Moyamoya Angiopathy: An Underdiagnosed Cause of Ischemic Stroke in a Tunisian Pediatric Cohort

BACKGROUND

Moyamoya angiopathy is a rare cerebral vasculopathy and an underdiagnosed cause of arterial ischemic stroke in children. We aim to report the clinical and radiological presentations in a Tunisian pediatric cohort.

METHODS

We identified moyamoya angiopathy in pediatric patients managed at the Child Neurology Department of Hedi Chaker Sfax University Hospital between 2008 and 2020 and reviewed their clinical and radiological data as well as their evolutionary profile.

RESULTS

We collected 14 patients with median age 40.6 months and a female predominance (sex ratio of 0.75). An arterial ischemic stroke (AIS) revealed the disease in all patients, with the major symptom being a motor deficit. Symptoms related to a transient ischemic attack before the diagnostic consultation were reported in four patients. Carotid territory was, clinically and radiologically, the most frequently involved. Brain magnetic resonance imaging with angiography was performed in 12 patients confirming the diagnosis by revealing the development of collateral vessels. All the investigations concluded to moyamoya disease in 57.2% and moyamoya syndrome in 42.8%. The latter was related to Down syndrome in five patients and neurofibromatosis type 1 in one patient. With a mean follow-up of 2.35 years, two patients had at least two more AISs during the first two years following diagnosis and 42.8% of patients were diagnosed with vascular or poststroke epilepsy. Full recovery was noted in 14.3% of cases.

CONCLUSIONS

Moyamoya angiopathy in children is a serious condition that needs to be recognized due to the high risk of recurrent ischemic strokes.

Dysferlinopathy in Tunisia: clinical spectrum, genetic background and prognostic profile

Dysferlinopathy is a rare group of hereditary muscular dystrophy with an autosomal recessive mode of inheritance caused by a mutation in the DYSF gene. It encodes for the dysferlin protein, which has a crucial role in multiple cellular processes, including muscle fiber membrane repair. This deficit has heterogeneous clinical presentations. In this study, we collected 20 Tunisian patients with a sex ratio of 1 and a median age of 50.5 years old (Interquartile range (IQR) = [36,5-54,75]). They were followed for periods ranging from 5 to 48 years. The median age at onset was 17 years old (IQR = [16,8-28,4]). Five major phenotypes were identified: Limb-girdle muscular dystrophy (LGMDR2) (35%), a proximodistal phenotype (35%), Miyoshi myopathy (10%),  Distal myopathy with anterior tibial onset (DMAT) (10%), and asymptomatic HyperCKemia (10%). At the last evaluation, more than half of patients (55%) were on wheelchair. Loss of ambulation occurred generally during the fourth decade. After 20 years of disease progression, two patients with a proximodistal phenotype (10%) developed dilated cardiomyopathy and mitral valve regurgitation. Restrictive respiratory syndrome was observed in three patients (DMAT: 1 patient, proximodistal phenotype: 1 patient, LGMDR2: 1 patient). Genetic study disclosed five mutations. We observed clinical heterogeneity between families and even within the same family. Disease progression was mainly slow to intermediate regardless of the phenotype.

Juvenile Dermatomyositis Without Skin Lesions in an Antinuclear Matrix Protein 2 Antibody Seropositive Pediatric Case

ABSTRACT

We report a 5-year-old boy who presented with progressive weakness in 4 limbs and gait disorders over 7 months. No skin rash was observed on admission. A symmetrical proximodistal weakness was found. The creatine kinase level was normal with a slightly elevated lactate dehydrogenase level. Biopsy specimens showed infiltration of mononuclear cells, few necrotic fibers, and perifascicular atrophy. Screening for myositis-specific antibodies was positive for the antinuclear matrix protein 2 antibody, which is mainly associated with dermatomyositis. Symptoms improved on receiving corticosteroids. Our findings suggest that in cases where inflammatory muscle disease is suspected, antinuclear matrix protein 2 antibody analyses should be considered for precise diagnosis, even with the absence of dermatological symptoms. The case suggests consideration of juvenile dermatomyositis in children with no associated skin manifestations or elevated creatine kinase levels and highlights the importance of screening for myositis-specific antibodies in helping with the diagnosis, given the possible heterogeneity of its clinical presentations.

Gayet wernicke encephalopathy: Don’t miss this neuropsychiatric emergency!

Introduction

Gayet Wernicke Encephalopathy (GWE) is a diagnostic and therapeutic neuropsychiatric emergency due to thiamin deficiency (vitamin B1).

Objectives

The purpose of our work is to recall some clinical situations suspecting GWE, along with radiological and evolutionary profile.

Methods

We conducted a retrospective study concerning patients who were hospitalized in the neurology department of Habib Bourguiba Hospital between 2013 and 2020 for management of GWE.

Results

The median age of 7 patients was 39.57 years with sex ratio (H/F):1.33. The most common risk factor found is incoercible vomiting (5 patients), followed by chronic alcoholism (3 patients). Confusional state was the most frequent symptom found in 4 patients. The characteristic clinical triad of confusion, oculomotor disorders and ataxia was only found in 2 patients. Neuroimaging showed a typical aspect in 3 patients. The serum levels of thiamine were low in five patients and normal in two patients. After receiving parental than oral thiamin supplementation, three patients were independent after one month with a mRS score <3.

Conclusions

GWE is an acute neuropsychiatric emergency. Chronic alcoholism is recognized as its most common cause. The clinical triad is not constantly present. MRI shows typically bilateral symmetrical hyperintensities in periaqueductal area, periventricular region, thalami and mammillary bodies. Thiamin level can be normal since it does not accurately represent body thiamine status or in case of mutations in a thiamine-transporter gene. Thiamine therapy is warranted if any component of the GWE triad is present in an appropriate clinical setting to prevent irreversible neurological sequelae.