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Pal H, Singh A, Shrestha S, Sharawat IK, Panda PK, Kumar B. An atypical case of bilateral optic neuritis after strabismus surgery under general anesthesia. Strabismus 2024; 32:102-107. [PMID: 38494633 DOI: 10.1080/09273972.2024.2324166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Strabismus surgery under general anesthesia is a common procedure with rare complications in the form of hemorrhage, infection, slipped muscle, lost muscle, scleral perforation, and anterior segment ischemia. We report a unique case of bilateral optic neuritis following squint surgery under general anesthesia in a 15-year-old girl. METHODS A 15-year-old girl presented with accommodative esotropia with V pattern. She underwent uneventful bilateral inferior oblique recession surgery under general anesthesia with Propofol 60 mg, Atracurium 30 mg, and Fentanyl 70 mcg. On the first post-operative day, the patient had an acute onset of temporal headache which was non-radiating. She responded to supportive treatment and was discharged. However, on the 7th postoperative day, she presented with a constant severe headache in the bitemporal region (left > right) for 3 days. She also experienced a painless diminution of vision for 2 days. There was no vomiting, fever, loose stools, diplopia, difficulty in breathing, peripheral sensation loss, generalized weakness, or bowel/bladder incontinence. RESULTS The best corrected visual acuity was 6/9 in right eye, and 6/9p in left eye with a relative afferent pupillary defect (RAPD) in the left eye. Both optic discs appeared hyperemic with blurred margins. Magnetic resonance imaging (MRI) of the brain and orbit showed hyperintensity along the intraorbital and intracanalicular parts of bilateral optic nerves on T2 weighted image suggesting bilateral optic neuritis. She received intravenous methylprednisolone pulse therapy followed by oral steroids and responded to the medical treatment with improvement in vision but developed steroid-induced glaucoma requiring medical management over several weeks. DISCUSSION Neuro-ophthalmic complication in the form of non-arteritic ischemic optic neuropathy has been reported after various ophthalmic surgeries, but bilateral optic neuritis has not been reported to date. This possibility should be kept in mind if any patient presents with similar symptoms. This report also highlights IOP monitoring in pediatric patients receiving systemic steroids to prevent loss of vision due to steroid-induced glaucoma.
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Affiliation(s)
- Himani Pal
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh
| | - Anupam Singh
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh
| | - Sandhya Shrestha
- Department of Ophthalmology, All India Institute of Medical Sciences, Rishikesh
| | | | | | - Barun Kumar
- Department of Cardiology, All India Institute of Medical Sciences, Rishikesh
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Hardy D. Monophasic Acquired Demyelinating Syndromes of the Central Nervous System in Children. Semin Pediatr Neurol 2023; 46:101050. [PMID: 37451746 DOI: 10.1016/j.spen.2023.101050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/23/2023] [Indexed: 07/18/2023]
Abstract
Acquired demyelinating syndromes of the central nervous system are immune-mediated demyelinating disorders that can affect the brain, optic nerves, and spinal cord. These disorders have become increasingly recognized in children due to advances in imaging techniques, improvements in diagnostic testing, extensive research into understanding the pathophysiology underlying these disorders, and collaborative multi-institutional efforts to raise awareness of these disorders in children. Moreover, developments in the field of neuroimmunology have allowed us to identify autoantibodies that have presumed causal roles in acquired demyelinating syndromes. Identification of these autoantibodies helps determine clinical course (ie, monophasic vs relapsing course), prognosis, and treatment approach. Acquired demyelinating disorders can affect both children and adults. However, the clinical features, disease course, and treatments are often unique in the pediatric population. Thus, it is important to understand the spectrum of these disorders in children to help provide a timely diagnosis and prompt treatment to achieve optimal outcomes. In this article, the epidemiology, clinical features, diagnosis, treatment, and outcomes of the most common monophasic acquired demyelinating syndromes in children will be reviewed.
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Affiliation(s)
- Duriel Hardy
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX.
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Branson HM, Longoni G. Clinical Neuroimaging in Pediatric Dysimmune Disorders of the Central Nervous System. Semin Roentgenol 2023; 58:67-87. [PMID: 36732013 DOI: 10.1053/j.ro.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/23/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Helen M Branson
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Department of Medical Imaging, Toronto, Ontario, Canada.
| | - Giulia Longoni
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada; Garry Hurvitz Centre for Brain & Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Department of Paediatrics, Toronto, Ontario, Canada
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Muacevic A, Adler JR, Gaidhane SA, Kumar S, Acharya S, Gemnani RR. Fatal Acute Disseminated Encephalomyelitis Post-COVID-19 Vaccination: A Rare Case Report. Cureus 2022; 14:e31810. [PMID: 36579193 PMCID: PMC9788800 DOI: 10.7759/cureus.31810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/22/2022] [Indexed: 11/24/2022] Open
Abstract
Acute disseminated encephalomyelitis (ADEM) is a disease of the brain and spinal cord that is an immune-mediated inflammatory and demyelinating disorder, which is commonly preceded by an infection. Some reports have also shown the association of acute demyelination of the central nervous system (CNS) with vaccination. Primarily, the involvement of the white matter of the cerebral hemispheres, brain stem, and spinal cord is observed. Such lesions should be considered as the differentials of ADEM. We would like to report a case of a 77-year-old female who was of post-COVID-19 vaccination status and presented to us with altered sensorium with imaging revealing acute demyelination.
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Micheletti L, Maldonado FR, Watal P, Toronchik MS, Erripa JI, Princich JP, Rugilo C. Utility of paramagnetic rim lesions on 1.5-T susceptibility phase imaging for the diagnosis of pediatric multiple sclerosis. Pediatr Radiol 2022; 52:97-103. [PMID: 34611736 DOI: 10.1007/s00247-021-05188-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/27/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Studies have suggested that paramagnetic rim lesions on 7-tesla (T) and 3-T susceptibility-based brain MRI are specific features of multiple sclerosis (MS) lesions in adults. OBJECTIVE The aim of this study was to investigate whether the presence of paramagnetic rim lesions on 1.5-T phase images can help discriminate pediatric patients with MS from those with other demyelinating diseases. MATERIALS AND METHODS In this retrospective study we reviewed brain MRIs performed on 1.5-T scanners that included susceptibility-weighted imaging (SWI) sequences with phase images in children younger than 18 years diagnosed with MS and other acquired demyelinating syndromes. In each case, five white matter lesions were selected using T2/fluid-attenuated inversion recovery images for further paramagnetic rim evaluation on SWI. Two researchers performed independent assessments of the presence of paramagnetic rim lesions. Discrepancies between them were settled by consensus, with input from a senior neuroradiologist. RESULTS We included 13 children diagnosed with MS and 16 children diagnosed with non-MS demyelinating diseases and analyzed a total of 132 focal white matter lesions. Seventy-one percent of the lesions in the MS group had paramagnetic rims, while none of the lesions in the non-MS group had rims. All but one of the children with MS had at least one lesion with a paramagnetic rim. The presence of one lesion with a paramagnetic rim on 1.5-T phase-contrast images resulted in 70% sensitivity and 100% specificity for MS. CONCLUSION Paramagnetic rim lesions detected on 1.5-T phase-contrast MR images can help discriminate MS from other acquired demyelinating syndromes in the pediatric population.
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Affiliation(s)
- Lucía Micheletti
- Department of Radiology, Hospital de Pediatría J. P. Garrahan Buenos Aires, Combate de los Pozos 1881 (C 1245 AAM), Buenos Aires, Argentina.
| | - Francisco R Maldonado
- Department of Radiology, Hospital de Pediatría J. P. Garrahan Buenos Aires, Combate de los Pozos 1881 (C 1245 AAM), Buenos Aires, Argentina
| | - Pankaj Watal
- Department of Radiology, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, FL, USA
| | - María S Toronchik
- Department of Radiology, Hospital de Pediatría J. P. Garrahan Buenos Aires, Combate de los Pozos 1881 (C 1245 AAM), Buenos Aires, Argentina
| | - José I Erripa
- Department of Radiology, Hospital de Pediatría J. P. Garrahan Buenos Aires, Combate de los Pozos 1881 (C 1245 AAM), Buenos Aires, Argentina
| | - Juan P Princich
- Department of Radiology, Hospital de Pediatría J. P. Garrahan Buenos Aires, Combate de los Pozos 1881 (C 1245 AAM), Buenos Aires, Argentina
| | - Carlos Rugilo
- Department of Radiology, Hospital de Pediatría J. P. Garrahan Buenos Aires, Combate de los Pozos 1881 (C 1245 AAM), Buenos Aires, Argentina
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Management of Acute Demyelinating Attacks in the Pediatric Population: A Swiss Consensus Statement. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.3390/ctn5020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and methods: Acquired demyelinating syndromes (ADS) encompass distinct entities and occur in approximately 1/100,000 children. While the use of high dose intravenous corticosteroids is well-established, agreement on steroid taper and type of second line therapy is lacking. A comprehensive, unified and standardized treatment approach is crucial in the management of patients with rare diseases. Therefore, this study performed from July 2018 to June 2020 aimed at developing a national consensus on the management of ADS in the pediatric population using the Delphi approach. Consensus was defined as agreement in >75%. Designated Neuropediatricians with an expertise in the management of pediatric neuroinflammatory diseases in all university and cantonal hospitals of Switzerland were included. The response rate was 100%. Results: High-dose i.v. methylprednisolone (20–30 mg/kg/die for 5 days) is the first line treatment irrespective of the distinct entity of the ADS. An oral steroid taper is recommended in acute demyelinating encephalomyelitis (ADEM) and in neuromyelitis optica spectrum disorder (NMO-SD). However, in the latter more in the sense of bridging. The choice of second line treatment depends on the entity of ADS: in optic neuritis (ON) and ADS due to relapsing remitting multiple sclerosis, first line treatment should be repeated, whereas plasma exchange is recommended in NMO-SD, ADEM and transverse myelitis. Conclusions: A national guideline allowing for a more unified approach in the management of pediatric ADS will enhance future research in this field, making data more comparable. The definition of inadequate treatment response to first line therapy remains a challenge and requires future research.
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Brill L, Ganelin-Cohen E, Dabby R, Rabinowicz S, Zohar-Dayan E, Rein N, Aloni E, Karmon Y, Vaknin-Dembinsky A. Age-Related Clinical Presentation of MOG-IgG Seropositivity in Israel. Front Neurol 2021; 11:612304. [PMID: 33584514 PMCID: PMC7874097 DOI: 10.3389/fneur.2020.612304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Myelin oligodendrocyte glycoprotein (MOG) antibody associated disorders (MOGAD) have been recognized over the past 10 years as distinct inflammatory, demyelinating diseases of the central nervous system (CNS). Antibodies against MOG are found mostly in patients with optic neuritis (ON), acute disseminated encephalomyelitis (ADEM), and aquaporin-4 antibody (AQP4-abs)-seronegative neuromyelitis optica spectrum disorders (NMOSD). However, data on the disease course and disability outcomes of these patients are scarce. Aim: To describe clinical and paraclinical features associated with MOG antibodies (abs) in a cohort of patients in Israel, and to assess baseline prognostic features of MOG-ab-associated diseases after a first acute demyelinating event. Methods: MOG-abs were identified in serum using a cell-based assay, and clinical data were collected from the patients' medical records. Results: Of 683 patients with demyelinating diseases tested for MOG-abs, 53 were positive (7.7%), with ON the most common presenting phenotype (68%). The age range of MOG-abs seropositive patients was 1-66 years, with increased prevalence in children (19% compared to 6.7% in adults) (p < 0.01). The highest prevalence of seropositivity was observed in children aged younger than 10 years (25.5%), followed by those aged 31-40 years (16.6%). Conclusions: MOGAD are distinct autoimmune diseases that occurs at all stages of life with a significantly higher prevalence in children; the main clinical presenting phenotype in the entire cohort is ON and young children most often presented with ON or ADEM. Our data highlight the need for repeated evaluation of MOG-abs in patients with acquired CNS demyelinating disorders, especially in children under 10 and adults between 31 and 40 years of age.
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Affiliation(s)
- Livnat Brill
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes Ginges Center for Neurogenetics, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Esther Ganelin-Cohen
- Schneider Children's Medical Center, Institute of Pediatric Neurology, Affiliated With Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ron Dabby
- Department of Neurology, Edith Wolfson Medical Center, Holon, Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Shira Rabinowicz
- Pediatric Neurology Unit, Sheba Medical Center, Ramat Gan, Israel. Sackler School of Medicine, The Edmond and Lilly Safra Children's Hospital, Tel-Aviv University, Tel-Aviv, Israel
| | - Efrat Zohar-Dayan
- Pediatric Neurology Unit, Sheba Medical Center, Ramat Gan, Israel. Sackler School of Medicine, The Edmond and Lilly Safra Children's Hospital, Tel-Aviv University, Tel-Aviv, Israel
| | - Netaniel Rein
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes Ginges Center for Neurogenetics, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eyal Aloni
- Department of Ophthalmology, Barzilai University Medical Center, Ashkelon, Israel
| | - Yuval Karmon
- Department of Neurology, Meir General Hospital, Kfar Saba, Israel
| | - Adi Vaknin-Dembinsky
- Department of Neurology and Laboratory of Neuroimmunology, The Agnes Ginges Center for Neurogenetics, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Britton PN, Dale RC, Blyth CC, Clark JE, Crawford N, Marshall H, Elliott EJ, Macartney K, Booy R, Jones CA. Causes and Clinical Features of Childhood Encephalitis: A Multicenter, Prospective Cohort Study. Clin Infect Dis 2021; 70:2517-2526. [PMID: 31549170 DOI: 10.1093/cid/ciz685] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/24/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND We aimed to determine the contemporary causes, clinical features, and short-term outcome of encephalitis in Australian children. METHODS We prospectively identified children (≤14 years of age) admitted with suspected encephalitis at 5 major pediatric hospitals nationally between May 2013 and December 2016 using the Paediatric Active Enhanced Disease Surveillance (PAEDS) Network. A multidisciplinary expert panel reviewed cases and categorized them using published definitions. Confirmed encephalitis cases were categorized into etiologic subgroups. RESULTS From 526 cases of suspected encephalitis, 287 children met criteria for confirmed encephalitis: 57% (95% confidence interval [CI], 52%-63%) had infectious causes, 10% enterovirus, 10% parechovirus, 8% bacterial meningoencephalitis, 6% influenza, 6% herpes simplex virus (HSV), and 6% Mycoplasma pneumoniae; 25% (95% CI, 20%-30%) had immune-mediated encephalitis, 18% acute disseminated encephalomyelitis, and 6% anti-N-methyl-d-aspartate receptor encephalitis; and 17% (95% CI, 13%-21%) had an unknown cause. Infectious encephalitis occurred in younger children (median age, 1.7 years [interquartile range {IQR}, 0.1-6.9]) compared with immune-mediated encephalitis (median age, 7.6 years [IQR, 4.6-12.4]). Varicella zoster virus encephalitis was infrequent following high vaccination coverage since 2007. Thirteen children (5%) died: 11 with infectious causes (2 influenza; 2 human herpesvirus 6; 2 group B Streptococcus; 2 Streptococcus pneumoniae; 1 HSV; 1 parechovirus; 1 enterovirus) and 2 with no cause identified. Twenty-seven percent (95% CI, 21%-31%) of children showed moderate to severe neurological sequelae at discharge. CONCLUSIONS Epidemic viral infections predominated as causes of childhood encephalitis in Australia. The leading causes include vaccine-preventable diseases. There were significant differences in age, clinical features, and outcome among leading causes. Mortality or short-term neurological morbidity occurred in one-third of cases.
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Affiliation(s)
- Philip N Britton
- Discipline of Child and Adolescent Health, Sydney Medical School, Children's Hospital at Westmead, New South Wales.,Marie Bashir Institute of Infectious Diseases and Biosecurity Institute, University of Sydney, New South Wales.,Departments of Infectious Diseases and Microbiology, New South Wales
| | - Russell C Dale
- Discipline of Child and Adolescent Health, Sydney Medical School, Children's Hospital at Westmead, New South Wales.,Neurology, Children's Hospital at Westmead, New South Wales
| | - Christopher C Blyth
- Perth Children's Hospital, Nedlands, Perth, Western Australia.,Telethon Kids Institute and School of Medicine, University of Western Australia, Nedlands, Perth, Western Australia.,PathWest Laboratory Medicine Western Australia and Queen Elizabeth II Medical Centre, Nedlands, Perth, Western Australia
| | - Julia E Clark
- Children's Health Queensland, Brisbane.,School of Clinical Medicine, University of Queensland, Brisbane
| | - Nigel Crawford
- Murdoch Children's Research Institute and Royal Children's Hospital, Victoria.,University of Melbourne, Victoria
| | - Helen Marshall
- Women's and Children's Hospital, South Australia.,Robinson Research Institute, University of Adelaide, South Australia, and
| | - Elizabeth J Elliott
- Discipline of Child and Adolescent Health, Sydney Medical School, Children's Hospital at Westmead, New South Wales.,Australian Paediatric Surveillance Unit, New South Wales, Australia
| | - Kristine Macartney
- Discipline of Child and Adolescent Health, Sydney Medical School, Children's Hospital at Westmead, New South Wales.,Departments of Infectious Diseases and Microbiology, New South Wales.,National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Robert Booy
- Discipline of Child and Adolescent Health, Sydney Medical School, Children's Hospital at Westmead, New South Wales.,Marie Bashir Institute of Infectious Diseases and Biosecurity Institute, University of Sydney, New South Wales.,Departments of Infectious Diseases and Microbiology, New South Wales.,National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Cheryl A Jones
- Marie Bashir Institute of Infectious Diseases and Biosecurity Institute, University of Sydney, New South Wales.,Murdoch Children's Research Institute and Royal Children's Hospital, Victoria.,University of Melbourne, Victoria
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update on advances in the understanding of pediatric demyelinating optic neuritis. RECENT FINDINGS In the past decade, the disease phenotypes for demyelinating syndromes in children have been more clearly defined. Pediatric optic neuritis may present as a clinically isolated syndrome or in the setting of underlying neurologic disease. In addition to optic neuritis associated with multiple sclerosis or neuromyelitis optica, recent work has identified antibodies to the myelin oligodendrocyte glycoprotein (MOG IgG) as a unique demyelinating cause with distinct features regarding treatment and prognosis. The disease phenotypes for demyelinating pediatric optic neuritis have expanded. Treatment strategies vary and are not universally effective for each cause of demyelinating disease. Accurately distinguishing among these unique clinical syndromes is therefore critical for initiation of appropriate treatment to prevent disability, to maximize visual outcomes, and to provide insight into long-term prognosis.
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Affiliation(s)
- Ryan A Gise
- Department of Ophthalmology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Gena Heidary
- Department of Ophthalmology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
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Suzuki Y, Hashimoto K, Hoshi K, Ito H, Kariya Y, Miyazaki K, Sato M, Kawasaki Y, Yoshida M, Honda T, Hashimoto Y, Hosoya M. Ratio of Alpha 2-Macroglobulin Levels in Cerebrospinal Fluid and Serum: An Expression of Neuroinflammation in Acute Disseminated Encephalomyelitis. Pediatr Neurol 2019; 98:61-67. [PMID: 31248670 DOI: 10.1016/j.pediatrneurol.2019.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acute encephalitis and encephalopathy are life-threatening diseases in children. However, no laboratory examinations are performed for their early diagnosis and treatment. Alpha 2-macroglobulin (α2M) is a blood glycoprotein that increases during the early stages of inflammation. In the present study, we investigated the role of α2M levels in acute encephalitis and encephalopathy. METHODS We analyzed the cerebrospinal fluid and serum samples from patients with acute disseminated encephalomyelitis, infection-related acute encephalopathy, febrile status epilepticus, and febrile seizure simplex type. Samples were collected from the pediatric department of hospitals throughout the Fukushima Prefecture between January 1, 1999, and May 31, 2012. RESULTS α2M levels in the cerebrospinal fluid were 4.7 (3.8-8.4) μg/mL for acute disseminated encephalomyelitis, 2.1 (1.1-2.3) μg/mL for infection-related acute encephalopathy, 1.1 (0.9-6.4) μg/mL for febrile status epilepticus, and 1.0 (0.8-1.1) μg/mL for febrile seizure simplex type. α2M levels in patients with acute disseminated encephalomyelitis were significantly higher than those in patients with infection-related acute encephalopathy and febrile seizure simplex type (P = 0.019 and P = 0.002, respectively). The ratio of α2M level in the cerebrospinal fluid to that in the serum in patients with acute disseminated encephalomyelitis was significantly higher than the ratio in patients with febrile status epilepticus (P = 0.04). In patients with acute disseminated encephalomyelitis, α2M levels in the cerebrospinal fluid decreased with treatment. CONCLUSIONS Our results suggest that α2M levels in the cerebrospinal fluid reflect the neuroinflammatory status of patients with acute disseminated encephalomyelitis.
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Affiliation(s)
- Yuichi Suzuki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan.
| | - Koichi Hashimoto
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kyoka Hoshi
- Department of Biochemistry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiromi Ito
- Department of Biochemistry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoshinobu Kariya
- Department of Biochemistry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kyohei Miyazaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masatoki Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan
| | - Takashi Honda
- Department of Human Life Sciences, Fukushima Medical University School of Nursing, Fukushima, Japan
| | - Yasuhiro Hashimoto
- Department of Biochemistry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
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Miki Y. Magnetic resonance imaging diagnosis of demyelinating diseases: An update. ACTA ACUST UNITED AC 2019. [DOI: 10.1111/cen3.12501] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Yukio Miki
- Department of Diagnostic and Interventional Radiology Osaka City University Graduate School of Medicine Osaka Japan
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13
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Wong YYM, de Mol CL, van der Vuurst de Vries RM, van Pelt ED, Ketelslegers IA, Catsman-Berrevoets CE, Neuteboom RF, Hintzen RQ. Real-world validation of the 2017 McDonald criteria for pediatric MS. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2018; 6:e528. [PMID: 30697581 PMCID: PMC6340337 DOI: 10.1212/nxi.0000000000000528] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/23/2018] [Indexed: 11/15/2022]
Abstract
Objective To compare the diagnostic accuracy of the McDonald 2017 vs the McDonald 2010 criteria to predict a second attack of MS (clinically definite MS [CDMS]) at the first attack of acquired demyelinating syndromes (ADS). Methods One hundred sixty-four children (aged <18 years) with an incident attack of ADS were included in a prospective multicenter study between June 2006 and December 2016. Brain (and spinal if available) MRI was performed ≤3 months after symptom onset. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were compared at baseline between the 2010 and 2017 criteria. Results Among the 164 patients, 110 patients (67%) presented without encephalopathy (ADS-, female 63%; median age 14.8 years, IQR 11.3-16.1years) and 54 (33%) with encephalopathy (acute disseminated encephalomyelitis [ADEM], female 52%; median age 4.0 years, IQR 2.6-6.1 years). Of the 110 ADS- patients, 52 (47%) were diagnosed with CDMS within a median follow-up of 4.5 years (IQR 2.6-6.7 years). The sensitivity was higher for the 2017 criteria than for the 2010 criteria (83%; 95% CI 67-92, vs 49%; 95% CI 33-65; p < 0.001), but the specificity was lower (73%; 95% CI 59-84 vs 87%; 95% CI 74-94, p = 0.02). At baseline, 48 patients fulfilled the 2017 criteria compared with 27 patients when using the 2010 criteria. The results for children aged <12 years without encephalopathy were similar. In patients with ADEM, 8% fulfilled the 2010 criteria and 10% the 2017 criteria at baseline but no patient fulfilled the criteria for CDMS. Conclusions The McDonald 2017 criteria are more sensitive than the McDonald 2010 criteria for predicting CDMS at baseline. These criteria can also be applied in children aged <12 years without encephalopathy but not in children with ADEM. Classification of evidence This study provides Class II evidence that in children with ADS, the 2017 McDonald criteria are more sensitive but less specific than the 2010 McDonald criteria for predicting CDMS.
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Affiliation(s)
- Yu Yi M Wong
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - C Louk de Mol
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - Roos M van der Vuurst de Vries
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - E Daniëlle van Pelt
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - Immy A Ketelslegers
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - Coriene E Catsman-Berrevoets
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - Rinze F Neuteboom
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
| | - Rogier Q Hintzen
- Department of Neurology (Y.Y.M.W., C.L.d.M., R.M.v.d.V.d.V., E.D.v.P., I.A.K., R.Q.H.), MS Centre ErasMS, Erasmus MC, Rotterdam, The Netherlands; and Department of Pediatric Neurology (C.E.C.-B., R.F.N.), Erasmus MC, Rotterdam, The Netherlands
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14
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Di Pauli F, Berger T. Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disorders: Toward a New Spectrum of Inflammatory Demyelinating CNS Disorders? Front Immunol 2018; 9:2753. [PMID: 30555462 PMCID: PMC6281762 DOI: 10.3389/fimmu.2018.02753] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022] Open
Abstract
Inflammatory demyelinating CNS syndromes include, besides their most common entity multiple sclerosis (MS), several different diseases of either monophasic or recurrent character—including neuromyelitis optica spectrum disorders (NMOSDs) and acute disseminated encephalomyelitis (ADEM). Early diagnostic differentiation is crucial for devising individual treatment strategies. However, due to overlapping clinical and paraclinical features diagnosis at the first demyelinating event is not always possible. A multiplicity of potential biological markers that could discriminate the different diseases was studied. As the use of autoantibodies in patient management of other autoimmune diseases, is well-established and evidence for the critical involvement of B cells/antibodies in disease pathogenesis in inflammatory demyelinating CNS syndromes increases, antibodies seem to be valuable diagnostic tools. Since the detection of antibodies against aquaporin-4 (AQP-4), the understanding of immunopathogenesis and diagnostic management of NMOSDs has dramatically changed. However, for most inflammatory demyelinating CNS syndromes, a potential antigen target is still not known. A further extensively studied possible target structure is myelin oligodendrocyte glycoprotein (MOG), found at the outermost surface of myelin sheaths and oligodendrocyte membranes. With detection methods using cell-based assays with full-length, conformationally correct MOG, antibodies have been described in early studies with a subgroup of patients with ADEM. Recently, a humoral immune reaction against MOG has been found not only in monophasic diseases, but also in recurrent non-MS diseases, particularly in pediatric patients. This review presents the findings regarding MOG antibodies as potential biological markers in discriminating between these different demyelinating CNS diseases, and discusses recent developments, clinical implementations, and data on immunopathogenesis of MOG antibody-associated disorders.
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Affiliation(s)
- Franziska Di Pauli
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Berger
- Clinical Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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15
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Ruet A. Update on pediatric-onset multiple sclerosis. Rev Neurol (Paris) 2018; 174:398-407. [PMID: 29784250 DOI: 10.1016/j.neurol.2018.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 12/29/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS) has distinctive features compared with adult-onset multiple sclerosis (AOMS), and warrants caution despite being a rare form of MS. POMS diagnostic criteria are somewhat different from those used in AOMS, with acute disseminated encephalomyelitis being a key differential diagnosis of MS in children. Other differential diagnoses that have to be ruled out before diagnosing MS include demyelinating syndromes, autoimmune and systemic pathologies, and infectious, genetic, metabolic and neoplastic diseases. Compared with AOMS, POMS has several different clinical, biological and imaging findings. At onset, high-level inflammatory activity is mainly reported, and patients with POMS are also at high risk of developing early physical disabilities and early cognitive impairment. Yet, treating patients with POMS is challenging due to a lack of randomized controlled trials. Some of the disease-modifying drugs currently prescribed are analogous to therapies used in adults, and are associated with good tolerability in pediatric patients. However, a few clinical trials dedicated to POMS are now in progress, and the future outlook is to improve the long-term prognosis of POMS patients with early effective and safe treatments.
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Affiliation(s)
- A Ruet
- University of Bordeaux, 146, rue Léo Saignat, 33076 Bordeaux cedex, France; Inserm U1215, neurocentre Magendie, 146, rue Léo Saignat, 33000 Bordeaux, France; Hospital of Bordeaux, place Amélie Raba Léon, 33076 Bordeaux cedex, France.
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16
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17
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Alghalith Y, Neverman EM, Binalsheikh IM. Acquired Mutism and Hypertonia in a Toddler. Clin Pediatr (Phila) 2017; 56:586-588. [PMID: 27364777 DOI: 10.1177/0009922816656628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Ibrahim M Binalsheikh
- 3 Division of Neurology in the Department of Child Health, all at the University of Missouri, Columbia, MO, USA
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18
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Abstract
Optic neuritis is rare in children in comparison to adults, but accounts for approximately 25% of pediatric acute demyelinating syndromes. Features of pediatric optic neuritis that differ from adults include a higher rate of bilaterality, poor visual acuity on presentation, and papillitis. Diagnostic work-up includes brain magnetic resonance imaging, lumbar puncture, and blood tests to exclude infectious and inflammatory disorders. Pediatric optic neuritis may occur following infection or vaccination, or in association with a systemic demyelinating process such as acute disseminated encephalomyelitis, neuromyelitis optica, or multiple sclerosis. Treatment is controversial, but most practitioners administer corticosteroids. Most children with optic neuritis experience full visual recovery. The recently launched Pediatric Optic Neuritis Prospective Data Collection Study (PON1) aims to provide estimates of visual acuity outcome and assess the potential to recruit for a future pediatric optic neuritis treatment trial.
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Affiliation(s)
- Melinda Y Chang
- Department of Ophthalmology, Stein Eye Institute, University of California, Los Angeles, CA
| | - Stacy L Pineles
- Department of Ophthalmology, Stein Eye Institute, University of California, Los Angeles, CA.
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19
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Babl FE, Gardiner KK, Kochar A, Wilson CL, George SA, Zhang M, Furyk J, Thosar D, Cheek JA, Krieser D, Rao AS, Borland ML, Cheng N, Phillips NT, Sinn KK, Neutze JM, Dalziel SR. Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study. J Paediatr Child Health 2017; 53:339-342. [PMID: 28177168 DOI: 10.1111/jpc.13463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/29/2016] [Accepted: 11/18/2016] [Indexed: 12/19/2022]
Abstract
AIM The aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT). METHODS A retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap). RESULTS Three hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%. CONCLUSION Treatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.
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Affiliation(s)
- Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Kaya K Gardiner
- Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Amit Kochar
- Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Catherine L Wilson
- Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Shane A George
- Emergency Department, Gold Coast University Hospital, School of Medicine, Griffith University, Gold Coast, Townsville, Queensland, Australia
| | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Jeremy Furyk
- Emergency Department, Townsville Hospital and James Cook University College of Medicine and Dentistry, Townsville, Queensland, Australia
| | - Deepali Thosar
- Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - John A Cheek
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - David Krieser
- Emergency Department, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Arjun S Rao
- Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Schools of Paediatric and Child Health and Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Western Australia, Australia
| | - Nicholas Cheng
- Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Natalie T Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Kam K Sinn
- Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Jocelyn M Neutze
- Emergency Department, KidzFirst Middlemore Hospital, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Stuart R Dalziel
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Emergency Department, Starship Children's Hospital, Auckland, New Zealand
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20
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Yeshokumar AK, Hopkins S. The Differential Diagnosis and Initial Management of Pediatric Transverse Myelitis. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0120-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Babl FE, Mackay MT, Borland ML, Herd DW, Kochar A, Hort J, Rao A, Cheek JA, Furyk J, Barrow L, George S, Zhang M, Gardiner K, Lee KJ, Davidson A, Berkowitz R, Sullivan F, Porrello E, Dalziel KM, Anderson V, Oakley E, Hopper S, Williams F, Wilson C, Williams A, Dalziel SR. Bell's Palsy in Children (BellPIC): protocol for a multicentre, placebo-controlled randomized trial. BMC Pediatr 2017; 17:53. [PMID: 28193257 PMCID: PMC5307816 DOI: 10.1186/s12887-016-0702-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 09/27/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Bell's palsy or acute idiopathic lower motor neurone facial paralysis is characterized by sudden onset paralysis or weakness of the muscles to one side of the face controlled by the facial nerve. While there is high level evidence in adults demonstrating an improvement in the rate of complete recovery of facial nerve function when treated with steroids compared with placebo, similar high level studies on the use of steroids in Bell's palsy in children are not available. The aim of this study is to assess the utility of steroids in Bell's palsy in children in a randomised placebo-controlled trial. METHODS/DESIGN We are conducting a randomised, triple-blinded, placebo controlled trial of the use of prednisolone to improve recovery from Bell's palsy at 1 month. Study sites are 10 hospitals within the Australian and New Zealand PREDICT (Paediatric Research in Emergency Departments International Collaborative) research network. 540 participants will be enrolled. To be eligible patients need to be aged 6 months to < 18 years and present within 72 hours of onset of clinician diagnosed Bell's palsy to one of the participating hospital emergency departments. Patients will be excluded in case of current use of or contraindications to steroids or if there is an alternative diagnosis. Participants will receive either prednisolone 1 mg/kg/day to a maximum of 50 mg/day or taste matched placebo for 10 days. The primary outcome is complete recovery by House-Brackmann scale at 1 month. Secondary outcomes include assessment of recovery using the Sunnybrook scale, the emotional and functional wellbeing of the participants using the Pediatric Quality of Life Inventory and Child Health Utility 9D Scale, pain using Faces Pain Scale Revised or visual analogue scales, synkinesis using a synkinesis assessment questionnaire and health utilisation costs at 1, 3 and 6 months. Participants will be tracked to 12 months if not recovered earlier. Data analysis will be by intention to treat with primary outcome presented as differences in proportions and an odds ratio adjusted for site and age. DISCUSSION This large multicenter randomised trial will allow the definitive assessment of the efficacy of prednisolone compared with placebo in the treatment of Bell's palsy in children. TRIAL REGISTRATION The study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561 (1 June 2015).
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Affiliation(s)
- Franz E. Babl
- Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
| | - Mark T. Mackay
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
- Department of Neurology, Royal Children’s Hospital, Parkville, VIC Australia
| | - Meredith L. Borland
- Princess Margaret Hospital for Children, Perth, Australia
- Schools of Paediatric and Child Health and Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Western Australia Australia
| | - David W. Herd
- Lady Cilento Children’s Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
- Mater Research Institute, Brisbane, Australia
| | - Amit Kochar
- Women’s & Children’s Hospital, Adelaide, Australia
| | - Jason Hort
- The Children’s Hospital at Westmead, Sydney, Australia
| | - Arjun Rao
- Sydney Children’s Hospital, Randwick, New South Wales, Australia
| | - John A. Cheek
- Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Monash Medical Centre, Clayton, Victoria, Australia
| | - Jeremy Furyk
- Townsville Hospital and James Cook University College of Medicine and Dentistry, Townsville, Australia
| | - Lisa Barrow
- Sunshine Hospital, St Albans, Victoria Australia
| | - Shane George
- Gold Coast University Hospital, Southport, Queensland Australia
| | - Michael Zhang
- John Hunter Hospital, Newcastle, New South Wales Australia
| | - Kaya Gardiner
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
| | - Katherine J. Lee
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
| | - Andrew Davidson
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
- Department of Anaesthesia, Royal Children’s Hospital, Parkville, Victoria Australia
| | - Robert Berkowitz
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
- Department of Otolaryngology, Royal Children’s Hospital, Parkville, Victoria Australia
| | - Frank Sullivan
- Department of Family & Community Medicine, North York General Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Emily Porrello
- Pharmacy Department, Royal Children’s Hospital, Parkville, Victoria Australia
| | - Kim Marie Dalziel
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
- Centre for Health Policy Melbourne School of Global and Population Health, The University of Melbourne, Carlton, Victoria Australia
| | - Vicki Anderson
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Psychological Sciences & Paediatrics, University of Melbourne, The Royal Children’s Hospital, Melbourne, VIC Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
| | - Sandy Hopper
- Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
| | - Fiona Williams
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
| | - Catherine Wilson
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
| | - Amanda Williams
- Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
| | - Stuart R Dalziel
- Starship Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - for the PREDICT (Paediatric Research In Emergency Departments International Collaborative) research network
- Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 3052 Australia
- Murdoch Children’s Research Institute, Parkville, Victoria Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC Australia
- Department of Neurology, Royal Children’s Hospital, Parkville, VIC Australia
- Princess Margaret Hospital for Children, Perth, Australia
- Schools of Paediatric and Child Health and Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Western Australia Australia
- Lady Cilento Children’s Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
- Mater Research Institute, Brisbane, Australia
- Women’s & Children’s Hospital, Adelaide, Australia
- The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Children’s Hospital, Randwick, New South Wales, Australia
- Monash Medical Centre, Clayton, Victoria, Australia
- Townsville Hospital and James Cook University College of Medicine and Dentistry, Townsville, Australia
- Sunshine Hospital, St Albans, Victoria Australia
- Gold Coast University Hospital, Southport, Queensland Australia
- John Hunter Hospital, Newcastle, New South Wales Australia
- Department of Anaesthesia, Royal Children’s Hospital, Parkville, Victoria Australia
- Department of Otolaryngology, Royal Children’s Hospital, Parkville, Victoria Australia
- Department of Family & Community Medicine, North York General Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Pharmacy Department, Royal Children’s Hospital, Parkville, Victoria Australia
- Centre for Health Policy Melbourne School of Global and Population Health, The University of Melbourne, Carlton, Victoria Australia
- Psychological Sciences & Paediatrics, University of Melbourne, The Royal Children’s Hospital, Melbourne, VIC Australia
- Starship Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
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22
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D’Amico E, Zanghì A, Patti F. Can new chemical therapies improve the management of multiple sclerosis in children? Expert Opin Pharmacother 2016; 18:45-55. [DOI: 10.1080/14656566.2016.1267139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Emanuele D’Amico
- Department of Neurosciences G.F. Ingrassia, University of Catania, Catania, Italy
| | - Aurora Zanghì
- Department of Neurosciences G.F. Ingrassia, University of Catania, Catania, Italy
| | - Francesco Patti
- Department of Neurosciences G.F. Ingrassia, University of Catania, Catania, Italy
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23
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Abstract
OBJECTIVES The aim of this study was to describe cognitive, academic, and psychosocial outcomes after an incident demyelinating event (acquired demyelinating syndromes, ADS) in childhood and to investigate the contribution of brain lesions and confirmed MS diagnosis on outcome. METHODS Thirty-six patients with ADS (mean age=12.2 years, SD=2.7, range: 7-16 years) underwent brain MRI scans at presentation and at 6-months follow-up. T2-weighted lesions on MRI were assessed using a binary classification. At 6-months follow-up, patients underwent neuropsychological evaluation and were compared with 42 healthy controls. RESULTS Cognitive, academic, and behavioral outcomes did not differ between the patients with ADS and controls. Three of 36 patients (8.3%) were identified with cognitive impairment, as determined by performance falling ≤1.5 SD below normative values on more than four independent tests in the battery. Poor performance on a visuomotor integration task was most common, observed among 6/32 patients, but this did not differ significantly from controls. Twelve of 36 patients received a diagnosis of MS within 3 years post-ADS. Patients with MS did not differ from children with monophasic ADS in terms of cognitive performance at the 6-months follow-up. Fatigue symptoms were reported in 50% of patients, irrespective of MS diagnosis. Presence of brain lesions at onset and 6 months post-incident demyelinating event did not associate with cognitive outcome. CONCLUSIONS Children with ADS experience a favorable short-term neurocognitive outcome, even those confirmed to have MS. Longitudinal evaluations of children with monophasic ADS and MS are required to determine the possibility of late-emerging sequelae and their time course. (JINS, 2016, 22, 1050-1060).
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24
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Khandaker G, Jung J, Britton PN, King C, Yin JK, Jones CA. Long-term outcomes of infective encephalitis in children: a systematic review and meta-analysis. Dev Med Child Neurol 2016; 58:1108-1115. [PMID: 27422743 DOI: 10.1111/dmcn.13197] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/26/2022]
Abstract
AIM The long-term outcomes of childhood infective encephalitis are variable and not well quantified. We aimed to systematically review the literature and undertake meta-analyses on predetermined outcomes to address this knowledge gap and identify areas for future research. METHOD We searched electronic databases, performed complementary reviews of references of fully extracted articles, and made contact with experts on infective encephalitis. Articles published up until April 2016 were selected for screening. RESULTS We evaluated sequelae of 1018 survivors of childhood infective encephalitis (934 with complete follow-up) from 16 studies. Mean age during acute encephalitis episodes was 5 years 3.6 months (range 1.2mo-17y), 57.6% were male (500/868), and mean follow-up period was 4 years 1.2 months (range 1-12y). Incomplete recovery was reported in 312 children (42.0%; 95% confidence interval [CI] 31.6-53.1% in pooled estimate). Among the other sequelae, developmental delay, abnormal behaviour, motor impairment, and seizures were reported among 35.0% (95% CI 10.0-65.0%), 18.0% (95% CI 8.0-31.0%), 17.0% (95% CI 10.0-26.0%), and 10.0% (95% CI 6.0-14.0%) respectively. INTERPRETATION Almost half of childhood infective encephalitis survivors report incomplete recovery in the long-term; most commonly developmental delay, behavioural abnormality, and neurological impairments (i.e. seizure). Well designed, large-scale prospective studies are needed to better quantify neurodevelopmental sequelae among childhood encephalitis survivors.
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Affiliation(s)
- Gulam Khandaker
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia. .,National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Sydney, NSW, Australia. .,Marie Bashir Institute for Infectious Diseases and Biosecurity Institute (MBI), University of Sydney, Sydney, NSW, Australia.
| | - Jenny Jung
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Philip N Britton
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity Institute (MBI), University of Sydney, Sydney, NSW, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Catherine King
- National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - J Kevin Yin
- National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Cheryl A Jones
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity Institute (MBI), University of Sydney, Sydney, NSW, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, NSW, Australia
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25
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Sudhakar SV, Muthusamy K, Mani S, Gibikote S, Shroff M. Imaging in Pediatric Demyelinating and Inflammatory Diseases of Brain- Part 2. Indian J Pediatr 2016; 83:965-82. [PMID: 27130513 DOI: 10.1007/s12098-016-2052-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 01/28/2016] [Indexed: 01/18/2023]
Abstract
Imaging plays an important role in diagnosis, management, prognostication and follow up of pediatric demyelinating and inflammatory diseases of brain and forms an integral part of the diagnostic criteria. This article reviews the spectrum of aquaporinopathies with an in-depth discussion on present criteria and differentiation from other demyelinating diseases with clinical vignettes for illustration; the latter part of article deals with the spectrum of CNS vasculitis.
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Affiliation(s)
- Sniya Valsa Sudhakar
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India.
| | - Karthik Muthusamy
- Department of Neurology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sunithi Mani
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India
| | - Sridhar Gibikote
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, 632004, India
| | - Manohar Shroff
- Department of Pediatric Neuroimaging, Hospital for Sick Children, Toronto, Canada
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Rebollo Polo M. Management of pediatric central nervous system emergencies: a review for general radiologists. RADIOLOGIA 2016; 58 Suppl 2:142-50. [PMID: 27138031 DOI: 10.1016/j.rx.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/15/2016] [Accepted: 03/28/2016] [Indexed: 10/21/2022]
Abstract
TEACHING OBJECTIVES To review the most common and most important diseases and disorders of the central nervous system (CNS) in pediatric emergencies, discussing the indications for different imaging tests in each context. DISCUSSION In pediatric patients, acute neurologic symptoms (seizures, deteriorating level of consciousness, focal neurologic deficits, etc.) can appear in diverse clinical situations (trauma, child abuse, meningoencephalitis, ischemia…). It is important to decide on the most appropriate neuroimaging diagnostic algorithm for each situation and age group, as well as to know the signs of the most typical lesions that help us in the etiological differential diagnosis. Pediatric patients' increased vulnerability to ionizing radiation and the possible need for sedation in studies that require more time are factors that should be taken into account when indicating an imaging test. It is essential to weigh the risks and benefits for the patient and to avoid unnecessary studies.
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Affiliation(s)
- M Rebollo Polo
- Hospital Universitario Maternoinfantil Sant Joan de Dèu, Esplugues de Llobregat, Barcelona, España.
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27
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Britton PN, Eastwood K, Paterson B, Durrheim DN, Dale RC, Cheng AC, Kenedi C, Brew BJ, Burrow J, Nagree Y, Leman P, Smith DW, Read K, Booy R, Jones CA. Consensus guidelines for the investigation and management of encephalitis in adults and children in Australia and New Zealand. Intern Med J 2016; 45:563-76. [PMID: 25955462 DOI: 10.1111/imj.12749] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/17/2015] [Indexed: 02/06/2023]
Abstract
Encephalitis is a complex neurological syndrome caused by inflammation of the brain parenchyma. The management of encephalitis is challenging because: the differential diagnosis of encephalopathy is broad; there is often rapid disease progression; it often requires intensive supportive management; and there are many aetiologic agents for which there is no definitive treatment. Patients with possible meningoencephalitis are often encountered in the emergency care environment where clinicians must consider differential diagnoses, perform appropriate investigations and initiate empiric antimicrobials. For patients who require admission to hospital and in whom encephalitis is likely, a staged approach to investigation and management is preferred with the potential involvement of multiple medical specialties. Key considerations in the investigation and management of patients with encephalitis addressed in this guideline include: Which first-line investigations should be performed?; Which aetiologies should be considered possible based on clinical features, risk factors and radiological features?; What tests should be arranged in order to diagnose the common causes of encephalitis?; When to consider empiric antimicrobials and immune modulatory therapies?; and What is the role of brain biopsy?
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Affiliation(s)
- P N Britton
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
| | - K Eastwood
- Health Protection, Hunter New England Population Health, Newcastle, New South Wales, Australia.,Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - B Paterson
- Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - D N Durrheim
- Biopreparedness, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - R C Dale
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Neurology, The Children's Hospital at Westmead, Sydney, Australia
| | - A C Cheng
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - C Kenedi
- Departments of, General Medicine, Auckland City Hospital, Auckland, New Zealand, USA.,Liaison Psychiatry, Auckland City Hospital, Auckland, New Zealand, USA.,Department of Medicine and Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA
| | - B J Brew
- St Vincent's Centre for applied medical research, University of New South Wales, Sydney, Australia.,Department of Neurology, St Vincent's Hospital, Sydney, Australia
| | - J Burrow
- Department of Neurology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Y Nagree
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.,Emergency Department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - P Leman
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.,Emergency Department, Royal Perth Hospital, Perth, Australia
| | - D W Smith
- Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia
| | - K Read
- Department of Infectious Diseases, North Shore Hospital, Auckland, New Zealand, USA
| | - R Booy
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia.,National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, Sydney, Australia
| | - C A Jones
- Discipline of Paediatrics and Child Health and Marie Bashir Institute for Emerging Infectious Diseases and Biosecurity, Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, Australia
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Hassanein SM, Ibrahim YA. Posttraumatic Acute Disseminated Encephalomyelitis in a Child Resolved by Steroid Therapy: Case Report. J Clin Neurol 2016; 12:245-7. [PMID: 26833988 PMCID: PMC4828576 DOI: 10.3988/jcn.2016.12.2.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/11/2015] [Accepted: 10/13/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sahar M.A. Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Trabatti C, Foiadelli T, Spartà MV, Gagliardone C, Rinaldi B, Delmonte M, Lozza A, Savasta S. Paediatric clinically isolated syndromes: report of seven cases, differential diagnosis and literature review. Childs Nerv Syst 2016; 32:69-77. [PMID: 26584554 DOI: 10.1007/s00381-015-2959-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/05/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE Few paediatric cases of clinically isolated syndrome (CIS) have been described in literature, even though it has been increasingly recognized also in this age group. Our study retrospectively enrolled seven Italian patients (four males and three females) who met the International Paediatric Multiple Sclerosis Study Group (IPMSSG) 2012 criteria for clinically isolated syndrome over the period 2010-2014; their clinical, laboratory and imaging findings were compared with current literature and with those seen in five patients (three males and two females) with acute disseminated encephalomyelitis, who were followed in our department over the same years (mean follow-up time 2.84 ± 1.8 years). RESULTS In our CIS sample, male sex was prevalent, 42.8 % of patients had a multifocal presentation, MRI lesions mostly appeared confluent and with poorly defined margins, and CSF oligoclonal bands (OCBs) were identified in 28.6 %. All acute disseminated encephalomyelitis (ADEM) patients had polyfocal presentation and encephalopathy; large MRI subcortical lesions and polyclonal IgG distribution were identified. During the subsequent follow-up assessments, MRI scan revealed new lesions in three CIS patients, while in ADEM children it appeared normal. CONCLUSIONS Paediatric CIS patients often show peculiar epidemiological, clinical and radiological features, which significantly differ from adult ones. The presence of encephalopathy and of extended MRI lesions leads to a diagnosis of ADEM, instead. In CIS patients the presence of multiple asymptomatic MRI lesions and of OCBs revealed to be the most predictive risk factors for progression to clinically definite multiple sclerosis (CDMS), so a regular long-term follow-up is recommended; in ADEM, no suitable risk factors for a relapse could be identified.
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Affiliation(s)
- Chiara Trabatti
- Department of Paediatrics, University of Pavia, IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100, Pavia, Italy.
| | - Thomas Foiadelli
- Department of Paediatrics, University of Pavia, IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Maria Valentina Spartà
- Department of Paediatrics, University of Pavia, IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Chiara Gagliardone
- Department of Paediatrics, University of Pavia, IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100, Pavia, Italy
| | - Berardo Rinaldi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Maria Delmonte
- Department of Radiology, Radio diagnostic service, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Lozza
- Clinical Neurophysiology Service, IRCCS C. Mondino National Neurological Institute, Pavia, Italy
| | - Salvatore Savasta
- Department of Paediatrics, University of Pavia, IRCCS Policlinico San Matteo, viale Camillo Golgi, 19, 27100, Pavia, Italy
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Nationwide Incidence of Acquired Central Nervous System Demyelination in Icelandic Children. Pediatr Neurol 2015; 53:503-7. [PMID: 26463471 DOI: 10.1016/j.pediatrneurol.2015.08.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/27/2015] [Accepted: 08/28/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Recognizing acquired demyelinating syndromes and multiple sclerosis is important to commence early treatment. The objective of this study was to describe the incidence of acquired demyelinating syndromes and multiple sclerosis among the entire Icelandic pediatric population according to recently promoted criteria. PATIENTS AND METHODS The study included all children in Iceland (<18 years) with acquired demyelinating syndromes and multiple sclerosis from 1990 to 2009 with a minimum of 5-year follow-up. Clinical data were gathered and radiological images reviewed. The cohort included all patients with acquired demyelinating syndromes and multiple sclerosis in the Icelandic pediatric population. RESULTS Eighteen patients with acquired demyelinating syndromes and multiple sclerosis were included, the total annual incidence being 1.15/100,000 (acquired demyelinating syndromes 1.02 and multiple sclerosis 0.45/100,000). The median age at diagnosis was 14.25 years (range 1.25-17.5 years). Thirteen patients were initially diagnosed with clinically isolated syndrome, two had acute disseminated encephalomyelitis, two had multiple sclerosis, and one had neuromyelitis optica. Seven children were diagnosed with multiple sclerosis; three patients with clinically isolated syndrome developed multiple sclerosis after the age of 18 and were not included in the multiple sclerosis group. The gender ratio was equal. Of the nine girls, seven were diagnosed with clinically isolated syndrome. Most patients (11 of 18) were diagnosed during the period January through March. Oligoclonal bands in cerebrospinal fluid were exclusively found in patients with multiple sclerosis and clinically isolated syndrome and 13 of 14 available magnetic resonance images revealed clear abnormalities. CONCLUSION The annual incidence of acquired demyelinating syndromes and multiple sclerosis in Iceland was 1.15/100,000 children. The risk of progression from clinically isolated syndrome to multiple sclerosis was high. There was no female preponderance.
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Gulati S, Chakrabarty B, Kumar A, Jain P, Patel H, Saini L. Acquired demyelinating disorders of central nervous system: A pediatric cohort. Ann Indian Acad Neurol 2015; 18:S48-55. [PMID: 26538849 PMCID: PMC4604698 DOI: 10.4103/0972-2327.164829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: This is a retrospective chart review of consecutive children with acquired demyelinating disorders presenting to a north Indian tertiary care hospital over 4 years. The aim of this review is to describe all the patients (with single event as well as those with recurrences) with detailed description of those who recurred. Materials and Methods: Overall 35 cases were reviewed and their clinical presentations, diagnosis, management, and follow-up are being presented. Results: Out of 35 cases, 24 did not show any recurrences (seven acute disseminated encephalomyelitis (ADEM) and 17 clinically isolated syndromes). Amongst the 11 patients with recurrent demyelination, majority were multiple sclerosis (8/11, 72.7%) followed by neuromyelitis optica (NMO; 2/11), and multiphasic ADEM (1/11). The median disease duration and follow-up since onset for those with recurrent episodes is 4 years (2.5-4.5 years). Steroids caused significant improvement in acute episodes of demyelination. However, recurrent demyelinating disorders like multiple sclerosis and NMO required long-term immunomodulation. Azathioprine currently is the most favored long-term immunomodulator used in NMO. Interferon-β and glatiramer acetate are currently recommended for multiple sclerosis. However, azathioprine may be a suitable alternative in a resource-limited setting. Conclusion: The consensus definitions for these groups of disorders need further validation in the pediatric age group. Studies with larger population size are required to characterize features that predict future recurrences.
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Affiliation(s)
- Sheffali Gulati
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Biswaroop Chakrabarty
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radio-Diagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Jain
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Harsh Patel
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Lokesh Saini
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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32
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Lee CG, Lee B, Lee J, Lee M. The natural course of clinically isolated syndrome in pediatric patients. Brain Dev 2015; 37:432-8. [PMID: 25085837 DOI: 10.1016/j.braindev.2014.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 07/09/2014] [Accepted: 07/10/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The first episode of central nervous system (CNS) symptoms with a presumed inflammatory demyelinating cause is defined as clinically isolated syndrome (CIS) according to the 2007 consensus of the International Pediatric Multiple Sclerosis Study Group, which developed diagnostic criteria for CNS demyelination disease in children. Using this definition of CIS, we attempted to identify the natural course of pediatric patients with CIS in a single Korean institution and to determine the factors affecting their prognosis. METHODS We retrospectively reviewed the medical records of all pediatric patients (age <18 years old) who presented with clinical symptoms of CNS events between 1997 and 2008. RESULTS We identified 32 patients with CIS. Their mean age with standard deviation was 10.0±4.1 years. The most common type of presentation of CIS was optic neuritis (ON). Sixteen (16/32, 50%) patients experienced a second demyelinating event. The mean interval between the first event and the recurrent episode was 21±20 months. The mean follow-up was 6.1±1.6 years. Eleven (34%) patients developed childhood onset multiple sclerosis (MS). In contrast to previous studies, asymptomatic brain lesions on magnetic resonance imaging (MRI) and the presence of cerebrospinal fluid (CSF) oligoclonal bands (OCBs) were not predictors of conversion to MS. CONCLUSION In our study, a second relapse and initial presentation with brain stem, cerebellar, cerebral dysfunction, or multifocal CIS were strongly associated with the development of MS (p=0.002). Despite clinical definitions and increased understanding of CIS in children, challenges remain in predicting its progression to a chronic demyelinating disease.
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Affiliation(s)
- Cha Gon Lee
- Department of Pediatrics, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Republic of Korea
| | - Bolyun Lee
- Department of Pediatrics, Pusan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Munhyang Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Pfeifenbring S, Bunyan RF, Metz I, Röver C, Huppke P, Gärtner J, Lucchinetti CF, Brück W. Extensive acute axonal damage in pediatric multiple sclerosis lesions. Ann Neurol 2015; 77:655-67. [PMID: 25612167 DOI: 10.1002/ana.24364] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 01/05/2015] [Accepted: 01/14/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Axonal damage occurs early in multiple sclerosis (MS) and contributes to the degree of clinical disability. Children with MS more often show disabling and polyfocal neurological symptoms at disease onset than adults with MS. Thus, axonal damage may differ between pediatric and adult MS patients. METHODS We analyzed axonal pathology in archival brain biopsy and autopsy samples from 19 children with early MS. Lesions were classified according to demyelinating activity and presence of remyelination. Axonal density and extent of acute axonal damage were assessed using Bielschowsky silver impregnation and immunohistochemistry for amyloid precursor protein (APP), respectively. Axonal injury was correlated with the inflammatory infiltrate as well as clinical characteristics. Results were compared with data from adult MS patients. RESULTS Acute axonal damage was most extensive in early active demyelinating (EA) lesions of pediatric patients and correlated positively with the Expanded Disability Status Scale at attack leading to biopsy/autopsy. Comparison with 12 adult patients showed a 50% increase in the extent of acute axonal damage in EA lesions from children compared to adults, with the highest number of APP-positive spheroids found prior to puberty. The extent of acute axonal damage correlated positively with the number of lesional macrophages. Axonal density was reduced in pediatric lesions irrespective of the demyelinating activity or the presence of remyelination. Axonal reduction was similar between children and adults. INTERPRETATION Our results provide evidence for more pronounced acute axonal damage in inflammatory demyelinating lesions from children compared to adults.
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Affiliation(s)
- Sabine Pfeifenbring
- Department of Neuropathology, University Medical Center, Georg August University, Göttingen, Germany
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Britton PN, Dale RC, Booy R, Jones CA. Acute encephalitis in children: Progress and priorities from an Australasian perspective. J Paediatr Child Health 2015; 51:147-58. [PMID: 24953748 DOI: 10.1111/jpc.12650] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 11/27/2022]
Abstract
Encephalitis is a complex neurological syndrome caused by inflammation of the brain that occurs with highest incidence in children. It is challenging to diagnose and manage due to the variety of aetiologies and non-specific clinical presentations. We discuss the recent progress in clinical case definitions; review recent, large, prospective epidemiological studies; and describe aetiologies. We emphasise infectious causes relevant to children in Australasia but also consider emerging immune-mediated syndromes responsive to immune therapies. We identify priorities for future research in children, given the potential for climate change and international travel to influence the emergence of infectious agents in our region.
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Affiliation(s)
- Philip N Britton
- Department of Infectious Diseases and Microbiology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity (MBI), University of Sydney, Sydney, New South Wales, Australia
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35
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Sorte DE, Poretti A, Newsome SD, Boltshauser E, Huisman TAGM, Izbudak I. Longitudinally extensive myelopathy in children. Pediatr Radiol 2015; 45:244-57; quiz 241-3. [PMID: 25636706 DOI: 10.1007/s00247-014-3225-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 08/09/2014] [Accepted: 10/27/2014] [Indexed: 12/13/2022]
Abstract
When children present with acute myelopathy manifested by sensory, motor, or bowel and bladder symptoms, MRI of the neuraxis with contrast agent is the most important imaging study to obtain. Although occasionally normal, MRI often demonstrates signal abnormality within the spinal cord. Classically, longitudinally extensive transverse myelitis (≥3 vertebral bodies in length) has been described with neuromyelitis optica (NMO), but alternative diagnoses should be considered. This pictorial essay reviews the differential diagnoses that may present with longitudinally extensive spinal cord signal abnormalities. Multiple inflammatory, infectious, vascular, metabolic and neurodegenerative etiologies can present with a myelopathy. Thus, radiologists can assist in the diagnosis by familiarizing themselves with the spectrum of diseases in childhood that result in longitudinally extensive signal abnormalities in the absence of trauma.
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Affiliation(s)
- Danielle Eckart Sorte
- Division of Interventional Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Kelly JE, Mar S, D’Angelo G, Zhou G, Rajderkar D, Benzinger TL. Susceptibility-weighted imaging helps to discriminate pediatric multiple sclerosis from acute disseminated encephalomyelitis. Pediatr Neurol 2015; 52:36-41. [PMID: 25532777 PMCID: PMC4275621 DOI: 10.1016/j.pediatrneurol.2014.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/09/2014] [Accepted: 10/09/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Susceptibility-weighted imaging is a relatively new magnetic resonance imaging sequence that can identify lesions of multiple sclerosis in adults. This study was designed to determine if susceptibility-weighted imaging is a useful discriminator between children who develop multiple sclerosis and children with monophasic acute disseminated encephalomyelitis. METHODS Eighteen children who presented with acute central nervous system demyelination and had a brain magnetic resonance imaging study including susceptibility-weighted imaging within 6 months of the first clinical attack were studied. Final diagnosis was based on international consensus definitions. Brain lesions detected on the fluid-attenuated inversion recovery sequence were assessed for abnormal signal on susceptibility-weighted imaging. The burden of susceptibility abnormalities was then analyzed for differences between the multiple sclerosis and acute disseminated encephalomyelitis groups. RESULTS Eight patients had a final diagnosis of acute disseminated encephalomyelitis and ten had multiple sclerosis. Twenty-two percent of fluid-attenuated inversion recovery lesions were identified on susceptibility-weighted imaging. The percentage of fluid-attenuated inversion recovery lesions identified on susceptibility-weighted imaging differed between the multiple sclerosis and acute disseminated encephalomyelitis groups (P = 0.04). The median percentage (minimum-maximum) of lesions identified on susceptibility-weighted imaging in the multiple sclerosis group was 0.22 (0-0.68) and in the acute disseminated encephalomyelitis group was 0.0 (0-0.17). CONCLUSION Susceptibility-weighted imaging may be a useful technique in differentiating acute disseminated encephalomyelitis from multiple sclerosis at initial presentation.
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Affiliation(s)
- James E. Kelly
- Department of Radiology, Washington University School of Medicine, Saint
Louis, MO
| | - Soe Mar
- Department of Pediatrics, Washington University School of Medicine, Saint
Louis, MO
| | - Gina D’Angelo
- Department of Biostatistics, Washington University School of Medicine, Saint
Louis, MO
| | - Gongfu Zhou
- Department of Biostatistics, Washington University School of Medicine, Saint
Louis, MO
| | - Dhanashree Rajderkar
- Department of Radiology, Washington University School of Medicine, Saint
Louis, MO
| | - Tammie L.S. Benzinger
- Department of Radiology, Washington University School of Medicine, Saint
Louis, MO,Department of Neurological Surgery, Washington University School of
Medicine, Saint Louis, MO
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Saltik S, Besli GE, Koltka N, Akcan N. A rare cause of upper airway obstruction: isolated demyelinating brainstem lesion. Pediatr Emerg Care 2014; 30:896-9. [PMID: 25198764 DOI: 10.1097/pec.0000000000000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute upper airway obstruction derived from any cause can be a life-threatening emergency in pediatric patients. The major causes are infection, foreign body aspiration, and trauma. However, acute neurological disorders occasionally may manifest as severe airway obstruction.In our case, we report a 10-year-old patient presenting with prominent upper airway obstruction requiring intubation and respiratory support. He also had fever, encephalopathy, and involvement of multiple cranial nerves. Cranial magnetic resonance imaging showed a hyperintense lesion covering all of the medulla oblongata on T2-weighted images and a lesion that was hypointense on T1-weighted images with no enhancement. Diffusion maps were normal. High-dose steroids and then intravenous immunoglobulin were given because these findings were mostly consistent with an inflammatory demyelinating process in the brainstem. A dramatic improvement was observed, and he was extubated on the 10th day. He completely recovered within 3 weeks without any neurological deficit.We emphasize that emergency physicians should be familiar with the airway manifestations of acute neurological disorders. Although rare, acute demyelinating brainstem disorders should be considered a part of the differential diagnosis of upper airway obstruction in children. Prompt recognition of this entity in light of additional neurological findings, neuroimaging, and other laboratory test results is critical. Early immunomodulatory treatment of these patients can be lifesaving.
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Affiliation(s)
- Sema Saltik
- From the *Department of Pediatric Neurology, Istanbul, Turkey, Istanbul Medeniyet University Goztepe Training and Research Hospital; †Department of Pediatrics, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey; ‡Intensive Care Unit; §Department of Pediatrics, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
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Huhn K, Lee DH, Linker RA, Kloska S, Huttner HB. Pneumococcal-meningitis associated acute disseminated encephalomyelitis (ADEM) - case report of effective early immunotherapy. SPRINGERPLUS 2014; 3:415. [PMID: 25140291 PMCID: PMC4137046 DOI: 10.1186/2193-1801-3-415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/01/2014] [Indexed: 11/26/2022]
Abstract
Introduction Unvaccinated patients with history of splenectomy are prone to fulminant courses of Streptococcus pneumoniae-associated bacterial meningitis. Besides direct brain damage those patients may additionally suffer from parainfectious syndromes, notably vasculitis and acute disseminated encephalomyelitis (ADEM). Differentiation and treatment of these immunological reactions is challenging. Methods Case report. Results A 61 year-old woman with history of splenectomy without vaccination for S. pneumoniae presented with progressive headache and meningism. CSF-analysis revealed pleocytosis with microbiological evidence for pneumococcal meningitis. After unsuspicious initial cranial CT imaging and initiation of appropriate antibiotic therapy, MRI two days later showed widespread FLAIR- and T2-hyperintense white matter lesions that further progressed upon follow-up MRI and that fulfilled imaging criteria of ADEM. Meanwhile the patient deteriorated and required mechanical ventilation. Cranial angiography showed no signs of vasculitis or vasospasms. Screening for autoimmune diseases remained negative, however oligoclonal bands turned positive. Brain biopsy mainly revealed perivascular CD4+ T-cells and demyelinated areas. Despite ongoing acute meningitis, a 10-day corticosteroid-pulse was initiated followed by steroid-tapering. Within 4 weeks, clinical and MRI findings ameliorated. In an one-year follow-up visit, the patient significantly recovered, MRI lesions were markedly reduced and no further relapses occurred. Conclusion Acute pneumococcal meningitis in unvaccinated splenectomized patients may be complicated by a monophasic course of parainfectious ADEM that can be controlled with high-dose corticosteroids. Parainfectious vasculitis or cerebritis are important differential diagnoses and exact differentiation of these entities is important to initiate early appropriate immunotherapy.
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Affiliation(s)
- Konstantin Huhn
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - De-Hyung Lee
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Ralf A Linker
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Stephan Kloska
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054 Erlangen, Germany
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39
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Rocca MA, Valsasina P, Absinta M, Moiola L, Ghezzi A, Veggiotti P, Amato MP, Horsfield MA, Falini A, Comi G, Filippi M. Intranetwork and internetwork functional connectivity abnormalities in pediatric multiple sclerosis. Hum Brain Mapp 2014; 35:4180-92. [PMID: 24510680 PMCID: PMC6869159 DOI: 10.1002/hbm.22469] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/27/2013] [Accepted: 01/07/2014] [Indexed: 11/10/2022] Open
Abstract
Active motor functional magnetic resonance imaging (fMRI) studies have shown that pediatric multiple sclerosis (MS) patients have a strictly lateralized pattern of activations and a preserved functional connectivity (FC) within the motor system when compared to age-matched healthy controls. However, it is still not clear whether a preserved FC in pediatric MS is present only in the motor system, or involves other relevant functional system. Resting-state (RS) fMRI is a valuable tool for an unbiased investigation of FC abnormalities of multiple networks. This study explored abnormalities of RS FC within and between large-scale neuronal networks from 44 pediatric MS patients and 27 controls and their correlation with clinical, neuropsychological, and conventional MRI measures. Compared to controls, pediatric MS patients had a decreased FC of several regions of the sensorimotor, secondary visual, default-mode (DMN), executive control, and bilateral working memory (WMN) networks. They also experienced an increased FC in the right medial frontal gyrus of the attention network, which was correlated with T2 lesion volume. Cognitively impaired patients had decreased RS FC of the right precuneus of the left WMN. An increased FC between the sensorimotor network and the DMN, and between the L WMN and the attention network as well as a decreased FC between L WMN and the DMN were also found. A distributed pattern of FC abnormalities within large-scale neuronal networks occurs in pediatric MS patients, contributes to their cognitive status, and is partially driven by focal white matter lesions. Internetwork connectivity is relatively preserved in these patients.
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Affiliation(s)
- Maria A. Rocca
- Neuroimaging Research UnitInstitute of Experimental NeurologyDivision of NeuroscienceSan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
- Department of NeurologySan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
| | - Paola Valsasina
- Neuroimaging Research UnitInstitute of Experimental NeurologyDivision of NeuroscienceSan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
| | - Martina Absinta
- Neuroimaging Research UnitInstitute of Experimental NeurologyDivision of NeuroscienceSan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
- Department of NeurologySan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
| | - Lucia Moiola
- Department of NeurologySan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
| | - Angelo Ghezzi
- Multiple Sclerosis Study CenterDepartment of NeurologyHospital of GallarateGallarateItaly
| | - Pierangelo Veggiotti
- Child Neuropsychiatry UnitFondazione “Istituto Neurologico Casimiro Mondino”PaviaItaly
| | - Maria P. Amato
- Department of NeurologyUniversity of FlorenceFlorenceItaly
| | - Mark A. Horsfield
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUnited Kingdom
| | - Andrea Falini
- Department of NeuroradiologySan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
- CERMACDivision of NeuroscienceSan Raffaele Scientific InstituteVita‐Salute San Raffaele UniversityMilanItaly
| | - Giancarlo Comi
- Department of NeurologySan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
| | - Massimo Filippi
- Neuroimaging Research UnitInstitute of Experimental NeurologyDivision of NeuroscienceSan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
- Department of NeurologySan Raffaele Scientific Institute, Vita‐Salute San Raffaele UniversityMilanItaly
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40
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Lavery AM, Verhey LH, Waldman AT. Outcome measures in relapsing-remitting multiple sclerosis: capturing disability and disease progression in clinical trials. Mult Scler Int 2014; 2014:262350. [PMID: 24883205 PMCID: PMC4026972 DOI: 10.1155/2014/262350] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/25/2014] [Indexed: 11/24/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease that manifests as acute relapses and progressive disability. As a primary endpoint for clinical trials in MS, disability is difficult to both characterize and measure. Furthermore, the recovery from relapses and the rate of disability vary considerably among patients. Given these challenges, investigators have developed and studied the performance of various outcome measures and surrogate endpoints in MS clinical trials. This review defines the outcome measures and surrogate endpoints used to date in MS clinical trials and presents challenges in the design of both adult and pediatric trials.
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Affiliation(s)
- Amy M. Lavery
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Leonard H. Verhey
- The Pediatric Demyelinating Disease Program, Program in Neuroscience & Mental Health, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada M5G 1X8
| | - Amy T. Waldman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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41
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Per H, Canpolat M, Tümtürk A, Gumuş H, Gokoglu A, Yikilmaz A, Özmen S, Kaçar Bayram A, Poyrazoğlu HG, Kumandas S, Kurtsoy A. Different etiologies of acquired torticollis in childhood. Childs Nerv Syst 2014; 30:431-40. [PMID: 24196698 DOI: 10.1007/s00381-013-2302-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 10/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Torticollis can be congenital or may be acquired in childhood. Acquired torticollis occurs because of another problem and usually presents in previously normal children. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders. OBJECTIVE We performed this study to evaluate the underlying causes of torticollis in childhood. MATERIAL AND METHODS Ten children presented with complaints of torticollis between April 2007 and April 2012 were enrolled in this study. The additional findings of physical examination included neck pain, twisted neck, walking disorder, imbalance, and vomiting The identified etiologies of the enrolled children was acute disseminated encephalomyelitis in a 2.5-year-old boy, posterior fossa tumor in a 10-month-old boy, spontaneous spinal epidural hematoma in a 5-year-old hemophiliac boy, cervical osteoblastoma in a 3-year-old boy, arachnoid cyst located at posterior fossa in a 16-month-old boy, aneurysm of the anterior communicating artery in a 6-year-old girl, pontine glioma in a 10-year-old girl, and a psychogenic torticollis in a 7-year-old boy were presented. CONCLUSION There is a wide differential diagnosis for a patient with torticollis, not just neurological in etiology which should be considered in any patient with acquired torticollis. Moreover, early diagnosis of etiological disease will reduce mortality and morbidity. Therefore, clinicians managing children with torticollis must be vigilant about underlying neurological complications.
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Affiliation(s)
- Hüseyin Per
- Medical Faculty, Department of Pediatrics, Division of Pediatric Neurology, Erciyes University, Talas, Kayseri, Turkey,
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42
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Behan PO. Acute disseminated encephalomyelitis: postinfectious, postimmunization and variant forms. Expert Rev Neurother 2014; 9:1321-9. [DOI: 10.1586/ern.09.90] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Moharir M, Shroff M, Benseler SM. Childhood central nervous system vasculitis. Neuroimaging Clin N Am 2013; 23:293-308. [PMID: 23608691 DOI: 10.1016/j.nic.2012.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Inflammatory brain diseases in childhood are underrecognized and lead to devastating yet potentially reversible deficits. New-onset neurologic or psychiatric deficits in previously healthy children mandate an evaluation for an underlying inflammatory brain disease. Distinct disease entities, such as central nervous system (CNS) vasculitis, are now being increasingly reported in children. Clinical symptoms, initial laboratory test, and neuroimaging studies help to differentiate between different causes; however, more invasive tests, such as lumbar puncture, conventional angiography, and/or brain biopsy, are usually necessary before the start of treatment. This article focuses on childhood CNS vasculitis.
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Affiliation(s)
- Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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44
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Twilt M, Benseler SM. CNS vasculitis in children. Mult Scler Relat Disord 2013; 2:162-71. [DOI: 10.1016/j.msard.2012.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 10/27/2012] [Accepted: 11/19/2012] [Indexed: 01/20/2023]
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45
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Afectación difusa del cerebelo en la edad pediátrica: hallazgos en resonancia magnética. RADIOLOGIA 2013; 55:253-60. [DOI: 10.1016/j.rx.2011.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/02/2011] [Accepted: 09/05/2011] [Indexed: 11/24/2022]
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46
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Tomljenovic L, Shaw CA. Human papillomavirus (HPV) vaccine policy and evidence-based medicine: are they at odds? Ann Med 2013; 45:182-93. [PMID: 22188159 DOI: 10.3109/07853890.2011.645353] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
All drugs are associated with some risks of adverse reactions. Because vaccines represent a special category of drugs, generally given to healthy individuals, uncertain benefits mean that only a small level of risk for adverse reactions is acceptable. Furthermore, medical ethics demand that vaccination should be carried out with the participant's full and informed consent. This necessitates an objective disclosure of the known or foreseeable vaccination benefits and risks. The way in which HPV vaccines are often promoted to women indicates that such disclosure is not always given from the basis of the best available knowledge. For example, while the world's leading medical authorities state that HPV vaccines are an important cervical cancer prevention tool, clinical trials show no evidence that HPV vaccination can protect against cervical cancer. Similarly, contrary to claims that cervical cancer is the second most common cancer in women worldwide, existing data show that this only applies to developing countries. In the Western world cervical cancer is a rare disease with mortality rates that are several times lower than the rate of reported serious adverse reactions (including deaths) from HPV vaccination. Future vaccination policies should adhere more rigorously to evidence-based medicine and ethical guidelines for informed consent.
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Affiliation(s)
- Lucija Tomljenovic
- Neural Dynamics Research Group, Department of Ophthalmology and Visual Sciences, University of British Columbia, 828 W. 10th Ave, Vancouver, BC, V5Z 1L8, Canada.
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O'Mahony J, Bar-Or A, Arnold DL, Sadovnick AD, Marrie RA, Banwell B. Masquerades of acquired demyelination in children: experiences of a national demyelinating disease program. J Child Neurol 2013; 28:184-97. [PMID: 22573735 DOI: 10.1177/0883073812443006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The diagnosis of acquired demyelinating syndromes of the central nervous system in children requires exclusion of other acute central nervous system disorders. In a 23-site national demyelinating disease study, standardized clinical, laboratory, and magnetic resonance imaging (MRI) data were obtained prospectively from onset, and serially at 3, 6, and 12 months and annually. Twenty of 332 (6%) participants (mean [SD] age, 10.21 [4.32] years; 12 (60%) female) were ultimately diagnosed with vascular disorders (primary or secondary central nervous system vasculitis, vasculopathy, stroke, or migraine, n = 11 children), central nervous system malignancy (n = 3), mitochondrial disease (n = 2), or central nervous system symptoms in the accompaniment of confirmed infection (n = 4). Red flags that may serve to distinguish disorders in the differential of acquired demyelination are described.
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Affiliation(s)
- Julia O'Mahony
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Toronto, Canada.
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Verhey LH, Shroff M, Banwell B. Pediatric multiple sclerosis: pathobiological, clinical, and magnetic resonance imaging features. Neuroimaging Clin N Am 2013; 23:227-43. [PMID: 23608687 DOI: 10.1016/j.nic.2012.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In this article, the pathobiological, clinical, and treatment aspects of pediatric-onset multiple sclerosis (MS) are summarized, and the conventional magnetic resonance (MR) imaging (ie, T1-weighted, proton-density, and T2-weighted imaging) features of MS in children are discussed, as well as the application of MR imaging in the diagnosis of pediatric-onset MS and in prediction of MS in children with an incident central nervous system demyelination. Insights gained from studies comparing MR imaging features of pediatric-onset and adult-onset MS are presented.
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Affiliation(s)
- Leonard H Verhey
- Pediatric Demyelinating Disease Program, The Hospital for Sick Children, Toronto, Ontario, Canada
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49
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Inflammatory, vascular, and infectious myelopathies in children. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:999-1017. [PMID: 23622308 DOI: 10.1016/b978-0-444-52910-7.00020-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute nontraumatic myelopathies of childhood include inflammatory, infectious, and vascular etiologies. Inflammatory immune-mediated disorders of the spinal cord can be categorized as idiopathic isolated transverse myelitis, neuromyelitis optica, and multiple sclerosis. In recent years, human T-cell lymphotropic virus type 1, West Nile virus, enterovirus-71, and Lyme disease have been increasingly recognized as infectious etiologies of myelopathy, and poliomyelitis remains an important etiology in world regions where vaccination programs have not been universally available. Vascular etiologies include vasculopathies (systemic lupus erythematosus, small vessel primary angiitis of the central nervous system), arteriovenous malformations, and spinal cord infarction (fibrocartilaginous embolism, diffuse hypoxic ischemia-mediated infarction). Vascular myelopathies are less common than inflammatory and infectious myelopathies, but are more likely to lead to devastating clinical deficits. Current therapeutic strategies include acute anti-inflammatory treatment and rehabilitation. Stem cell transplantation, nerve graft implantation, and stimulation of endogenous repair mechanisms represent promising strategies for spinal cord repair.
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50
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Sinclair AJ, Wienholt L, Tantsis E, Brilot F, Dale RC. Clinical association of intrathecal and mirrored oligoclonal bands in paediatric neurology. Dev Med Child Neurol 2013; 55:71-5. [PMID: 23095051 DOI: 10.1111/j.1469-8749.2012.04443.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM Biomarkers such as autoantibodies, neopterin, and oligoclonal bands (OCBs) are increasingly used for the diagnosis of treatable inflammatory central nervous system (CNS) disorders. We investigated the correlation between the results of OCB testing and clinical diagnoses in a large contemporary cohort of children with a broad range of neurological conditions. METHOD Cerebrospinal fluid (CSF) and serum from 200 children (94 females, 106 males; age range 2 mo-15 y 10 mo, mean age 6 y 9 mo, SD ±4.9) who underwent CSF investigation for their neurological condition were tested for OCBs using isoelectric focusing. RESULTS The patients were divided into those with inflammatory (n=58) and non-inflammatory (n=142) CNS disorders. Intrathecal OCBs (OCBs restricted to the CSF) were found in 11 out of 58 (19%) of those with inflammatory CNS disorders compared with none of the 142 patients with non-inflammatory CNS disorders (p<0.001). Diseases associated with intrathecal OCB were multiple sclerosis, Rasmussen encephalitis, N-methyl-d-aspartate receptor (NMDAR) encephalitis, voltage-gated potassium channel (VGKC) encephalopathy, herpes (HSV) encephalitis, 'other' encephalitides, acute cerebellar ataxia, and aseptic meningitis. Mirrored OCBs (identical OCBs in the serum and CSF) were less specific but were still found in 14 out of 58 (24%) children with inflammatory CNS disorders compared with only 6 out of 142 (4%) children with non-inflammatory CNS disorders (p<0.001). Diseases associated with mirrored OCBs included acute disseminated encephalomyelitis (ADEM), VGKC encephalopathy, West syndrome, NMDAR encephalitis, 'other' encephalitides, polio-like illness, Rasmussen encephalitis, cerebral vasculitis, metachromatic leukodystrophy, and bacterial meningitis. Intrathecal OCBs and mirrored OCBs had a positive predictive value for inflammatory CNS disease of 1 (95% confidence interval [CI] 0.68-1) and 0.7 (95% CI 0.46-0.87) respectively. CONCLUSION Intrathecal OCBs were restricted to patients with inflammatory CNS disorders. They are a useful, but non-specific, biomarker of CNS inflammation of multiple causes. Mirrored OCBs are less specific, but still support a possible inflammatory CNS disorder. The presence of either intrathecal or mirrored OCBs should raise suspicion of an inflammatory CNS disorder.
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Affiliation(s)
- Adriane J Sinclair
- Department of Child Neurology, Sydney Children's Hospital, Sydney, Australia
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