an acute ischemic stroke meeting the criteria for the diagnosis of SLE and findings consistent with an aortitis on imaging but mimicking the diagnosis of Takayasu’s pulseless arteritis. Blood and imaging investigations revealed the finding of SLE aortitis following an acute stroke presentation. Thus, it is imperative to note that even though it is infrequent, SLE can be associated with a large vessel vasculitis.

Endovascular Coiling for a Ruptured Proximal Lenticulostriate Artery Aneurysm

Aneurysms of the lenticulostriate artery （LSA） are rare lesions that are categorized into either proximal （at the junction of the middle cerebral artery trunk） or distal （within the basal ganglia）.