[Neonatal lupus and maternofetal transmission of anti-SSA/Ro and anti-SSB/La antibodies]

Neonatal lupus (NL) is a rare syndrome caused by placental transfer of maternal anti-SSA/Ro (60 and 52kDa) or anti-SSB/La antibodies. The aim of this study was to evaluate the clinical and biological profile of NL at the neonatal unit of Sfax, Tunisia, over a 10-year period. Six mother-NB pairs (two sets of twins and two sisters) had positive ANA by transplacental transmission during the study period. The ANA pattern was speckled and the NBs' sera titer was half that of their mothers'. Anti-SSA, anti-Ro52, and anti-SSB were found in 100%, 33%, and 50% of the mothers' sera, respectively. The transmission of anti-SSA was observed in four pregnancies out of six, anti-Ro52 in two pregnancies out of two, and anti-SSB in one pregnancy out of three. The patients' clinical records showed that two NBs had a congenital heart block: one with anti-SSA, whose mother had Sjögren syndrome, and another with anti-SSA, anti-SSB, anti-Ro52, and anti-mitochondrial antibodies (M2 type), whose mother had no diagnosis at the child's birth (cutaneous erythema and positive ANA with the same profile). Cutaneous signs (erythema, petechia) were described in three NBs out of six. The two sets of fraternal twins had cutaneous signs with the same ANA titer and profile (no anti-SSA transmission from their mother with lupus and anti-phospholipid syndrome). The two sisters' (two pregnancies 3 years apart) mother had Sjögren syndrome, one of them had heart block with positive anti-SSA, and the other was asymptomatic with anti-SSA and anti-Ro52. The same mother had a history of three pregnancies with two NBs who died of heart block.

[Intrauterine upper limb ischemia due to a heterozygous mutation (677C>T) of the methylene-tetrahydrofolatereductase gene]

Limb ischemia rarely occurs in utero. The diagnosis can be made by clinical observation at birth or a few hours later. Color duplex ultrasound is the first imaging test used to confirm the diagnosis. The etiology appears to be complex and multifactorial. We report 2 cases of intrauterine limb ischemia involving the upper limb in 2 newborns. Both children were heterozygous for the 5,10-methylenetetrahydrofolate reductase 677C>T gene variant. The first patient was born by caesarean section at 34 weeks of gestation. At delivery, the infant presented with pallor in his right upper limb and weak radial arterial pulsation. Doppler ultrasound and computed tomography angiography demonstrated a totally occlusive thrombus within the right brachial artery. The newborn underwent systemic thrombolysis with good recovery. The second patient was born via cesarean section at 37 weeks of gestation. At delivery, the infant presented with a motionless, cold, and gangrenous right upper limb. The demarcation line was just below the right elbow. Doppler ultrasound revealed a complete occlusion of the right subclavian artery. After failure of antithrombotic therapy, the limb was amputated with no further complication. We discuss the epidemiology, etiology, and clinical features of this rare pathology.

Differential diagnosis of hallucinations in a patient with myasthenia gravis

We present the case of a 63-year-old woman with comorbidity of myasthenia gravis and psychosis. Different diagnostic hypotheses based on a review of the literature are discussed. A protracted history of physical spousal abuse, patient symptoms, and results of different investigations allowed us to conclude that the patient had a form of posttraumatic stress disorder with secondary psychotic features. Psychosis due to myasthenia gravis is rarely seen, and it remains unclear what is the pathophysiology, if any, for such an association. The present case highlights the difficulties the physician faces in disentangling psychosis as a potential manifestation of myasthenia gravis itself versus being caused by a medical side effect of treatment, or psychosis due to a distinct co-occurring neurologic or psychiatric condition.

Antepartum detection of macrosomic fetus: the effect of misdiagnosis

AIM

To determine the effect of misdiagnosis of macrosomia on maternal and perinatal outcomes.

METHODS

We conducted a retrospective study ,between January 2007 and December 2008 of women (n = 464) who delivered singleton neonates with actual birth weight over 4000g and in whom fetal weight was estimated, by both methods :sonographic and clinical, up to 3 days before delivery.Statistical comparisons were made between patients in whom fetal macrosomia was predicted : «prediction » group (n=336)and those in whom it was not « non prediction »group (n=128) for outcome variables.

RESULTS

The cesarean delivery was performed in 35.9% in « non predicted » group, and in 35.7% in the « predicted » group.The difference was not statistically significant. Failure to detect macrosomia was associated with higher rates of maternal and fetal complications in the group « non predicted » compared with the group « predicted » :perineal trauma,post partum hemorrhage, 5- minute Apgar scores less than 7, and shoulder dystocia, mostly related to the higher rate of surgical vaginal deliveries.

CONCLUSIONS

The misdiagnosis of fetal macrosomia substantially did not modify the cesarean section rate but leads to increase the maternal and neonatal complications.

Clinical and single-photon emission computed tomography study of pure akinesia with freezing of gait

The clinical syndrome of pure akinesia (PA) is considered the third phenotype of progressive supranuclear palsy (PSP), and is characterized by freezing of gait and prominent speech disturbance without rigidity or tremor. It is frequently considered one of the dopamine resistant motor syndromes, and its pathophysiology remains unclear. We report a patient followed in the Department of Neurology of Razi Hospital, Tunisia, with PA with gait freezing (PAGF) with a frontal hypoperfusion on single photon emission CT and non-responsive dopa therapy. We discuss the clinical features of PAGF and efficiency of treatment options.

Hot water epilepsy with pachygyria

Hot water epilepsy (HWE) refers to a specific type of reflex epilepsy precipitated by the stimulus of bathing in hot water. Pathogenesis is still unknown and temporal lobe has been thought to take part in the epileptogenesis. HWE can be symptomatic of focal cortical malformation, and few cases were reported. This is the third report of HEW in which a parietal malformation has been observed. Our hypothesis that sensory cortex might be implicated in the epileptogenic process is corroborated by two previous reports on patients with HWE and malformation of the parietal cortical development.

Familial form of typical childhood absence epilepsy in a consanguineous context

Causative genes for childhood absence epilepsy (CAE) are unknown partly because families are small or phenotypically heterogeneous. In five consanguineous Tunisian families with at least two sibs with CAE, 14 patients fulfilled the diagnostic criteria for CAE (Epilepsia 1989; 30:389-399). Linkage analyses or direct sequencing excluded CACNG2, CACNA1A, CACNB4, and CACNA2D2, orthologs of genes responsible for autosomal recessive (AR) absence seizures in mice. These families will help identify (a) gene(s) responsible for CAE.

[Congenital nasal pyriform aperture stenosis]

INTRODUCTION

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare and an unusual cause of airway obstruction in newborns.

OBSERVATION

We report the case of a female neonate delivered by C-section at 39 weeks of amenorrhea for hydramnios and macrosomia. She presented with mandibular retrognathia, nasal saddling, submucous cleft palate, and loud mouth respiration. She presented with cyanosis every time feeding was attempted. CT revealed permeable choans with a single central incisor and nasal pyriform aperture stenosis. Nasal respiration returned to normal progressively after 56 days of hospitalization. The status was unchanged at 5 months.

DISCUSSION

CNPAS is a rare cause of congenital nasal obstruction. It is sometimes associated to a median incisor syndrome. The diagnosis should be made as early as possible for an optimal management. Cyanosis and swallowing disorders may be lethal consequences. Associated abnormalities should be screened for with TDM or MRI. The treatment depends on the severity and may be surgical for a severe stenosis. The prognosis is good if no severe malformation or mental retardation is associated.

[Neurological complications of acute intermittent porphyria precipitated by porphyrinogenic drugs and efficiency of heme-arginate treatment]

BACKGROUND

Acute intermittent porphyria (AIP) is a rare metabolic disorder of heme biosynthesis characterized by enzymatic defect of porphobiligen desaminase with accumulation and increased excretion of porphyrins and their precursors. Clinical picture is characterized by attacks with a triad of abdominal pain, psychiatric disorder and neurological involvement (central and peripheral). Peripheral nervous system manifestations, often precipitated by porphyrinogenic medications are of poor outcome.

AIM

We report a new cases A 13-year-old girl who presented several attacks of AIP and developed acute severe axonal motor neuropathy, three weeks after porphyrinogenic medications (Famotidin, Phenobarbital and Nifedipine).

CONCLUSION

We stress on the importance of early diagnosis of AIP to prevent serious neurological complications often precipitated by medications and the efficiency of heme arginate treatment when administrated early during the attacks.