A Case of Gas Geyser Syndrome with Peculiar Findings on MRI Brain
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.319197
Source of Support: None, Conflict of Interest: None
Neurological syndromes due to acute carbon monoxide toxicity, arising from the use of gas geysers, have been described in India.
The typical findings seen on magnetic resonance imaging (MRI) of brain in gas geyser syndrome are bilateral symmetrical hyperintensities in globi pallidi and white matter lesions, especially in the periventricular region. We report a case with peculiar neuroimaging findings, not frequently described.
A 31-year-old healthy lady went for a trip to a hill station. After going for a bath, she didn't come out for an hour. On forcibly opening the door of the bathroom, she was found unconscious on the floor without any tonic movements of the limbs or frothing at mouth. The entire bathroom was full of toxic fumes. She was rushed to a nearby hospital and given oxygen therapy and intravenous fluids. She regained consciousness within half an hour. A week later, she presented to us with complaints of acute onset memory disturbances, blurring of vision, and headache for four days. She had complete amnesia of the event.
On physical examination, her vitals were stable. She had both anterograde and retrograde amnesia. Her visual acuity was affected (left eye- 6/60, right eye- 6/36; near vision- N18 bilaterally). Color vision was significantly impaired in both eyes. Fundus examination revealed bilateral temporal disc pallor. The remainder of her general and systemic examination was normal.
Her routine blood investigations (including hemogram, liver, and renal function tests) were normal. MRI Brain [Figure 1] revealed symmetrical signal abnormality in bilateral occipital cortices, hippocampi, and cerebellar cortex. These areas were hyperintense on T2W and FLAIR images and showed restricted diffusion and mild patchy post contrast enhancement. MR Angiography was normal.
Her headache gradually subsided, however, memory disturbances persisted. Visual acuity improved to 6/18 in both eyes and color vision improved significantly over next five days. In retrospect, we found that the hotel where she had checked in used gas geysers. We postulate that her clinical syndrome was due to acute carbon monoxide toxicity.
Very often, such cases present to the emergency room with sudden unconscious state. Various other symptoms including rarely a delayed onset of neuropsychiatric symptoms are described. Visual impairment, which may be transient, with normal to near normal recovery has been noted in both children and elderly patients.
Besides the typical changes described in the globi pallidi, demyelination and hemorrhage (affecting cerebral cortex as well as subcortical white matter), cerebral atrophy and focal structural lesions are described. The temporal lobe and hippocampus are more commonly affected than the cerebral cortex.
In our case, the typical changes in the basal ganglia were not seen. This probably emphasizes the fact that various mechanisms of toxicity exist. Affection of different areas of the brain is duration dependent, and certain areas like hippocampus are also equally predisposed to the basal ganglia.
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