Molecular characterization of Spanish patients with MECP2 duplication syndrome

MECP2 duplication syndrome (MDS) is an X-linked neurodevelopmental disorder characterized by a severe to profound intellectual disability, early onset hypotonia and diverse psycho-motor and behavioural features. To date, fewer than 200 cases have been published. We report the clinical and molecular characterization of a Spanish MDS cohort that included 19 boys and 2 girls. Clinical suspicions were confirmed by array comparative genomic hybridization and multiplex ligation-dependent probe amplification (MLPA). Using, a custom in-house MLPA assay, we performed a thorough study of the minimal duplicated region, from which we concluded a complete duplication of both MECP2 and IRAK1 was necessary for a correct MDS diagnosis, as patients with partial MECP2 duplications lacked some typical clinical traits present in other MDS patients. In addition, the duplication location may be related to phenotypic severity. This observation may provide a new approach for genotype-phenotype correlations, and thus more personalized genetic counselling.

Optic neuritis in paediatric patients: Experience over 27 years and a management protocol

INTRODUCTION AND OBJECTIVE

In this article, we present our experience on optic neuritis (ON) and provide a diagnostic/therapeutic protocol, intended to rule out other aetiologies (particularly infection), and a fact sheet for parents.

MATERIAL AND METHODS

We conducted a descriptive, retrospective study of patients with ON over a 27-year period (1990-2017). A review of the available scientific evidence was performed in order to draft the protocol and fact sheet.

RESULTS

Our neuropaediatrics department has assessed 20,744 patients in the last 27 years, of whom 14 were diagnosed with ON: 8 had isolated ON, 1 had multiple sclerosis (MS), 1 had clinically isolated syndrome (CIS), 3 had acute disseminated encephalomyelitis, and 1 had isolated ON and a history of acute disseminated encephalomyelitis one year previously. Patients' age range was 4-13 years; 50% were boys. Eight patients were aged over 10: 7 had isolated ON and 1 had MS. Nine patients had bilateral ON, and 3 had retrobulbar ON. MRI results were normal in 7 patients and showed involvement of the optic nerve only in 2 patients and optic nerve involvement + central nervous system demyelination in 5. Thirteen patients received corticosteroids. One patient had been vaccinated against meningococcus-C the previous month. Progression was favourable, except in the patient with MS. A management protocol and fact sheet are provided.

CONCLUSIONS

ON usually has a favourable clinical course. In children aged older than 10 years with risk factors for MS or optic neuromyelitis (hyperintensity on brain MRI, oligoclonal bands, anti-NMO antibody positivity, ON recurrence), the initiation of immunomodulatory treatment should be agreed with the neurology department. The protocol is useful for diagnostic decision-making, follow-up, and treatment of this rare disease with potentially major repercussions. The use of protocols and fact sheets is important.

Effect of prematurity and low birth weight in visual abilities and school performance

BACKGROUND

Prematurity and low birth weight are known risk factors for cognitive and developmental impairments, and school failure. Visual perceptual and visual motor skills seem to be among the most affected cognitive domains in these children.

AIMS

To assess the influence of prematurity and low birth weight in visual cognitive skills and school performance.

METHODS

We performed a prospective cohort study, which included 80 boys and girls in an age range from 5 to 13. Subjects were grouped by gestational age at birth (preterm, <37 weeks; term, 37-42 weeks) and birth weight (small for gestational age (SGA), <10th centile; appropriate weight for gestational age (AGA), ≥10th centile). Each child underwent full ophthalmologic assessment and standardized testing of visual cognitive abilities (Test of Visual Perceptual Skills and Test of Visual Analysis Skills). Parents completed a questionnaire on school performance in children.

RESULTS

Figure-ground skill and visual motor integration were significantly decreased in the preterm birth group, compared with term control subjects (figure-ground: 45.7 vs 66.5, p=0.012; visual motor integration, TVAS: (9.9 vs 11.8, p=0.018), while outcomes of visual memory (29.0 vs 47.7, p=0.012), form constancy (33.3 vs 52.8, p=0.019), figure-ground (37.4 vs 65.6, p=0.001), and visual closure (43.7 vs 62.6 p=0.016) testing were lower in the SGA (vs AGA) group. Visual cognitive difficulties corresponded with worse performance in mathematics (r=0.414, p=0.004) and reading (r=0.343, p=0.018).

CONCLUSION

Specific patterns of visual perceptual and visual motor deficits are displayed by children born preterm or SGA, which hinder mathematics and reading performance.

Descriptive study of symptomatic epilepsy by age of onset in patients with a 3-year follow-up at the Neuropaediatric Department of a reference centre

OBJECTIVE

We conducted a descriptive study of symptomatic epilepsy by age at onset in a cohort of patients who were followed up at a neuropaediatric department of a reference hospital over a 3-year period PATIENTS AND METHODS: We included all children with epilepsy who were followed up from January 1, 2008 to December 31, 2010 RESULTS: Of the 4595 children seen during the study period, 605 (13.17%) were diagnosed with epilepsy; 277 (45.79%) of these had symptomatic epilepsy. Symptomatic epilepsy accounted for 67.72% and 61.39% of all epilepsies starting before one year of age, or between the ages of one and 3, respectively. The aetiologies of symptomatic epilepsy in our sample were: prenatal encephalopathies (24.46% of all epileptic patients), perinatal encephalopathies (9.26%), post-natal encephalopathies (3.14%), metabolic and degenerative encephalopathies (1.98%), mesial temporal sclerosis (1.32%), neurocutaneous syndromes (2.64%), vascular malformations (0.17%), cavernomas (0.17%), and intracranial tumours (2.48%). In some aetiologies, seizures begin before the age of one; these include Down syndrome, genetic lissencephaly, congenital cytomegalovirus infection, hypoxic-ischaemic encephalopathy, metabolic encephalopathies, and tuberous sclerosis.

CONCLUSIONS

The lack of a universally accepted classification of epileptic syndromes makes it difficult to compare series from different studies. We suggest that all epilepsies are symptomatic because they have a cause, whether genetic or acquired. The age of onset may point to specific aetiologies. Classifying epilepsy by aetiology might be a useful approach. We could establish 2 groups: a large group including epileptic syndromes with known aetiologies or associated with genetic syndromes which are very likely to cause epilepsy, and another group including epileptic syndromes with no known cause. Thanks to the advances in neuroimaging and genetics, the latter group is expected to become increasingly smaller.

[Gorlin syndrome in the paediatric age]

INTRODUCTION

Gorlin syndrome (GS) is a disorder transmitted by dominant autosomal inheritance associated to mutations in PTCH1, the main characteristic of which is the appearance of basal cell carcinomas, together with skeletal abnormalities, odontogenic keratocysts and intracranial tumours.

CASE REPORT

A girl aged 3 years and 10 months, who was admitted due to acute ataxia. Some of the more striking features in the patient's personal history include psychomotor retardation and a family history of suspected GS in the mother as a result of a maxillary cyst. An examination revealed macrocephaly with a prominent forehead and hypertelorism, as well as nevus. A genetic study for GS was requested, in which mutation c.930delC was detected in exon 6 of the PTCH1 gene in heterozygosis.

CONCLUSIONS

In GS there is an increase in the likelihood of developing basal cell carcinomas and strict dermatological monitoring is necessary. A clinical neurological follow-up and also magnetic resonance imaging scans are needed for an early diagnosis of intracranial tumours, especially in the case of medulloblastomas. Odontogenic keratocysts, other skin disorders, and cardiac and ovarian fibromas are characteristic, as are skeletal abnormalities, which require regular clinical and neuroimaging controls and treatment if needed, but radiation must be avoided. GS is a rare disorder, but it must be suspected in the presence of characteristic alterations. It requires a multidisciplinary follow-up, and it is also necessary to establish a protocol on how to act so as to allow early diagnosis and treatment of the potentially severe complications deriving from this disease.

[Congenital infection by cytomegalovirus. A review of our 18 years' experience of diagnoses]

INTRODUCTION

Infection by cytomegalovirus (CMV) is the most frequent congenital viral infection. Although it offers a wide range of manifestations, it nevertheless continues to be underdiagnosed if there are no symptoms in the newborn infant, which is what most commonly happens. A definitive retrospective diagnosis can only be reached after the first three weeks by detecting CMV DNA in blood on the filter paper used in the neonatal screening test.

PATIENTS AND METHODS

The article reviews our experience with congenital CMV from a diagnostic perspective and with the study of CMV DNA in the heel prick test.

RESULTS

Of the 10,855 patients included in the neuropaediatric service database, there were 11 cases of congenital CMV. The diagnosis was only probable in four cases and it was definitive in seven of them, the diagnosis being obtained in the neonatal period in four of these patients and retrospectively in three others, by means of the heel prick test. The heel prick test was performed in 10 cases altogether, and was positive in five of them.

CONCLUSIONS

There can be no doubt that many cases of congenital CMV infection are still not diagnosed. Retrospective study of congenital infection by CMV by detecting DNA in blood from the filter paper used in the neonatal screening test should be considered in the presence of severe symptoms and different clinical pictures such as: delayed intrauterine growth, microcephaly, neurosensory hypoacusis, chorioretinitis, mental retardation, behavioural disorders (especially autistic spectrum disorders), intracranial calcifications, encephaloclastic disorders, leukoencephalopathy, cortical dysplasia and malformations of the temporal lobe or the hippocampus. Given its availability, ready access and low cost, the benefits to be gain from continuing to use the heel prick test should be reconsidered.

[Epilepsy with onset between the ages of 3 and 12 months. Our experience gained over a 10-year period]

INTRODUCTION

The prognosis of epilepsy is essentially determined by its aetiology and a poorer prognosis is generally associated with an early onset of the seizures.

PATIENTS AND METHODS

In this study we review our experience in epilepsies in children born after 1st January 1997 and who had their first acute non-symptomatic seizure before 31st March 2007 and between the ages of 3 and 12 months. Special attention is given to the analysis of cases of remote non-symptomatic epilepsies.

RESULTS

Of the children born in that period, 267 were diagnosed with epilepsy, and the first seizure occurred between 3 and 12 months of age in 69 cases: 39 of which were symptomatic and 30 were cryptogenic and idiopathic epilepsies. West's syndrome/childhood spasms were observed in 20 cases (17 of the symptomatic cases and three of the cryptogenic and idiopathic patients). The cryptogenic and idiopathic cases were divided into three groups depending on their electroencephalogram pattern: nine generalised, 18 with no generalised alterations and three hypsarrhythmias. In addition, the three groups were analysed taking into account three degrees of psychomotor development: normal, slight retardation and moderate/severe retardation. None of the non-generalised cases presented severe psychomotor retardation, whereas 78% of the generalised and 33% of those with West's syndrome developed an important degree of retardation in their course.

CONCLUSIONS

Our experience is compatible with the existence of epilepsies that have their onset in the early months of life and a good prognosis, which is important when it comes to the information and therapeutic approaches in cases of remote non-symptomatic epilepsy.

[Our experience in the diagnosis of peroxisomal diseases with an abnormal fatty acid profile]

INTRODUCTION

The aetiology and clinical features of peroxisomal diseases vary widely. An altered very-long-chain fatty acid (VLCFA) profile is commonly found in many of these diseases, and this makes it easier to point the diagnosis in the right direction.

PATIENTS AND METHODS

We review our experience in the diagnosis of cases of peroxisomal diseases with an altered VLCFA pattern; these were determined in serum only when there was a strong clinical suspicion up to the end of 1998, when their quantification by chromatography was introduced into our laboratory.

RESULTS

The neuropaediatric database included 10,239 cases between May 1990 and 1st October 2007. Ten cases of peroxisomal disease with an altered VLCFA pattern were identified, all of them males. There were two cases of Zellweger syndrome spectrum, one unclassified peroxisomal oxidation defect and seven X-linked adrenoleukodystrophies (four with neurological compromise and three with no neurological damage; two were identified in siblings of patients and the other due to the presence of Addison's syndrome).

CONCLUSIONS

In our 10 cases, the diagnosis was guided by the clinical or familial features that led to the determination of VLCFA. Being able to determine VLCFA makes early systematic diagnosis of patients possible. At present, VLCFA determination is performed when there is a clinical suspicion of Zellweger spectrum, suspected X-linked adrenoleukodystrophy/adrenomyeloneuropathy of unclear causation, Addison's disease, both in males and females, and above all in cases of chronic encephalopathy of unknown causation, with or without prenatal onset.

[Early care and botulinum toxin. Our experience in the 21st century]

INTRODUCTION

In neuropaediatrics, the aetiological diagnosis rarely allows a causal treatment to be established. In many cases, all we can offer is referral to early intervention (EI) and botulinum toxin type A (BTA). The only requirement before starting both interventions is a functional or syndromic diagnosis.

PATIENTS AND METHODS

Here we analyse the experience gained from an EI programme carried out in the region of Aragon since February 2003 and with the BTA service in the Neuropaediatric Unit of the Hospital Universitario Miguel Servet since November 2003.

RESULTS

By the end of 2007, 2629 requests had been made for admission to the EI programme and in the year 2007 a total of 702 children were treated. In four years and four months 122 children with infantile cerebral palsy (ICP) were infiltrated with BTA, with positive results in 70% of cases and mild, transient side effects in 13.1%.

CONCLUSIONS

The children, parents and professionals involved all view EI and BTA with satisfaction. Neuropaediatrics is one of the medical specialties that are best suited to child development and early intervention centres (CDIAT). The neuropaediatrician participates in all the stages of the EI: detection, diagnosis, information and intervention. He or she may act as the coordinating and homogenising element in EI, that is to say, as a link between CDIAT and health care services. Neuropaediatricians are also essential in EI training and education, in family training, information and awareness campaigns, primary care, social services and nurseries. Treatment with BTA cannot be viewed as an isolated technique, but instead as part of a programme in which physiotherapy, orthosis and sometimes surgery play a fundamental role. Coordination among the different professionals involved in treating the child with ICP is absolutely crucial.

[Neuropaediatrics and primary care. Our experience in the 21st century]

INTRODUCTION

The quality of the health care in a major part of neuropaediatrics benefits from appropriate communication and strategies that have been agreed with primary care (PC) paediatricians.

PATIENTS AND METHODS

We analyse the children who were assessed in the Neuropaediatric service at the Hospital Universitario Miguel Servet in Saragossa over a period of eight years and we also discuss the most important courses of action followed in the most prevalent problems.

RESULTS

Eight reasons for visiting accounted for 86% of the total number: paroxysmal disorders (33%), headache (27%), psychomotor retardation (11.5%), alterations affecting the shape or size of the head (5.6%), problems at school and/or attention deficit (4.5%), behavioural disorders (4.25%), gait disorders (3.5%) and perinatal distress (3.4%). The most frequent diagnoses are headaches/migraines (26%), non-epileptic paroxysmal disorders (16.5%), prenatal encephalopathy (10.5%), epilepsy (8%), mental retardation (7.5%), infantile cerebral palsy (4.6%), cryptogenic attention deficit hyperactivity disorder (ADHD) (3.8%) and cryptogenic autism (3.6%).

CONCLUSIONS

The PC paediatrician working in close relation with the children and their families in all cases is the person mainly responsible for conducting a follow-up on some of the most prevalent problems, such as headaches, many non-epileptic paroxysmal disorders and ADHD. The processes must be established, clearly specified, based on the best evidence, with the participation and within reach of all the professionals involved, in order to favour homogeneity and keep variability in the interventions to a minimum. Channels of communication, including the information and communications technologies, need to be set up to allow health professionals to be permanently up-to-date and capable of controlling their patients in the best possible way.

[Neurological newborn in our center and follow-up]

INTRODUCTION

The progress made in perinatal health care in recent years has changed the epidemiology of neurological diseases during the neonatal period. The reduction in neonatal mortality has been accompanied by an increasingly large number of patients suffering from disabling diseases or with a risk of suffering from them; a prolonged follow-up and the joint efforts of neonatologists and neuropaediatricians are therefore essential.

DEVELOPMENT

We review the welfare work and demand for health care for newborn infants with neurological disorders in our service, as well as perinatal neurological morbidity, the functioning of the follow-up outpatients department, and we also report some of the findings from our experience in following up high-risk newborn infants.

CONCLUSIONS

The demand for neonatal health care is increasing, and it is important to take this into account so as to be able to plan better strategies for the use of health care resources and for caring for patients. In our population, preterm delivery and asphyxia are the chief perinatal factors leaving neurological sequelae, with an overall incidence that is similar to that reported in other research and a high proportion of severe sequelae. The follow-up programmes must be made cost-effective by better selection of the high risk population to be monitored and coordination with primary care paediatricians. Early detection of the deficits is essential to be able to implement early intervention, and this can be aided by a series of recommendations aimed at professionals and relatives, as well as by improved coordination between the different multidisciplinary groups involved in prevention and care programmes.

[Facial paralysis reported in a paediatric emergency department: actuation protocol reviewed and verified]

INTRODUCTION

As result of our aim to improve the quality standard of our emergency system, work has been carried out in relation to the development and monitorization of effective clinical protocols in the department of paediatric practice.

PATIENTS AND METHODS

An evidence based review approach was taken to design a clinical protocol about Bell's palsy condition for the paediatric emergency department. Previous protocol approved in March 2003 was reviewed accordingly with the new designed protocol's quality standards. The Bell's palsy cases reported since March 2003 until June 2006 to paediatric emergency department were analyzed.

RESULTS

A total of 27 patients affected by Bell's palsy were reported to the hospital's emergency department. Facial expression was described in 85.19% of the cases. Cranial nerves normal function was reported in 77.78%. Fundoscopic examination was described in 77.78% and otoscopic findings in 44.44%; the absence of herpes vesicles was analyzed only in 11.11%. All patients received steroid therapy (prednisone) and the treatment resulted in the complete recovery. The mean time to resolution was 58.6 days.

CONCLUSIONS

In order to improve hospital's quality standards, clinical protocols should be designed and verified regularly to ensure the proper performance. Medical auditing also contributes to improve effectiveness in health attendance.

[Hereditary neuromuscular diseases in paediatrics. Our experience over the last 14 years]

INTRODUCTION

Hereditary neuromuscular diseases are disorders which can vary largely in their age of onset, symptoms and severity. Many are severe, disabling and have an important personal, familial and social impact and can restrict the prognosis for survival. The constant progress being made in diagnostics makes it necessary to continually update knowledge and information.

PATIENTS AND METHODS

We carried out a review of the hereditary neuromuscular diseases contained in the Neuropaediatrics database at the Hospital Miguel Servet in Zaragoza from May 1990 to October 2004.

RESULTS

Of the 7,805 patients in the database, 123 (1.5% of the total) were patients with hereditary neuromuscular diseases, of whom 71 were males and 52 females. These included: 35 sensory-motor hereditary neuropathies, 17 dystrophinopathies, 10 myotonic dystrophies, 10 spinal muscular atrophies, four merosin-deficient congenital dystrophies, four other muscular dystrophies, three mitochondrial myopathies, three myasthenias, two familial neuropathies with insensitivity to pain, two Friedreich's ataxias, one familial neuropathy with liability to pressure palsies, one case of Walker-Warburg syndrome, five polyneuropathies associated to leukodystrophy and another 25 cases that could not be classified. Genetic studies provided a diagnosis in 36 cases (29.2%): nine myotonic dystrophies, eight dystrophinopathies, eight cases of spinal muscular atrophy, four demyelinating sensory-motor hereditary neuropathies, two instances of Friedreich's ataxia, two limb-girdle muscular dystrophies, one congenital myasthenia, one McArdle's disease and one case of Kearns-Sayre syndrome.

CONCLUSIONS

Genetic studies enable us to establish diagnoses that were previously limited to the realm of assumption, and allow us to avoid the need for muscle tissue biopsies, which is a welcome development, especially when dealing with children. Immunohistochemical studies need to be updated and biological samples should be systematically saved in cases where no diagnosis is reached.

Congenital endplate acetylcholinesterase deficiency responsive to ephedrine

The authors describe two patients with congenital myasthenic syndrome (CMS) with end plate acetylcholinesterase (AChE) deficiency caused by mutations in the collagenic tail (ColQ) of AChE: a homozygous C-terminal Y230S mutation in Patient 1 and Y430S and a C-terminal splice-site mutation in Patient 2. In Patient 1, a Prostigmin (neostigmine bromide) test failed to distinguish between AChE deficiency and a slow-channel CMS. Both patients responded dramatically to ephedrine therapy.

[Retrospective diagnosis of congenital infection by cytomegalovirus in the case of one infant]

INTRODUCTION

10-15% of asymptomatic congenital infections by cytomegalovirus (CMV) in the neonatal period develop persistent problems with varying degrees of severity, fundamentally involving neurological disorders, neurosensory hypoacusis and hypovision, which appear from the age of 6-9 months onwards, when a diagnosis is no longer possible. The PCR (polymerase chain reaction) technique can detect DNA of CMV in blood samples on filter paper used for screening hypothyroidism and metabolic pathologies that were kept from the neonatal period.

CASE REPORT

A child aged 3 years and 8 months with delayed intrauterine growth, autism, mental retardation, microcephalus and neurosensory hypoacusis; periventricular calcifications, leukoencephalopathy and bilateral malformation of the temporal lobe; and a diagnosis of congenital CMV confirmed by detection of DNA by PCR in the blood sample on filter paper saved from the neonatal period.

CONCLUSIONS

The retrospective study of congenital infection by CMV should be considered when faced with severity and varying association of delayed intrauterine growth, microcephalus, neurosensory hypoacusis, chorioretinitis, mental retardation, autism or other behavioural disorders, intracranial calcifications, encephaloclastic alterations, leukoencephalopathy, cortical dysplasia and malformations of the temporal lobe and the hippocampus. Since the filter papers from neonatal screening are not kept for ever, perhaps the idea of doing so ought to be considered, given the possibilities they offer for retrospective studies.

[Shaken baby syndrome and osteogenesis imperfecta]

INTRODUCTION

Shaken baby syndrome (SBS) is a form of physical abuse that includes the presence of a subdural or subarachnoid haematoma or diffuse cerebral oedema, retinal haemorrhages and, in general, absence of other physical signs of traumatic injury. Osteogenesis imperfecta (OI) is a genetic disorder affecting the synthesis of type I collagen that leads to brittle bones with frequently occurring fractures, with presenting clinical symptoms taking a variety of forms. A differential diagnosis allowing it to be distinguished from physical abuse is known, due to the existence of bone fractures with no known traumatic injuries, but we do not understand the link between OI and SBS.

CASE REPORT

We describe the case of an infant who, at the age of 3 months, suffered symptoms of acute encephalopathy with convulsions, subdural haematoma and retinal haemorrhages compatible with SBS, as well as bilateral rib fractures. The skeletal series of X-rays revealed alterations in bone structure and texture, which led to a diagnosis of OI that was confirmed by a study of the collagen in skin fibroblasts.

CONCLUSIONS

The suspected existence of SBS is unpleasant both for the health care professional and for the patient's relatives. The existence of rib fractures in an obvious case of shaken baby syndrome suggested malicious abuse; however, the parents' attitude and the existence of OI made us think that no harm was intended. Shaking could have been secondary to bouts of crying due to microfissures related to the OI. The differential diagnosis of processes that can be mistaken for shaken baby or from favourable or predisposing medical factors must be taken into consideration.

[Benign paroxysmal vertigo. Our 14 years' experience with this entity]

INTRODUCTION

Benign paroxysmal vertigo (BPV) is characterised by the sudden onset of brief recurring episodes of loss of balance, sometimes accompanied by vegetative symptoms, which tend to disappear spontaneously in a matter of months or years and have no intercritical alterations.

PATIENTS AND METHODS

We analyse the clinical and developmental characteristics of the patients who were listed as possible cases of benign paroxysmal vertigo in the database of the Neuropaediatric Unit of the Hospital Miguel Servet in Zaragoza over a 14 year period. Clinical records were reviewed and cases no longer controlled were contacted by telephone.

RESULTS

18 patients were considered to be cases of BPV, with the typical criteria, and 13 were found to be possible BPV (p-BPV). The atypical data of the p-BPV included late age of onset, prolonged persistence of the episodes and long duration of each episode. Neuroimaging was performed in 8 (44%) of the BPV and 10 (77%) of the p-BPV, and electroencephalogram recordings were carried out in 15 (83%) of the BPV and 11 (85%) of the p-BPV, with normal results in all cases.

CONCLUSIONS

Establishing a diagnosis of BPV with strict criteria can mean that some atypical cases are excluded. As no biological marker is available, the diagnosis is clinical-developmental and sometimes complementary tests need to be conducted in order to rule out other pathological conditions. A broader clinical spectrum, cases in which the episodes last longer and a greater range of ages of onset and complete remission are all possible. A diagnosis of BPV should reassure the patients' families as it is a benign process that tends to disappear spontaneously.

[Absence epilepsy. A review of our 14 years' experience]

INTRODUCTION

Absence epilepsy (AE), typically occurring at the paediatric age, is characterised by episodes of diminished consciousness accompanied by a generalised rapid spike-wave in electroencephalogram recordings.

PATIENTS AND METHODS

Our study involved children with AE from the Neuropaediatrics database between May 1990 and May 2004. Patient records were reviewed and cases no longer controlled were contacted by telephone.

RESULTS

Of a total of 7,562 patients surveyed in the period under study, 757 subjects (10%) had epilepsy and there were 49 cases of AE (6.47% of the total number of cases of epilepsy): 29 were females (59.2%) and 20 were males (40.8%). Mean age at the time of the first visit was 7.93 years (ranging between 3 years and 10 months and 13 years and 6 months). The average follow-up time between the first visit and the last time information was updated was 5.3 years (ranging between 10 days and 13 years and 2 months). Only two females, receiving treatment, still have absences. 42 children have been without absences for more than six months, 16 with treatment and 26 without therapy; 21 children have been without absences for over four years and are not under treatment. 12 have problems at school.

CONCLUSIONS

AE is easy to diagnose and usually responds well to treatment either as monotherapy or, in some cases, in association with two antiepileptic agents. Strict initial control by experts in its management prevents absences from continuing over long periods of time. The psychosocial and learning dysfunctions that are associated in some cases require close attention.

[Neuropaediatric care in the Hospital General Universitario de Guadalajara]

INTRODUCTION AND AIMS

Influenced by medical, scientific and social advances, the changes that have taken place in the needs of the population have given rise to a growing demand for health care in neuropaediatric pathology. The aim of this study was to determine the neuropaediatric health care requirements at the Hospital General Universitario de Guadalajara, a secondary care hospital that is a reference centre for the province of Guadalajara.

PATIENTS AND METHODS

We studied the children up to the age of 10 years with a neurological pathology attended at the Hospital General Universitario de Guadalajara over an 8-year period, since the Neuropaediatric unit was opened on 1 July 1992.

RESULTS

In all 1,236 children were evaluated, which represents 8.45% of all the children below the age of 10 in the province of Guadalajara, with an average of 154.5 new patients per year. There was a predominance of males, 56.4%, and a high percentage of very young children: 26.05% under the age of 1 year and 50.56% under the age of 3. There has been a progressive increase in the number of Neuropaediatric outpatients, which in the year 2000 accounted for 20% of first visits and 16% of the total number (first and successive) of Paediatric outpatients. 12.94% of the patients in our series had also been examined in different tertiary care hospitals.

CONCLUSIONS

There is a very high demand for neuropaediatric care in Guadalajara and it is growing in a significant and progressive manner. We suggest it would be advisable to have a tertiary reference hospital available to help cope with this situation.

[Growth charts for the Spanish population with neurofibromatosis type 1]

OBJECTIVE

To make the charts of stature and head circumference of Spanish pediatric patients affected with neurofibromatosis type 1 (NF1), to compare them with the ones from a healthy population and to review the possible causes of its alterations.

PATIENTS AND METHODS

We obtained the data from 251 Spanish patients (122 women and 129 men) with NF1 seen in seven hospitals between the years 2000 and 2002, with ages between 1 month and 18 years old. The calculation of the 50th centile or median was done using the method of mobile variables, and the 3rd and 97th centiles where calculated from this median.

RESULTS

Girls with NF1 have a shorter stature than the healthy ones, which becomes evident after 10 years of age. We have not found differences in the stature between boys with the disease and those without it. In regards to head circumference, in boys and girls we have observed that it is bigger throughout life in patients affected with NF1, and that the 50th centile of healthy people correlates with the 3rd centile of those affected, the 97th centile of the healthy ones with the 50th centile of those affected, being the 3rd centile of the healthy people well below the 3rd centile of the affected ones, and the 97th centile of the affected ones well above the 97th of the healthy people.

CONCLUSIONS

The short stature in postpuberal girls and the macrocephaly in both sexes at all ages, are primary characteristics in the NF1 and they are not usually related with other alterations, although they are not specific for this illness.

[Bilateral anterior opercular syndrome as a manifestation of a non-convulsive epileptic state]

INTRODUCTION

Foix-Chavany-Marie syndrome, or bilateral anterior opercular syndrome, is characterised by facio-pharyngo-glosso-masticatory diplegia with 'automatic-voluntary dissociation', which consists in the abolition of voluntary movements while involuntary movements and reflexes are preserved. It is produced by bilateral involvement of the anterior or frontal opercular region. In adults it is related to ischemic lesions. In childhood it presents congenitally in perisylvian dysplasias and as an acquired disorder in encephalitis or can be episodic in symptomatic or idiopathic epilepsies such as benign rolandic epilepsy.

CASE REPORT

A 13-year-old patient who presented, over five straight days, four episodes of facial dysplegia, anarthria, dysphagia, drooling, paralysis of the upper limbs, while involuntary facial expression was normal and the corneal, cough and gag reflexes were preserved. The first three come to an end spontaneously at 2, 4 and 20 hours, respectively; the fourth episode concluded an hour and a half after onset, following administration of intravenous phenytoin for 5 minutes. Computerised axial tomography and magnetic resonance images of the brain, as well as the interictal electroencephalograms (EEG), were normal. Administration of oxcarbazepine was started but at 8 months was stopped after a normal EEG during nocturnal sleep was obtained. After 15 months, the patient has not presented any more episodes.

CONCLUSIONS

The paroxysmal character of the disorder together with normal interictal periods, the normality of the neuroimages, and the speedy recovery achieved after the administration of phenytoin support the notion of an epileptic origin. We believe that we are dealing with a bilateral anterior opercular syndrome due to a non-convulsive epileptic state, compatible with the presentation of benign rolandic epilepsy.

[Fatal rhabdomyolysis in an 8-year-old female]

INTRODUCTION

Rhabdomyolysis is a syndrome characterised by the destruction of muscle fibres which results in the release of toxic intracellular metabolites into the circulatory system. It usually has a benign progression but can have serious, potentially fatal, complications that largely depend on the cause. Disorders affecting the metabolism of energy in muscles can manifest as recurring rhabdomyolysis, which usually has kidney failure as its most common complication.

CASE REPORT

An 8 year old girl who had suffered an episode of rhabdomyolysis one year earlier and later died in the Paediatric Intensive Care Unit while suffering from acute symptoms of rhabdomyolysis and refractory shock. A muscular biopsy specimen was collected, but it was not possible to establish a diagnosis from that sample.

CONCLUSIONS

Even with all today's progress in the biochemical, molecular and genetic fields, the cause of recurring rhabdomyolysis is not easy to identify. What stands out in this case is the fatal progression of a usually benign problem, whose most serious complication is considered to be the delayed production of kidney failure when there is severe decompensation that does not receive adequate treatment. We recommend having guidelines set out for the correct collection, preparation and storage of the biological samples needed for the biochemical, enzymatic, immunohistochemical and DNA studies that can provide a diagnosis when death due unknown causes occurs. We emphasise the fact that it is the doctor's duty and right to exhaust all the diagnostic possibilities available.

[Expansile cyst, twin formation and possible parasagittal cerebral injury]

INTRODUCTION

Prenatal intracranial anomalies of a cystic nature are mainly either malformations (arachnoid cysts) or disruptive (porencephaly). They are usually incidental findings and, unless they undergo a progressive increase in size and become expansile or offer clinical features, they are usually managed 'expectantly'. Disruptive defects are more frequent in twin pregnancies.

CASE REPORT

A one and a half-month-old male patient, fruit of a bichorial twin pregnancy, with bouts of paleness, cyanosis around the mouth and movements of the mouth that initially responded to treatment with valproate. Physical exploration was normal except for a significant increase in the cephalic perimeter. A notable anaemia was observed and neuroimaging revealed a left temporal intraparenchymatous cystic lesion; in addition, magnetic resonance imaging showed alterations in the linear and symmetrical signals in the parasagittal region. At three months the seizures reappeared and the cyst had increased in size, which led to the implantation of a cyst peritoneal shunt. The seizures ceased and the size of the cyst became stable, without full re expansion of the brain tissue.

DISCUSSION

It is necessary to carry out a differential diagnosis of an arachnoid cyst and porencephaly. Given the history of being a twin, the notable degree of anaemia at the age of one month and the image suggesting parasagittal cerebral injury (a pattern of hypoxic ischemic encephalopathy in the full term neonate), we think that our patient was suffering from antenatal or perinatal cerebrovascular damage, which conditioned the development of an expansile porencephalic cyst and cortical damage that accounted for the symptoms of epilepsy.

[Microcephalus as the reason for visiting a regional referral neuropaediatric service]

INTRODUCTION

The first contact between the patient and clinician takes place when the former visits because of some health problem.

PATIENTS AND METHODS

We carried out a review of the clinical records of children who had visited the Neuropaediatric Service because of, among other reasons, an isolated or associated microcephalus over a period of 12 years and 9 months. Factors that were considered included whether or not there was a cephalic perimeter below p3 and evidence of encephalopathy, as well as its prenatal, perinatal or postnatal origin, functional diagnoses and the aetiological diagnosis.

RESULTS

In 58 cases (0.92%) out of a total number of 6257 children the visit was due to microcephalus. The mean age at the last visit was 3.9 years. In five children (8.6%) the cephalic perimeter was not below p3. No encephalopathy was found in 20 patients (34.4%) and 38 (65.5%) were seen to have encephalopathy, 37 with a prenatal origin: nine genetic, three disruptive and 22 unspecified. Functional diagnoses were as follows: mental retardation in 29 patients, infantile cerebral palsy in 18, autistic spectrum in four and epilepsy in four. Neuroimaging studies aided diagnosis in 13 cases, i.e. 43.3% of those carried out.

CONCLUSIONS

Visits to the doctor because of microcephalus, as well as in normal children, include the whole range of prenatal encephalopathies and are associated, ordered according to the frequency of occurrence, with mental retardation and with infantile cerebral palsy. Individual evaluation and clinical progression allow the orientation of each case. Neuroimaging is the most useful complementary examination for diagnostic purposes.

[Neurofibromatosis in children. Our experience]

INTRODUCTION

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder with a high index of spontaneous mutations and extremely varied and unpredictable clinical manifestations. It is diagnosed by the existence of certain clinical criteria which cannot appear until adulthood.

PATIENTS AND METHODS

The clinical histories of the confirmed or possible cases of neurofibromatosis (NF) in the neuropaediatric databases at the Hospital Miguel Servet in Zaragoza and at the Hospital General in Guadalajara were analysed retrospectively.

RESULTS

Cases were distributed in 46 NF1, six compatible with NF1, 11 with just marks, five with marks and a family history of marks, and two cases of segmentary NF. Among the confirmed cases of NF1, the following alterations were found: optic glioma (OG) in eight, and one of them developed a glioblastoma multiforme, multiple radicular neurofibromas in one, mental retardation in one and learning disorders in 13 of the 29 school aged children, afebrile seizures in three, precocious puberty in two and scoliosis in nine. Brain areas with hypersignals were found in 71% of the cases submitted to magnetic resonance imaging (MRI) (20 out of 28), including seven of the eight patients suffering from OG.

DISCUSSION

Our case mix, like all the others, exemplifies the clinical heterogeneity and unpredictable progression of children with NF1 or who are suspected of suffering from it. We followed the most widely used method of clinical and ophthalmological control, and complementary examinations were performed according to the clinical features. If neuroimaging is used, it must be MRI.

[Cases of idiopathic and cryptogenic epilepsias in a regional referral neuropediatric unit]

INTRODUCTION AND OBJECTIVES

Advances in genetics, techniques for diagnosis and treatment, and increasing concern for the quality of life and neuropsychological aspects of epileptic children and the possible repercussions of treatment lead to changes in the approach to epilepsy and require continual adaptation. In this study we analysed a series of cases of idiopathic and cryptogenic epilepsy attended by the Neuropaediatric Department of the Hospital Miguel Servet in Zaragoza (Spain).

PATIENTS AND METHODS

We studied the cases diagnosed as having idiopathic or cryptogenic epilepsy between May 1990 and December 1999.

RESULTS

We assessed 4,507 children. In 1,794 (39.8%) consultation was for a paroxystic disorder. Epilepsy was diagnosed in 466 children (10.3%) and 103 cases were considered possibly or probably epilepsy but the diagnosis remains in doubt (2.3%). In 111 cases (23.8%) the epilepsy was considered idiopathic, in 122 (26.2%) cryptogenic and in 233 cases (50%) symptomatic. The following epileptic syndromes were identified: epilepsy-absence attacks in 28 cases (6%), benign myoclonic infantile epilepsy in 4 cases, other idiopathic generalized epilepsies in 61 cases (13%), benign Rolandic epilepsy in 18 cases (3.9%), 2 cases of cryptogenic Ohtahara syndrome, 6 cases of cryptogenic West syndrome, 1 severe case of infantile myoclonic epilepsy, 1 case of continuous wave epilepsy during slow eye movement sleep and 1 case of Landau-Kleffner syndrome.

CONCLUSION

Current requirements and the rate of advances in epilepsy make it essential for neuropaediatric teams to include experts in epilepsy.

[Cerebral ischemia following varicella. A case report]

INTRODUCTION

Varicella in childhood is a self-limiting disease which usually follows a benign course. However, a considerable number of complications occur, particularly involving the nervous system. On rare occasions hemiparesis has been reported following an ischemic cerebrovascular accident related to varicella.

CLINICAL CASE

We report the case of a 4 year old boy who presented with right hemiparesis eight days after the onset of varicella. CAT and MR showed a cerebral infarct involving the left caudate nucleus, putamen and internal capsule. Other possible causes of cerebral infarct were ruled out. Four years later he had slight residual right hemiparesis. The pathogenesis may have been due to vasculitis of the intracranial arteries caused by direct invasion of the vessels by virus from the nearby nerve tissue. Another theory suggest similarities with moyamoya disease, suggesting that lesions of the head and neck stimulate the superior cervical ganglion and this, together with the production of circulating immuno-complexes may be the cause of the vasculopathy of the intracranial blood vessels.

CONCLUSIONS

In most cases of cerebrovascular accidents occurring in childhood the cause is unknown. However, it is important to discover the cause since the risk of recurrence often depends on the primary disease. Once other commoner causes have been excluded, one should ask whether there is a history of varicella, since the prognosis is generally good and recurrence uncommon.

[McArdle's disease in a 14-year-old girl with fatigability and raised muscle enzymes]

INTRODUCTION

McArdle's disease is a disorder of muscle energy metabolism caused by a deficit of muscle phosphorylase. The typical form presents with fatigability muscle cramps and pains triggered by physical exercise. Some cases have few symptoms. We report the case of a 14 year old girl diagnosed on finding a significantly raised CPK, studied following her complaint of fatigability.

CLINICAL CASE

A 14 year old girl presented with a CPK of 1,243 UI/l (normal 10-32) which had been requested in view of her fatigability. She had never had cramps, muscle pains or dark urine. Neurological examination was normal. The levels of CPK after intense exercise on the previous days were 7,459 UI/l, and after rest for one week were 283 UI/l (normal 25-230). The ischemic exercise test showed that she was unable to finish the test, with flat lactate and pyruvate curves and markedly raised ammonia (basal 89 and maximum 571 micrograms/dl). On muscle biopsy, the morphology of the striated muscle was seen to be normal and staining for myophosphorylase was negative.

CONCLUSIONS

The fluctuations of muscle enzyme levels in relation to exercise orientate the diagnosis towards a disorder of muscle energy metabolism. To detect this, the investigation should be carried out following severe exercise for several days and then compared with a further test after some days of rest. The ischemic exercise test permits identification of defects of glycogenolysis, orientating the choice of suitable histochemical, enzymatic or molecular biological tests.

[Hemimegalencephaly and pathological left handedness. A case report]

INTRODUCTION

Hemimegalencephaly is a disorder of neurone proliferation and migration, associated with excessive growth of all or part of one cerebral hemisphere, and variable degrees of pachygyria, polymicrogyria, neuronal heterotopy and gliosis of white matter. It is considered to be a rare malformation with severe encephalopathy, epilepsy resistant to treatment started early, contralateral hemiparesia and severe retardation of development. However, there may also be milder forms. The syndrome of pathological left handedness is associated with disorders of language, visuo-spatial changes and weakness and hypertrophy of the right limbs, with no family history of left handedness. It occurs in lesions predominantly of the left hemisphere which have occurred in the first six years of life.

CLINICAL CASE

A 12 year old girl presented with a syndrome of pathological left-handedness and craniofacial asymmetry of the left hemisphere. MR showed the left ventricle and hemisphere to be of increased size and with focal hyperintensity in the white matter, and at the level of the left parietotemporoccipital region there was a thick cortex with little interdigitation of white and grey matter.

CONCLUSIONS

Minor forms of hemimegalencephaly are probably more frequent than is generally believed. A high index of suspicion is necessary to identify them. They should be considered in cases of left handedness, craniofacial or bodily asymmetry, cutaneous hamartomas, persistent electroencephalographic asymmetry and asymmetry on neuroimaging with an enlarged ventricle and homolateral hemisphere. Study of this may give information which is useful for understanding plasticity and mechanisms of recovery and functional compensation of immature nerve tissue.

[Demand for neuropediatric care in a regional general hospital. V. Complementary tests]

INTRODUCTION

Complementary tests orientated by the clinical findings and correctly interpreted, are useful in some cases in order to exclude certain pathologies and on other occasions to help to orientate towards or to confirm diagnoses. Material and methods. In this paper we analyze the complementary tests most often used in children evaluated during a five year period, from May 1990 to May 1995, by a neuropaediatrician who recently joined the staff of the Hospital Miquel Servet in Zaragoza (which had no neuropaediatrician before then).

RESULTS AND CONCLUSIONS

Neuroimaging is the technique which was most often useful in establishing the diagnosis. CT or MR orientated or established the diagnosis in 21% of the total number of children evaluated and in 39% of the children in whom this investigation was carried out. The EEG contributed to the diagnosis of epilepsy in 11% of the children. In 16% of the cases of epilepsy the EEG was normal or with nonspecific changes and diagnosis was made on clinical grounds alone. Biochemical tests enabled some pathologies to be ruled out, but contributed to diagnosis on few occasions, most frequently the CSF (basically in meningitis and encephalitis) and muscle enzyme tests were also useful. Routinely used investigations such as those involving amino acids, ammonia, lactate and pyruvate established the diagnosis in a smaller proportion of cases than those used more selectively. Genetics were not found to be very useful in diagnosis. Reallocation of resources is necessary to permit the population as a whole to benefit from the continuous advances being made in techniques of direct study of molecular genetics.

[Demand for neuropediatric services in a general referral hospital. III. Diagnosis]

INTRODUCTION AND OBJECTIVES

In order to determine the requirements for neuropaediatric attention in the Hospital Miguel Servet of Zaragoza, we studied the diagnoses of the 2,046 children evaluated during the 5 year period-May 1990 to May 1995-, when a neuropediatrician was appointed to the hospital (which previously did not have such a specialist).

RESULTS

The most frequent problems were non-epileptic paroxystic disorders, epilepsies and febrile crises. The following is a list in descending order, of diseases affecting these children: Prenatal encephalopathies, disorders of development and behaviour, head injury (TCE), peripheral nervous system and cranial nerve disorders (which were neither traumatic nor secondary to space-occupying lesions), headaches, perinatal encephalopathies, infections and para-infectious diseases of the nervous system, cardiovascular problems, hydrocephalus, metabolic disorders, hypovision and eye disorders, neuromuscular disorders, tumours, dyskinesias, medulla problems and neurocutaneous syndromes.

CONCLUSIONS

The frequency and diversity of the neurological pathology seen in childhood and the continual advances in knowledge and the related sciences are more than a single professional person can be expected to cope with. Experts are required in areas such as electroencephalography and epilepsy, neonatal neurology, the neurological aspects of intensive care, neuropsychology, neuro-oncology, neurometabolic disorders, neurogenetics and neuromuscular disorders. Neuropediatricians are required to control illnesses with great personal, family and social impact, such as the neurocutaneous syndromes and myelomeningocoele. Neuropaediatric services working in close inter-disciplinary collaboration with other specialists are necessary.

[Demand for neuropediatric services at a general referral hospital. IV. Psychomotor development and physical examination]

INTRODUCTION AND OBJECTIVE

Diagnosis in neuropediatrics requires a detailed personal and family history and thorough physical examination. In this paper we study the psychomotor development and physical examination of children evaluated during a 5 year period, from May 1990 to May 1995 by a neuropediatrician newly appointed to the Hospital Miguel Servet in Zaragoza, which previously did not have such a specialist.

RESULTS

Psychomotor retardation was seen in 19% of the children. In 50% of the children evaluated, significant data was obtained from the physical examination. The commonest finding, observed in 14% of the children, was of anomalous behaviour or an impression of mental deficiency. In decreasing order of frequency other data were: Diffuse pyramidal involvement, cranial nerve involvement, anomalous phenotype, microcephaly, microsomy, signs of neuromuscular involvement, hemiparesia, macrocephaly, skin markings, scoliosis, signs of extrapyramidal involvement, signs of cerebellar involvement, macrosomy and sensory disorders.

CONCLUSIONS

Diagnosis in neuropediatrics is directed or established, sometimes exclusively, by an extensive personal and family history and adequate interpretation of this, which in the end depends on the skill of the clinician.

[A study of the demand for neuropediatric services in a general hospital. II. Reasons for consultation]

INTRODUCTION AND OBJECTIVE

The ambit of the work of each medical specialty is determined initially by the consultations it receives. Study of this will contribute to discovering the needs of the population, to establishing diagnostic strategies in the commonest clinical conditions and to the design of the healthcare organization necessary to fulfil these needs. Material and methods. We reviewed the reasons for consultations for neurological problems in 2,046 children evaluated during a 5 year period, between May 1990 and May 1995 in the Hospital Miguel Servet in Zaragoza, which did not previously have such a specialist.

RESULTS AND CONCLUSIONS

The commonest reason for consultation was paroxystic disorders, which led to 33% of the consultations and affected 40% of the children seen. Other common causes of consultation, in decreasing order of frequency were: psychomotor retardation, head injury, perinatal distress, headache, disorders of movement, morphological changes, disorders of oculomotricity, visual disorders and acute encephalopathy.

[A study of the demand for neuropediatrics care at a regional hospital. I. Presentation of the study and general results]

INTRODUCTION AND OBJECTIVE

The need for healthcare in neuropediatric pathology has always existed. It increases with changes in the needs of the population determined by medical scientific and social advances. These needs, together with the frequency and diversity of the neurological pathology of infancy justify the existence of neuropediatricians and neuropediatric services in regional reference hospitals. To organize a regional neuropediatric service, it is first necessary to know the real needs of the population. The objective of this study was to determine the need for neuropediatric care in the Pediatric Department of the Hospital Miguel Servet in Zaragoza, the regional reference centre for Aragón, La Rioja and Soria.

MATERIAL AND METHODS

We studied the work carried out over 5 years by a neuropediatrician, newly arrived in a department which did not formerly have such a specialist, principally evaluating diagnostic work. In this first part we describe the material and methods used and the general results obtained.

RESULTS

We analyzed the children studied during a 5 year period (May 1990 to May 1995). We evaluated 1,294 children seen in the Outpatient department and 752 during hospital admission (not followed up in Outpatients). This gave an annual average of 409 new patients in neuropediatrics.

CONCLUSIONS

There is a great demand for neuropediatric attention. Its importance is due to the great frequency, diversity and the complexity of many of these conditions.