Therapy of systemic vasculitis

Primary Central Nervous System Angiitis in a 10-year-old Girl

Primary angiitis of central nervous system (PACNS) is well reported, however its occurrence in the pediatric population is infrequent. We describe the clinical, neuroimaging and histopathological features of PACNS in a young girl.

A ten year-old, previously healthy girl presented with a threeweek history of progressive left hemiparesis and facial weakness. Other findings included left hemineglect, impaired concentration and memory. She had no evidence of systemic disease. Head computed tomography (CT), with and without contrast, revealed no abnormalities. Magnetic resonance imaging (MRI) demonstrated multifocal, bilateral signal abnormalities within basal ganglia, thalami, right frontal cortex and subcortical white matter on T2 and FLAIR images. However, these areas did not show restricted diffusion on diffusion weighted imaging (DWI). Cerebral angiography revealed normal intracranial vessels (Figure 1). Neuroimaging, three weeks later, showed progression of these abnormalities. The areas of abnormal signal showed heterogeneous and nodular enhancement on gadolinium enhanced T1 weighted images (Figure 2). Rheumatologic, metabolic, prothrombotic and cerebral spinal fluid investigations were normal.

Primary angiitis of the central nervous system presenting with subacute and fatal course of disease: a case report

BACKGROUND

Primary angiitis of the central nervous system is an idiopathic disorder characterized by vasculitis within the dural confines. The clinical presentation shows a wide variation and the course and the duration of disease are heterogeneous. This rare but treatable disease provides a diagnostic challenge owing to the lack of pathognomonic tests and the necessity of a histological confirmation.

CASE PRESENTATION

A 28-year-old patient presenting with headache and fluctuating signs of encephalopathy was treated on the assumption of viral meningoencephalitis. The course of the disease led to his death 10 days after hospital admission. Postmortem examination revealed primary angiitis of the central nervous system.

CONCLUSION

Primary angiitis of the central nervous system should always be taken into consideration when suspected infectious inflammation of the central nervous system does not respond to treatment adequately. In order to confirm the diagnosis with the consequence of a modified therapy angiography and combined leptomeningeal and brain biopsy should be considered immediately.

Oral corticosteroid use among children in TennCare

BACKGROUND

Lack of information about medication effects and use in children is a long-standing and troublesome policy issue. Documenting patterns of use for medications with potential for suboptimal use and adverse effects, such as oral corticosteroids, would be useful.

OBJECTIVE

To describe the use of oral corticosteroids among children enrolled in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured individuals.

DESIGN

A retrospective cohort study. DRUG EXPOSURE: Children enrolled in TennCare who had prescriptions filled in their name for oral corticosteroids during 1998 were identified. Descriptive information included age, race, sex, and county of residence. We identified possible indications for corticosteroid use for new users by searching encounter files for encounters temporally related to the index prescription. Subsequent use of corticosteroids was measured in the 365 days after the index prescription.

RESULTS

Of 400 724 children continuously enrolled in TennCare during the study period, 29 362 (7327 per 100 000) children had a prescription filled for an oral corticosteroid. Steroid prescription filling was more common among young children and male children and less common among black children. Children in rural counties had oral corticosteroid prescriptions filled at a higher rate than children residing in urban counties. Nearly 75% of corticosteroid users filled only 1 prescription during the study period; 1319 children filled 4 or more prescriptions. Asthma was the most common indication for oral corticosteroid use (16%), whereas 1 in 5 users (22%) had an unknown indication for oral corticosteroid use.

CONCLUSIONS

A large number of children enrolled in TennCare had a prescription for oral corticosteroids filled in 1998. Further population-based studies describing the development of adverse effects in users of corticosteroids would be important.