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We report a case of changing semiology of intractable right temporal lobe epilepsy. The patient’s semiology of ictal spitting, altered awareness, automatisms and occasional secondary generalization remained stable for many years. 3T MRI head was normal, and subsequent advanced imaging and neu- rophysiology localised the seizure focus to the right temporal lobe and surrounding regions. He received a right temporal lobectomy, with subsequent redo surgery due to incomplete margins. These did not confer seizure freedom. Subsequently his seizure semiology changed to episodic fluent dysphasia with preserved awareness. This was correlated with scalp EEG changes now showing lateralisation to the bilateral temporal lobes.This case demonstrates that seemingly unilateral temporal lobe epilepsy may arise from bilateral networks, which can manifest for years from one hemisphere. It is also possible that extra-temporal origin seizures (for example from perisylvian, fronto-basal or parietal locations) can manifest with temporal-like semiology and can spread to either temporal lobe, and thus can be a cause of epilepsy surgery failure.nchlasim@doctors.org.uk35

Pre and post-herpetic SUNCT syndrome is a rare but previously reported complication of herpes zoster reactivation. We report a case of a zoster associated SUNCT syndrome developing at the same time as reactivation.A 79-year-old gentleman was referred to Neurology for refractory right sided facial pain. 7 months prior to presentation he had developed shingles in the right upper face around his forehead area, which was managed by his GP. At the same time, he developed daily attacks of sharp stabbing pain behind his eye, up to 5 a day, lasting up to 5 minutes each. This was associated with injection and lacrimation of the affected eye. The attacks can be triggered by touch, such as a shower. Neurological examination was unremarkable except for allodynia in the right V1 distribution. Plain MRI scan showed cortical atrophy only.He had a good response to lamotrigine. nchlasim@doctors.org.uk

GNE myopathy is an adult-onset autosomal recessive distal myopathy uniquely characterised by quadri- ceps sparing. It was previously described in Japanese patients and a large ethnic cluster was identified in Jews originating from Iran. Since then, it is recognised to have a worldwide prevalence with multiple pathogenic variants. While compound heterozygous c.830G>A GNE myopathy has previously been reported, homozygous disease has only previously been reported in a non-Jewish Iranian cohort and the Indian subcontinent. Here we report a case of apparent homozygous c.830G>A GNE myopathy in a non-Jewish Iraqi patient.

We present a case of Tolosa-Hunt syndrome with a headache phenotype mimicking a right-sided trigemi- nal autonomic cephalagia (hemicrania continua), and serial MRI imaging showing a stable enlarged pituitary. She was diagnosed initially with common migraine, revised to hemicrania continua, then chronic daily headache, before finally arriving at her diagnosis. She tried multiple anti-migraine therapies and her best response was to indomethacin, discontinued due to gastrointestinal side effects. Her diagnosis was achieved after her headache changed to a left sided headache with a left sided cavernous sinus syndrome, 4 years into her disease course, despite her serial surveillance scans. She responded well to steroids.This case demonstrates Tolosa-Hunt syndrome may not be side-locked, and the need to consider inflam- matory causes of headache when faced with a patient with persistent headaches and ‘incidental’ pituitary adenoma.nchlasim@doctors.org.uk54

Serotonin syndrome associated with clozapine withdrawal and concurrent selective serotonin reuptake inhibitor (SSRI) use has previously been reported.A 56-year-old female with schizophrenia was admitted for pyrexia, rigidity, and altered mental state after her second dose of clozapine restart. She had discontinued her long-term clozapine 2 weeks prior. She developed ventilatory failure, reduced consciousness, eye deviation, and worsening rigidity, requiring ICU support. Examination showed a right upper motor neurone syndrome with absent ankle reflexes.She had raised inflammatory markers and creatine kinase. Serum neuropathy, encephalitis screen, and COVID PCR were negative. Respiratory investigations were unfruitful. MRI head and spine did not show brain or cord signal change to correlate to signs. Lumbar puncture showed a quiet CSF, negative culture, viral PCR, and encephalitis antibodies. EEG showed bihemispheric background slowing.Despite clinical improvement, repeat examination showed persistent signs. She was diagnosed with serotonin syndrome after developing a bilateral tremor. Treatment with cyproheptadine correlated with an improvement in her signs, cognitive state, and EEG.Serotonin syndrome can present with reversible neuromuscular signs. With clozapine withdrawal, it can require a prolonged time course of recovery in contrast with classical serotonin syndrome. Cyprohepta- dine can cause agranulocytosis and this delays clozapine restart.

Guillain-Barré syndrome (GBS) is an acute, monophasic, polyradiculoneuropathy usually provoked by a preceding infection. The cardinal features are progressive weakness in the upper and lower limbs accompanied by loss of deep tendon reflexes. The diagnosis is made on the basis of the clinical history and examination findings, supported by typical cerebrospinal fluid and electrophysiology findings. Trauma and surgery are well understood but rare precipitants of GBS, which clinicians should be aware of, in order not to miss an opportunity to use immunomodulatory therapies. Furthermore, the presence of postsurgical or post-traumatic GBS should prompt careful assessment for underlying malignancy or autoimmune disease associated with an acute demyelinating polyradiculoneuropathy. Here, we present a case of post-traumatic GBS and discuss the potential mechanisms that might underlie this, as well as the investigations and treatment that should be considered.

Tolosa-Hunt syndrome is understood as a steroid-responsive, relapsing-remitting, unilateral headache disorder associated with ipsilateral cranial neuropathies, of a probable granulomatous aetiology. The diagnosis is made clinically from the history and examination, supported by appropriate imaging. Here the authors report a case of Tolosa-Hunt syndrome with a headache phenotype mimicking a trigeminal autonomic cephalalgias (hemicrania continua), and serial MRI studies showing a stable enlarged pituitary. Due to her initial lack of clinical signs, she was diagnosed with chronic migraine, revised to hemicrania continua based on indomethacin response, then revised back to chronic migraine. Her final diagnosis was achieved after she developed a left cavernous sinus syndrome 4 years into her disease course. This case shows that Tolosa-Hunt syndrome may present with a non-side-locked headache and delayed development of clinical signs. Clinicians should also maintain a high degree of suspicion when faced with incidental MRI findings.

Vasculitis and other autoimmune conditions are known complications of tumour necrosis factor alpha (TNF-α) inhibitor use. By definition, TNF-α inhibitor induced vasculitis is a secondary systemic vasculitis. However, its phenotype is varied and can present as an isolated vasculitic neuropathy. This presents a diagnostic challenge as the gold standard for diagnosis of a vasculitic neuropathy is a peripheral nerve biopsy that meets predefined histopathological criteria. Given the poor sensitivity of the peripheral nerve biopsy, it is important that clinicians take a good history and maintain a high index of suspicion, as this is a treatable iatrogenic condition. Here we present a case of adalimumab-induced sensory vasculitic neuropathy, treated according to the Peripheral Nerve Society guideline for non-systemic vasculitic neuropathy, given her disease phenotype.

The e-prescribing system at the Great Western Hospital offers a note taking system that pharmacy uses to record a 24-hour drug history and allows users to add notes clarifying any changes.A QI project aimed to reduce near-misses caused by prescribing errors by increasing the utilisation of the 24-hour drug history and note system. This was done via education targeted at the primary users of the system using pre-existing channels in the trust. Three cycles of interventions were implemented: teaching the prescribers how to use the system during teaching sessions, increasing publicity via posters in clinical areas and trust mailing lists, and making a version of the guide available on the trust intranet.The primary measure was the number of near-misses identified from pharmacy phone calls to the medical team in a 24-hour period, which fell from 22 to 10 to 8 to 7. Secondary measures were the percentage drug histories being ‘read’, which improved from 12.77% to 23.26% initially but fell to 2.38% and 4.65%; and the percentages of drug charts with notes clarifying discrepancies which changed little despite intervention from 18.92% to 28.00% to 33.33% to 29.54%.The interventions show that it is possible to use existing trust education channels to produce a sustainable reduction in near-misses. The reduction in percentage drug histories being ‘read’, and the lack of change in the percentages of drug charts with notes clarifying discrepancies illustrate the challenges in using an e-prescribing system.