Epstein-Barr virus encephalitis and encephalomyelitis: MR findings

The purpose of this project is to investigate the clinical and brain MR characteristics of Epstein-Barr virus (EBV) encephalitis and encephalomyelitis. Clinical and 30 MR findings of 29 patients with EBV encephalitis or encephalomyelitis were retrospectively reviewed. Patients included 24 with encephalitis, 3 with encephalomyelitis, and 2 with brain-stem encephalitis. Altered consciousness, seizures, visual hallucination, and acute psychotic reaction were the common presentations. Eight patients had positive MR findings. These included T2 prolongation over gray and white matter, periventricular leukomalacia, and brain atrophy. Transient T2 prolongation over gray and white matter was found in one patient. Our results indicate that EBV encephalitis and encephalomyelitis have a wide range of both clinical and MR findings. The MR lesions may disappear in a short period, so the timing for the MR scan may be critical.

Neuroimage in infants and children with mitochondrial disorders

Neuroimage studies of thirty-eight infants and children with mitochondrial disorders were reviewed: 24 ultrasound (US), 21 computed tomography (CT), and 27 magnetic resonance image (MRI) examinations were analyzed. Patients included seventeen with Leigh syndrome, two with Kearns-Sayre syndrome (KSS), one with myoclonus, epilepsy, and ragged red fibers (MERRF), one with Alpers disease, five with Menkes disease, two with fatty acid metabolic defect, two with Rett syndrome, and eight with unspecified mitochondrial disorders. KSS and MERRF tended to occur in older children, whereas Leigh syndrome, Menkes disease, and Alpers disease occurred in infants and young children. The deep cerebral nuclei and the cerebral white matter were commonly involved in Leigh syndrome and KSS. Subdural hematomas or effusions with profound cerebral atrophy was found in Alpers disease and Menkes disease. Tortuosities of basilar, Willis circle, and cerebral vessels were also noted in Menkes disease. MRI and CT examinations of Rett syndrome, fatty acid metabolic defect, and most of the unspecified mitochondrial disorders were normal. Our results indicate that neuroimage studies have characteristic findings for specific mitochondrial syndromes.

Magnetic resonance imaging of herpes simplex encephalitis

Eight brain magnetic resonance imagings (MRIs) and one spinal MRI of 7 small infants and children with herpes simplex encephalitis (HSE) were retrospectively studied. Hypointense and hyperintense areas of gray and white matters on T1- and T2- weighted images, respectively, were commonly present, with temporal lobes being the most common lesion sites. Hemorrhagic lesions were found in 4 patients (57%). Early involvement of the white matter, as early as day 4, was a common MRI finding in these patients. One patient had relapsed encephalomyelitis, whose spinal MRI showed diffuse hyperintense T2 signals from the lumbar spinal cord to the conus medullaris. All patients but one survived with major neurological sequelae. Our results indicate that MRI is a sensitive diagnostic modality in cases of HSE, and early involvement of white matter is not an uncommon MRI finding of HSE. Spinal MRI may be helpful in the diagnosis of relapsed herpes encephalomyelitis.

Lumboperitoneal shunt complicated with chronic tonsillar herniation: a case report

Lumbopritoneal shunt (L-P shunt) has been widely accepted as a treatment for communicating hydrocephalus. The technique offers many advantages such as easy insertion, a low infection rate, a reduced incidence of brain damage, et centera. Despite these advantages, there are also some associated complications, such as tonsillar herniation. This complication rarely occurs, but, when it does, it develops gradually. This report concerns an eight-year-old girl, who had received L-P shunt at the age of 20 days; she then developed tonsillar herniation, requiring operative decompression, eight years later. This case illustrates the necessity for carefully follow up patients who have undergone the L-P shunt procedure.

Unilateral porencephalic cyst presenting as infantile spasms: a case report

Multiple etiological factors have been associated with infantile spasms (IS), and are usually linked to diffuse or multifocal brain damage. It is generally believed that infants with symptomatic IS have a significantly higher incidence of mental retardation and epilepsy than those with cryptogenic IS. However, IS secondary to focal brain lesions in which surgical removal of the lesions has resulted in cessation of generalized spasms and subsequent normal development are rarely reported. A seven-month-old male infant who manifested head nodding and generalized flexor spasms one month prior to the admission is reported. Waking interictal electroencephalography revealed a pattern of burst-suppression variant of hypsarrhythmia. Brain magnetic resonance imaging disclosed a huge porencephalic cyst over the left temporo-parietal region. The infant underwent craniotomy with corpus callosotomy, causing marked improvement in seizures. He attained subsequent stable psychomotor development.

Varicella-zoster virus infection in children with malignancy

BACKGROUND

Immunocompromised children are potentially threatened by infections, among which, the highly contagious chickenpox infection is the most common. In the past six months, there has been a spate of five chickenpox infections in children with malignancy, all of whom were receiving chemotherapy at that time.

METHODS

The cases of 17 children with malignancies, who suffered from varicella-zoster infection during a period of chemotherapy at Taichung Veterans General Hospital were reviewed.

RESULTS

The diagnoses of their neoplasms were 12 acute lymphoblastic leukemia (ALL), 2 lymphoma, 3 solid tumors. The mean age was 6.8 +/- 4.0 year-old (range 3 to 15 year-old). The average duration from chickenpox skin eruption to admission was 3.3 +/- 1.8 days. Four patients suffered from abdominal pain and three of them died soon; three of them suffered from back pain and one died later. Seven of these 11 patients had impaired liver function (GOT > 45 U/L), of whom 4 died later. There were seven patients with pneumonitis, of whom five died later. Among 12 patients with ALL, 3 had absolute lymphocyte counts (ALC) < 500/mm3, but only 1 died later; 9 had ALC > 500/mm3, of whom 4 had pneumonitis, and all died later. Four patients developed disseminated intravascular coagulopathy, and three of them died later. Seven patients were prescribed acyclovir within three days after first skin eruption, none of these died. Ten patients were prescribed acyclovir three days or more after first skin eruption and five of them died later. Five patients were prescribed intravenous immunoglobulin (IVIG) within three days after first skin eruption, and none of them died; of the seven patients prescribed IVIG three days or more after first skin eruption, three died later.

CONCLUSIONS

Abdominal pain and disseminated intravascular coagulopathy (DIC) were signs of visceral dissemination. Severe liver function impairment, pneumonitis and DIC were the principal causes of death. Early administration of acyclovir and intravenous immunoglobulin (IVIG) can probably effectively prevent the dissemination of varicella-zoster virus (VZV). While varicella-zoster immunoglobulin (VZIG) was unavailable, IVIG was still valuable in treating VZV infection.

Lesch-Nyhan Syndrome: report on two brothers

Lesch-Nyhan syndrome is a rare X-linked disease characterized by over-production of uric acid and a central nervous system (CNS) disorder consisting of mental retardation, spasticity, choreoathetosis, and a compulsive form of self-mutilation. A deficiency in hypoxanthine-guanine phosphoribosyl transferase (HPRT) provides the underlying metabolic basis for this disease. A 12 month-old male baby who had orange crystals over the diapers since he was 3 months old was brought to our hospital due to developmental delay. Mental retardation and athetosis were also noted. Chemical analysis revealed hyperuricemia (uric acid 8.6 mg/dl). Urine routine showed microscopic hematuria and uric acid crystals. The activity of HPRT in erythrocyte lysates of parents were both within normal limits, but that of the patient was very low (0.0547 nm/min/mg protein, < 0.05% of control). His younger brother was born 2 months after this disorder diagnosed in this patient. The younger brother was noted to have uric acid crystals over the diapers when he was 40 days old and hyperuricemia (10.6 mg/dl) showed up later. He was also a case of Lesch-Nyhan syndrome since the activity of HPRT in erythrocyte lysates was also low (0.0327 nmol/min/mg protein, < 0.05% of control). Further studies, including carrier detection and deoxyribonucleic acid (DNA) analysis, could be helpful for genetic counseling. This syndrome is rare among Chinese, and this may be due to underdiagnosis.

Dural arteriovenous malformation with symmetrical calcification of the basal ganglia: a case report

Dural arteriovenous malformations associated with symmetrical calcification of the basal ganglia are rare in children. This report concerns a 22-month-old female infant who was admitted with the problem of acute onset of status epilepticus. Physical examination revealed a grade II/VI heart systolic murmur over the left sternal border, and engorged scalp veins. Neurologically, left side hemiparesis, brisk deep tendon reflexes, bilateral presence of Babinski sign and ankle clonus were present. Brain computed tomography without contrast medium showed cortical atrophy and symmetrical calcification of the basal ganglia. Brain magnetic resonance imaging showed a signal-voided tortuous structure over the right parietal region. Cerebral angiography disclosed a dural arteriovenous malformation, located over the right parietal region, which had two major feeding arteries from the branch of the anterior cerebral artery and the parietal branch of the middle cerebral artery, and had direct venous drainage into the superior sagittal sinus. The patient received craniotomy with ligation of feeding arteries. She became seizure-free, and her neurological deficits improved gradually.

Clinical and MRI study of the Hallervorden-Spatz syndrome: long-term follow-up of one case

Hallervorden-Spatz syndrome is generally considered to be an autosomal recessively hereditary disorder of unknown etiology. Some reported cases have been known to be sporadic. We present a boy who suffered from regressive developmental milestones since he was 2 years and 6 months old. He began to manifest tremors of the upper extremities, followed by unsteady gait, choreoathetosis, dystonia, dysarthria, and dysphagia at 4 years old, and subsequently became completely bedridden at 6 years old. Neurologically, opisthotonus, rigidity of extremities, dystonia, hyperreflexia, profound emaciation, and bilaterally positive Babinski signs were present. The brain magnetic resonance imaging (MRI) done at the age of 8 years revealed symmetrical low signal intensity over the bilateral globus pallidi in the T2-weighted images coexistent with an area of high signal intensity over the anteromedial portion, known as "eye of the tiger" sign. Another MRI, followed up two years later, did not show marked difference in signal abnormalities over the globus pallidi in the T2-weighted images as compared with that of the previous one. However, progressive neurological deterioration existed.

Langerhans cell histiocytosis: a 10-year review

Hospital records of seventeen patients (11 males & 6 females) with Langerhans cell histiocytosis, confirmed by electron microscopic demonstration of Birbeck granules, were studied retrospectively from October 1982 to October 1992 at Taichung Veterans General Hospital. The ages at presentation ranged from 5 months to 17 years (a median of 6 years). The clinical features were protean and included fever, pain, bony lesions, lung lesions, abnormal dentition, diabetes insipidus, oral ulcer, otorrhea, dermatitis, anemia, thrombocytopenia, lymphadenopathy, and hepatosplenomegaly. Skull and femur were the most common sites of bony lesions. The main therapeutic modalities were excision, radiotherapy, and chemotherapy with vincristine and prednisolone. The young age at presentation, several involved organ systems, presence of organ dysfunction, and clinical diagnosis with Letterer-Siwe disease were poor prognostic factors. Although Langerhans cell histiocytosis is not a rare disease, the cause is still unknown. It needs further research to disclose the mystery.

Clinical study of epileptic children with history of febrile convulsion

BACKGROUND

Clinically, some epileptic syndromes have been linked to febrile convulsions (FC), but the exact relationship between FC and later epilepsy remains a mystery.

METHODS

Detailed histories of 81 Chinese children among 1950 pediatric epileptics with a history of FC were obtained retrospectively. The clinical courses and risk factors were analyzed.

RESULTS

According to their epileptic patterns, the children were divided into a generalized group (Group G, 45/81), a partial group (Group P, 30/81) and those with severe myoclonic epilepsy in infancy (6/81). Patients of Group P had an earlier age of onset of FC with a larger number of risk factors than those of Group G (p < 0.01), and patients of Group G had a shorter interval from the last FC to later epilepsy than those of Group P (p < 0.01). More risk factors of FC were present in children of Group P; these included especially focal seizures, prolonged duration and retarded psychomotor development (p < 0.01).

CONCLUSIONS

For group of epileptics in this study, genetic factors might predispose for the expression of FC and later epilepsy, and anticonvulsant prophylaxis for FC seemed to be unnecessary.

Viral encephalitis in children: detection with technetium-99m HMPAO brain single-photon emission CT and its value in prediction of outcome

PURPOSE

To assess the role of regional cerebral blood flow measured by technetium-99m hexamethyl propyleneamine oxime (HMPAO) brain single-photon emission CT (SPECT) in viral encephalitis of children.

METHODS

Eighteen children diagnosed as having viral encephalitis (12 Epstein-Barr virus, 4 herpes simplex virus, and 2 Japanese B virus) underwent Tc-99m HMPAO brain SPECT and brain MR and/or CT.

RESULTS

During the acute episode, 4 (22%) of the 18 patients had localized abnormality on brain MR and/or CT. Tc-99m HMPAO brain SPECT in the acute phase showed that 17 (94%) of the 18 patients had increased regional cerebral blood flow and 1 (6%) of the 18 children had a normal brain SPECT. Follow-up brain SPECT was performed at least 15 days after the acute episode. In 17 patients with abnormal first brain SPECT, 12 (71%) had normal second brain SPECT and 5 (29%) had decreased regional cerebral blood flow. The group of patients with normal regional cerebral blood flow on the follow-up brain SPECT had a better outcome than the group of patients with decreased regional cerebral blood flow.

CONCLUSIONS

(a) The Tc-99m HMPAO brain SPECT was abnormal more often than CT or MR in children with acute viral encephalitis and provided better location. (b) In acute episodes of encephalitis, most patients showed locally increased regional cerebral blood flow. (c) After acute episodes, the regional cerebral blood flow returned to normal in most cases. (d) A normal Tc-99m HMPAO brain SPECT in the subacute phase usually indicates a good clinical outcome (no neurologic defect) 1 year after the acute illness in children with viral encephalitis.

Guillain-Barre syndrome in infants and children

BACKGROUND

Guillain-Barre syndrome (GBS) occurs at all ages, and population-based studies give it a crude average annual incidence rate ranging from 0.4 to 1.7 per 100,000 population. This retrospective study is performed for fifteen Chinese infants and children in light of the fact that GBS infrequently occurs during childhood years.

METHODS

Hospital records of fifteen Chinese infants and children, i.e. eleven males and four females, with GBS were included. Their ages ranged from one to sixteen years old, with a mean average of 8.5 years. Their performances were graded on a scale from 0 to 6 according to the GBS Study Group. Their performances were graded under categories of Grades 2 (2/15), 3 (2/15), 4 (8/15) and 5 (3/15).

RESULTS

Seven patients (46.7%) had preceding viral illness, occurring from seven to fourteen days prior to admission, with a mean average of twelve days. In addition to weakness and areflexia, musculoskeletal pain and subjective paresthesia were the most common presentations upon admission. The later the cerebrospinal fluid (CSF) was examined, the more cases had CSF features of increased protein level with no or mild pleocytosis. Eleven patients underwent serological examinations, and seven of their tests yielded positive for Epstein-Barr virus in five and Mycoplasma pneumoniae in two. Seven patients underwent electromyography and nerve conduction velocity measurement, all exhibiting the characteristic features of demyelination. Twelve patients had supportive treatment, and three of them required mechanical ventilation. Intravenous gamma globulin was administered in two patients, and oral prednisolone was administered in one patient. It took one to six months with a mean average of 3.4 months for patients' performance returning to Grade 0. All of the patients survived without residual disability.

CONCLUSIONS

Some infectious pathogens could play a role in the pathogenesis of GBS. Furthermore, complete recovery may be the rule for most infants and children with GBS.

Acute transverse myelitis in children: clinical analysis of seven cases

BACKGROUND

The reported annual incidence of acute transverse myelitis (ATM) is 1 per 3.4 million. Because of its rarity, we performed this retrospective clinical investigation.

METHODS

Hospital records of seven Chinese children with ATM were reviewed thoroughly. The diagnosis of ATM were made clinically with or without neuroimages.

RESULTS

Five males and two females were included, of age from three to sixteen years with a mean of 8.6 years. The common presentations included weakness of lower extremities, acute flaccid paralysis, urinary distention, constipation, hyporeflexia, sensory impairment and paresthesia. Slightly elevated protein level in cerebrospinal fluid was noted. Mycoplasma pneumoniae, varicella/zoster virus and Epstein-Barr virus infections were confirmed serologically in one, one, and two patients, respectively. All patients received supportive treatment. The duration required to reach peak severity from onset of illness ranged from six to forty-eight hours. All but one patient recovered, and one to six months were required to achieve maximum improvement.

CONCLUSIONS

Some infectious pathogens may play a role in the pathogenesis of ATM. In general, the prognosis of childhood ATM is good.

Tc-99m HMPAO brain SPECT findings in pediatric viral encephalitis

Two children were diagnosed with viral encephalitis, due to Epstein-Barr virus infection in one case and to herpes simplex virus infection in the other. Tc-99m HMPAO brain SPECT was arranged to detect changes in regional cerebral blood flow (rCBF) secondary to viral encephalitis. During the acute episode, Tc-99m HMPAO brain SPECT showed that the two cases had increased rCBF. After the acute episode, follow-up brain SPECT was arranged 6 months later. The rCBF in one case was restored to normal on the second brain SPECT, and that in the other case was decreased. The child with normal rCBF in the follow-up brain SPECT had better learning ability and intelligence than the other child with decreased rCBF.

Juvenile myoclonic epilepsy

BACKGROUND

Recognition of the significance of juvenile myoclonic epilepsy (JME) in the English-language neurological literature is relatively new. There are many factors responsible for delay in diagnosis of JME, including lack of familiarity with the syndrome, failure to elicit a history of myoclonic jerking and absence or generalized tonic-clonic seizures predating myoclonic jerks in some patients.

METHODS

The medical and electroencephalographic (EEG) records of seven Chinese children with JME, four males and three females, were reviewed.

RESULTS

The age of onset ranged from 10 to 14 years with mean 11.8 +/- 1.6 years. The precipitating factors were sleep deprivation (5/7), photostimulation (3/7), hyperventilation (2/7) and menstruation (1/3). Childhood and juvenile absence epilepsies predated JME in three and one patients, respectively. All patients had concomitant grand mal on awakening. Generalized 3-4 Hz polyspikes-wave complexes occurred in all patients, and two patients had additional 3-4 Hz spike-wave complexes. These activities were provoked with photic stimulation (3/7) and hyperventilation (2/7). All patients were treated with valproate for more than four years, and relapse occurred six months to one year after discontinuation of valproate.

CONCLUSIONS

JME is a benign generalized epilepsy with a strong genetic basis. Valproate is the drug of choice up to now, but long-term (life-long) medication may be needed.

Leukemoid reaction in a child with appendiceal abscess: a case report

A case of appendiceal abscess presenting leukemoid reaction is reported. A seven-month-old male infant was admitted because of fever and diarrhea. Anemic conjunctiva and mild abdominal distension were the only physical findings on arrival. Progressive leukocytosis with left shift maturation was noted during hospitalization. The maximal white blood cell count was 178,000/cumm, with a high leukocyte alkaline phosphatase score. On the fourth day of admission, a palpable right lower quadrant abdominal mass with local tenderness was found. Appendiceal abscess was diagnosed by both ultrasonography and computed tomography. The infant received triple antibiotic therapy consisting of ampicillin, gentamicin, and clindamycin for 10 days; the mass disappeared two weeks later. As appendiceal abscess is a rare occurrence in infants and its production of a leukemoid reaction is even rarer, the case described here may cause a diagnostic challenge, and deserves attention from clinicians.

Childhood absence epilepsy

BACKGROUND

Childhood absence epilepsy (CAE) is a relatively rare form of idiopathic generalized epilepsy, occurring in previously normal children with a strong genetic predisposition. The annual incidence of CAE has been estimated at 6.3/100,000 to 8/100,000 children aged 0-15 years.

METHODS

Medical and electroencephalographic records of 50 Chinese children with CAE were reviewed.

RESULTS

There were 22 males and 28 females. The age of onset ranged from 3 to 12 years with a mean of 6.9 +/- 2.4 years. Six children (12%) had positive familial epileptic history and 11 patients (22%) had a past history of febrile convulsion. Electroencephalographically, there were posterior delta rhythm (6/50), frontocentral (1/50), and centrotemporal (1/50) spikes in addition to the characteristic 3 Hz spike and wave complex. All patients received regular or irregular treatment with valproate. Sixteen patients (32%) evolved to generalized tonic-clonic seizure (GTCS) with a mean of 2.1 +/- 1.6 years of lag from stopping valproate. The patients with GTCS had significant late onset of age, a longer active period, and longer treatment duration than those without GTCS (p < 0.01). There were significantly more patients with irregular treatment evolving to GTCS than those with regular treatment (p < 0.01). None of the patients with posterior delta rhythm evolved to GTCS.

CONCLUSIONS

Regular treatment with valproate is the modality of choice in the management of CAE. Posterior delta rhythm seems to be a good prognostic factor electroencephalographically.

Leigh syndrome with progressive ventriculomegaly

A 6-month-old female infant was diagnosed with Leigh syndrome after an abnormal muscle specimen was obtained and after magnetic resonance imaging demonstrated characteristic cranial lesions. She presented with episodic hyperventilation, myoclonus, ophthalmoplegia, hypotonia, and elevation of lactate in the cerebrospinal fluid and blood. A series of cranial ultrasounds revealed progressive ventricular enlargement before the typical lesions were detected by magnetic resonance imaging. Myelin destruction is believed to play an important role in the early stage of Leigh syndrome. Ultrasonography may provide a convenient way to document changes in brain that provide early suspicion of Leigh syndrome.

Clinical observation of neonatal gastrointestinal perforation

BACKGROUND

Gastrointestinal perforation is an infrequent occurrence in neonates. Experience in its management is presented, while also attempting to analyze the factors affecting outcome.

METHODS

From 1983 to 1992, 31 neonates with gastrointestinal perforation were treated at Taichung Veterans General Hospital. The medical records of these patients were reviewed thoroughly. In the meantime, Mann-Whitney U and Yates' correction chi square tests were used to analyze the factors predicting the outcomes.

RESULTS

There were 21 males and 10 females, among whom 16 were premature births. The median age at diagnosis was 5 day; half (16/31) had occurred during the first 5 days of life. Abdominal distension was the most common manifestation (87%). Hemograms at admission showed leukopenia in 32% (10/31) and thrombocytopenia in 40% (8/20) of the patients. Metabolic acidosis was present in 46% (13/28) of the patients. Peritoneal fluid and preoperative blood cultures were positive in 71% (17/24) and 50% (13/26) of the patients, and both of them had Gram-negative enterobacteriacea as the most common pathogen. The overall mortality rate was 58%. The highest mortality rate was associated with gastric perforation (100%), followed by small bowel (50%) and colon (50%) perforations. The predominant cause of perforation was necrotizing enterocolitis (14/31), with the most common site the terminal ileum (16/29). Four patients with necrotizing enterocolitis had multiple perforations. Others who underwent surgery showed single perforation. The major cause of death in those patients who received operation was sepsis (8/13). An initial arterial pH value higher than 7.25, and surgical procedure performed within two days after disease onset may predict a favorable outcome (p < 0.01).

CONCLUSIONS

Gastrointestinal perforation is a life-threatening complication in neonates. A better survival rate can be obtained by cooperation among neonatologists, pediatric surgeons and the nursing staff taking care of these high risk babies.

Hypoxic-ischemic effect on infants and children with cyanotic congenital heart disease: clinical assessment of neurological examination and brain magnetic resonance images

BACKGROUND

Progress in early surgery and intensive care have enhanced survival for more individuals with serious cyanotic congenital heart disease (CHD). Parents are understandably concerned about patients' brain function. Therefore, a study was undertaken of brain magnetic resonance images (MRI) in infants and children with cyanotic CHD, stressing the correlation between clinical neurological examination and brain MRI findings.

METHODS

Sixteen infants and children with cyanotic CHD, 6 males and 10 females, were selected randomly from June 1991 to June 1993. Their ages ranged from 1 to 10 years, with a mean of 4.4 years. All patients underwent brain MRI and thorough clinical neurological examinations.

RESULTS

Prominent and tortuous vessels over the Willis circle and basal ganglia were the most common brain MRI findings among patients with normal neurological examination (7/9), while ventriculomegaly (5/7) was the common findings for patients with abnormal neurological examination. Two patients who presented with low-grade fever and Babinski sign were found incidentally to have brain abscesses.

CONCLUSIONS

It is not possible to make a conclusion from this preliminary report about the role which cyanotic CHD may play in the pathogenesis of brain insult, but the clinical neurological findings may provide guidance for the arrangement of brain MRI in infants and children with cyanotic CHD. Further larger scale, case-controlled study is needed to answer the controversial question whether cyanotic CHD per se causes brain insult.

Benign partial epilepsy with centrotemporal spikes: analysis of 94 Chinese children

From October 1982 to June 1992, 94 neurologically normal Chinese Children (50 males & 44 females) with benign partial epilepsy of childhood with centrotemporal spikes were studied among 1847 epileptic infants and children. Their ages at onset were between 3.6 and 12 years (a mean of 7.3 years). All of them had normal birth and developmental histories. Seven patients (7.5%) had past history of febrile convulsion and 12 cases (12.8%) had family history of epilepsy. The depicted seizure patterns were protean, but most attacks (83%) occurred during sleep (nocturnal & diurnal). The duration of active period and seizure frequency had no significant difference in terms of sex and treatment, but early-onset patients (< 7.3 years) had statistically significant longer duration of active period than that of late-onset group (p < 0.01). We recommend that antiepileptic drug treatment is not essential for this disease. Even if antiepileptic drug is used, the low-dosed carbamazepine is suggested.

Evolution of childhood absence epilepsy, juvenile myoclonic epilepsy and epilepsy with grand mal on awakening

Seventy-one Chinese children with idiopathic generalized epilepsy, from among 1931 pediatric epileptics, were reviewed clinically and electroencephalographically. They were classified under childhood absence epilepsy (CAE, 50/71), juvenile myoclonic epilepsy (JME, 7/71) and epilepsy with grand mal on awakening (GMA, 14/71). All the patients' family members with epilepsy were classified under idiopathic generalized epilepsy. Hyperventilation was the most common precipitating factor for CAE, and sleep deprivation was the most common one for JME and GMA. Electroencephalographically, fast generalized spike or polyspike-wave complex (> or = 3Hz) was the most common feature. Three JME (42%) and 4 GMA patients (28%) had been diagnosed as CAE about 5 to 7 years preceding JME and GMA, respectively. Sixteen CAE cases (32%) later evolved to be GMA. All JME patients had concomitant GMA and three GMA cases (21%) had concomitant JME at diagnosis. There is strong evolutional correlation among CAE, JME and GMA in this series.

A long-term follow-up study of West syndrome

BACKGROUND

Since the syndrome of infantile spasms, hypsarrhythmia and mental retardation was first delineated, there have been many publications about long-term prognosis of the West syndrome. This paper evaluates some of the early factors on which long-term prognosis may depend.

METHODS

Patients with West syndrome were reviewed retrospectively according to the medical records as classification, response to initial medication regimen, prognosis and present neurological status. Seizure control, speech, psychomotor development, mentality, learning ability, behavior and motor handicap were followed over a mean period of 6.1 years.

RESULTS

Thirty patients with complete hospital records were included in this study. Fourteen cases (46.7%) belonged to the symptomatic group, with a mean age of 3.4 months at onset. Four patients (13.3%) were cryptogenic type and a mean age of onset at 9.3 months. There were twelve cases (40%) in the doubtful group, whose mean onset age was 6.4 months. Of the symptomatic group, 92.8% patients had moderate to severe psychomotor retardation as compared to 25% in the cryptogenic group and 67% in the doubtful group; 35.7% of the symptomatic group patients suffered from motor handicap (spastic quadriplegia and hemiplegia as predominated), but only 8.3% of the doubtful group had motor handicap.

CONCLUSIONS

The data collected showed that the following factors seemed to be related to better prognosis: later onset, normal to mild psychomotor delay upon diagnosis, and good seizure control.

Brain electrical activity mapping in childhood absence epilepsy

BACKGROUND

Brain electrical activity mapping (BEAM) studies related to children with epileptic seizures have been rarely reported. The authors wished to search for BEAM values in children with epilepsy, to better understand the changes in the cerebral field distribution of epileptiform events.

METHODS

Electroencephalographies (EEGs) of 19 Chinese children with childhood absence epilepsy (CAE), but with normal intelligence, were studied prospectively and consecutively. Among them, 11 were boys aged from 6-12 years; 8 girls aged from 6-13 years. EEGs were simultaneously recorded on the Concerto (32 channels), and on the EEG machine, according to standardized recommendations. Frequency or spectral analysis was measured in terms of Band power (uv2), RMS (uv) and InstVolt (uv). Maps were also displayed simultaneously as color in their topographic distriution, with four-picture maximum.

RESULTS

In comparing the four bands of background activities in subjects with eyes closed and open, in the different subgroups, there were no significant differences between boys and girls, nor between the group with epileptiform discharge events (EDE) and the group without EDE, except for the beta band in subjects with eyes closed of the EDE group. There was a significant increase of band power in the group treated with valproic acid, and an increase over the F3 in beta band, Fp1, F4 in theta band, F3, F4, P4, 02 in delta band, but no significant increase was found in alpha band. EDE was also measured and mapped and showed bilateral symmetry with a mid-frontal maximum. Root mean square (RMS) measurements of epochs, from the beginning of EDE to the end of EDE, showed significant increases in voltage over the F8 area.

CONCLUSIONS

BEAM can clearly show cerebral field distribution, but also can employ statistical tests to give significance to the analyzed data. Furthermore, BEAM may be helpful for localization of the epileptiform discharges in EEG.

Epilepsy with grand mal on awakening

BACKGROUND

Epilepsy with grand mal (GMA) on awakening is a benign generalized idiopathic epilepsy, occurring around the time of puberty. There have been few reports regarding Chinese children with GMA, thus this analysis of fourteen Chinese children with GMA who have been encountered in the past 10 years.

METHODS

The medical and electroencephalographic (EEC) records of 14 Chinese children with GMA, 7 males and 7 females, were investigated retrospectively.

RESULTS

The age of onset ranged from 9 to 15 years with a mean of 12 +/- 1.6 years. Six patients had previous history of febrile convulsion; four and three patients had positive family history for epilepsy and febrile convulsion, respectively. All patients had generalized tonic-clonic seizures on awakening and three of them had concomitant myoclonic jerks. The precipitating factors were sleep withdrawal (9), photostimulation (4), hyperventilation (3), fevers (2), and menstruation (2). The first EEG findings included 3-4 Hz generalized spike-wave complex (8/14), photostimulation activated (4/14), and hyperventilation activated (3/14). Valproate had been regularly administered orally for a duration of 1 to 8 years with a mean of 3.8 +/- 2.0 years up to time of study. Six (75%) out of eight patients relapsed about 6 months to 1 years after discontinuation of anticonvulsant.

CONCLUSION

GMA may have some clinical relationship with other idiopathic generalized epilepsies, such as childhood absence epilepsy and juvenile myoclonic epilepsy. High-percentage relapse after drug discontinuation may be the rule for GMA patients, so long-term use of anticonvulsants may be needed.

MRI of Joubert's syndrome

OBJECTIVE

To report five cases of the rare Joubert's syndrome.

SUBJECTS

All five cases were studied by 1.0-Tesla MRI. All the patients showed typical clinical manifestations of Joubert's syndrome including neonatal respiratory abnormalities, developmental delay, ataxia, retinal atrophy and nystagmus.

RESULTS

The T1WI of MRI showed characteristic MRI features of Joubert's syndrome including dilatation of the fourth ventricle with some appearing bat-wing shaped, elongation and stretching of the superior cerebellar peduncles, dysphasia of the vermis, widening of the foramen of Magendie and the posterior cistern. One case was associated with encephalomeningocele.

CONCLUSIONS

MRI can provide characteristic findings of Joubert's syndrome and confirm the clinical diagnosis.

Congenital diaphragmatic hernia

BACKGROUND

The management of congenital diaphragmatic hernia (CDH) remains a subject of controversy. With the objective to achieve a better future survival rate, clinical analysis of 14 cases during a 10-year period was done.

METHODS

From 1983 to 1992, 14 cases with CDH were treated at Taichung Veterans General Hospital. The medical records of these patients were reviewed thoroughly. In the meantime, Mann-whitney U and Fisher's exact tests were used to analyze the factors predicting the outcomes.

RESULTS

The overall mortality rate was 36%. Bochdalek hernia represented the most common defect in those patients who were operated upon (10/13, 77%). Ipsilateral pulmonary hypoplasia was present in five patients, four of whom died. Unilateral diaphragm agenesis was noted in two cases and both expired postoperatively. Initial arterial pH < 7.2, PaCO2 > 60 mmHg and early onset of symptoms may predict a poor outcome. There were no significant benefits from preoperative stabilization in those patients whose initial arterial pH values were lower than 7.2.

CONCLUSIONS

CDH remains a major challenge for pediatricians and pediatric surgeons. Further studies are needed to deal with this frustrating disorder.

Lipomyelomeningocele: a 9-year review

Fourteen infants and children, 6 males & 8 females, with lipomyelomeningoceles were reviewed from October 1982 to December 1991 at Taichung Veterans General Hospital. The age at diagnosis ranged from 3 days to 5 years. The chief problems included mass on the back, urinary distention, weakness of lower limbs and poor bowel control. The cutaneous lesions over the lumbosacral region were subcutaneous lipoma, dimples and hemangioma. There were several associated anomalies, such as occult spina bifida, syringomyelia, sacrococcygeal dysgenesis, high-types imperforate anus, genitourinary anomalies, congenital heart disease, talipes equinovarus and annular pancreas. Among the 12 cases who were operated on, 8 had preoperative neurological deficits, but there was only little postoperative improvement in 2. It is important to recognize at an early stage the defect underlying skin lesions and its associated anomalies, rather than to be concerned about cosmetic factors. Early surgical repair before the appearance of neurological deficits is recommended.

Fatal brainstem encephalitis caused by Epstein-Barr virus

An 8-month-old male infant, previously well, developed acute changes of consciousness associated with high fever, vomiting, and respiratory failure. Brain CT showed hypodensity of the brainstem, which had shown hyperechogenicity on brain ultrasonography. Brainstem encephalitis caused by Epstein-Barr virus (EBV) was diagnosed, based on the clinical presentation, neuroimaging and paired serological examinations. The patient expired eventually due to central failure. We suggest that EBV infection should be a differential diagnosis in cases of brainstem encephalitis.

Herpes simplex encephalitis in infants and children

BACKGROUND

The estimated incidence of herpes simplex encephalitis (HSE) is 2 to 4 per million of the population per year, of whom one-third are neonates or older children and two-thirds, adults. As effective antiviral therapy improves the high mortality and morbidity for younger patients with HSE, early diagnosis has become important, especially in children.

METHODS

Hospital records, neuroimages and electroencephalographic (EEG) findings of 10 Chinese infants and children with HSE were reviewed thoroughly over a 7-year period. Diagnosis of HSE was made via clinical setting of acute encephalitis with serological examinations of serum and cerebrospinal fluid (CSF).

RESULTS

Fever, consciousness disturbance and seizures were the most common clinical presentations on admission. Most of the CSF findings were mild pleocytosis (< 200/cumm), red cells, slightly elevated protein level and normal ratio of CSF/serum glucose concentration. All patients had abnormal features, by brain computerized tomography, and most had low densities over the temporal and frontal regions. Five patients underwent follow-up brain magnetic resonance imaging and most showed features of brain atrophy and demyelinating changes over the temporal and frontal regions. Generalized slow background activity was the most common EEG finding. Four patients' EEGs showed periodic laterizing epileptiform discharge. Intravenous administration of acyclovir (30 mg/kg/day) for 10 days was the drug-of-choice in these patients. All patients but the three deaths had psychomotor or mental retardation and spasticity. Six patients had epileptic sequelae, and one patient had the sequela of amnesia.

CONCLUSIONS

HSE remains a serious illness with high mortality and morbidity despite appropriate antiviral therapy. Adequate intravenous acyclovir therapy should be started as soon as possible. CSF examinations, EEG, serology, brain computerized tomography and magnetic resonance imaging may provide some clues of HSE, but negative findings should not deter or delay treatment in suspicious cases.

Pseudomonas septicemia in infants and children: a retrospective analysis of 49 cases

Reviewed 49 cases of Pseudomonas bacteremia which occurred in pediatric patients during an 8-year period showed the annual rate, per 1000 discharges, was 1.7. In most of the patients (73.5%), the disease was hospital-acquired. Male to female distribution was about 3 to 2. The average age of the 49 patients was 1.29 years, and 55.1% were infected at less than 2 months old. Overall mortality was 44.9%; among the mortalities, 63.6% were under two months of age. Clinical features were not characteristic, but the most common sign associated with this infection was fever (42.9%). Ecthyma gangrenosum occurred in only one patient. Respiratory tract and skin were the most frequent sources of the bacteremia. Polymicrobial bacteremia occurred in 18.4%. Patients with shock, pneumonia, inadequate antibiotic therapy or persistent neutropenia had a substantially poorer prognosis. Administration of combination therapy to patients with Pseudomonas bacteremia seemed to be superior to monotherapy for positive outcome.

Central nervous system tuberculosis in infants and children

Hospital records of 16 infants and children (9 males & 7 females) with tuberculous meningitis or tuberculoma were reviewed retrospectively over a 10-year period. Patients were aged from 5 months to 16 years, with a mean age of 7.2 years. The diagnoses were confirmed via a positive culture for Mycobacterium tuberculosis from cerebrospinal fluid (CSF) in 14 patients, and from brain tissue in 2. Most patients presented with fever (100%), conscious change (80%), vomiting (80%) and headaches (75%). Neurologically, meningeal and pyramidal signs were the most common findings. Lymphocytic CSF pleocytosis with hypoglycorrhachia, increased protein, and decreased CSF/serum glucose ratio were the major CSF findings in our patients. Hyponatremia was present in 70%. Brain computerized tomography showed hydrocephalus (87%), basal exudate (50%), ischemic infarction (37%) and tuberculoma (12%). Two patients (12%) expired and 10 (71%) of the surviving patients had neurological sequelae. In summary, the characteristic CSF findings and hydrocephalus (87%) seemed to be sensitive clues supporting early initiation of antituberculous drug therapy and thorough investigation as reflected in this series.

Juvenile and adult dermatomyositis among the Chinese: a comparative study

Between 1983 and 1992, 11 children and 38 adults were seen at Taichung Veterans General Hospital with a definite diagnosis of dermatomyositis. Their clinical pictures, laboratory findings, courses and outcomes were compared. The mean age at diagnosis was 12 years and 50 years, respectively. Children had a higher female-to-male ratio (2.7:1 vs. 1.2:1) and a more acute onset, while adults had a higher incidence of malignancy and other connective tissue disease associations. Clinically, shawl sign was more common in the adults, whereas myalgia was more frequently seen in the children (0.05 < p < 0.1). Hemograms, serological parameters and immunological investigations showed no significant differences between the two groups. Elevated erythrocyte sedimentation rate and circulating immune complexes were found in over half of both groups of patients; however, their values bore no relationship to either disease activity or future outcome. Although no significant differences were demonstrated between the two groups of patients with regard to either clinical manifestations or laboratory findings, the disease entity seemed not to be the same because evidence of vasculopathy in muscle pathology was more prominent in the children, with endothelial swelling and necrosis the most common findings. Steroids had been used as the first choice of therapy in both groups of patients, followed by cytotoxic drugs and immunosuppressants. Children had a more favorable outcome compared to a 24% mortality rate in the adult group. Experience here recommends a complete cancer work-up in adults, especially for nasopharyngeal carcinoma among the Chinese. Various autoantibodies screenings may also be helpful for early detection of other associated connective tissue diseases.

Joubert syndrome in Chinese infants and children: a report of four cases

Four Chinese infants and children (3 females & 1 male), aged from five months to three years, are diagnosed with Joubert syndrome by clinical and radiological findings. The clinical presentations included panting respiration with apnea in the newborn period (4/4), psychomotor retardation (4/4) and ataxia (2/4). The ocular findings were strabismus (3/4), unilateral ptosis (2/4), jerky eye movement (1/4) and retinal atrophy (1/4). Associated cerebral anomalies were occipital encephalocele (1/4) and hypoplasia of corpus callosum (1/4). All four underwent electroencephalography, abdominal ultrasonography, auditory and visual evoked potential tests; results were all normal. Two patients underwent electroretinogram with normal findings. The brain magnetic resonance imagings of all four patients showed dysgenesis of cerebellar vermis. For children presenting with ataxia and psychomotor retardation, Joubert syndrome is a more obvious diagnostic choice, but it is also important to keep this unusual disorder in mind as a differential diagnosis of neonatal tachypnea with apnea.

Candidemia in the neonatal intensive care unit

The hospital records of 18 infants (9 males & 9 females) with one or more positive cultures for Candida species were studied retrospectively in an attempt to define the characteristics, associated factors and treatment for candidemia in the neonatal intensive care unit. The number of patients have increased recently and the mortality rate is 56% (10/18). The Candida species isolated from blood were Candida albicans in 16 cases and Candida parapsilosis in 2 cases. Fever, not-doing-well, and abdominal distention were the most common presentations, prompting us to the initial impression of bacterial sepsis and/or necrotizing enterocolitis. Eleven associated factors for candidemia were relating to the measures and therapy in the neonatal intensive care unit, such as prolonged use of broad-spectrum antibiotics, parenteral hyperalimentation etc. All of these 18 patients were treated with intravenous amphotericin B. Six patients were given adequate total dose (> 25 mg/Kg), while 12 patients underwent inadequate treatment (3.7 +/- 2.9 mg/Kg). The 10 fatal patients belonged to the inadequate treatment group. As there is continual progress in neonatal intensive care units, candidemia is becoming an increasing common problem and which deserves attention.

Epstein-Barr virus encephalitis: clinical observations in nine Chinese children

Nine Chinese children (four males, five females) in whom serology showed Epstein-Barr virus infection were studied retrospectively. They were from 1.5 to 14 years of age. Various symptoms and signs, including disturbance of consciousness, visual hallucination, cranial neuropathies and sphincter dysfunction, led to initial clinical impressions of encephalitis, encephalomyelitis and neuro-degenerative disease. Electroencephalography showed focal spikes over the frontal, occipital, temporal and parietal areas. The patients underwent brain computed tomography and/or magnetic resonance imaging, and three of them underwent HMPAO SPECT. Eight patients appeared normal neurologically during follow-up, and the single patient who had spastic quadriparesis improved gradually. Though visual hallucination is not a specific presentation, it is a peculiar picture of Epstein-Barr virus encephalitis. Epstein-Barr virus encephalitis seemed to be self-limiting without specific treatment in this group.

Abnormal mitochondria in Rett syndrome: one case report

A 6-year-9-month-old girl with the characteristic features of Rett syndrome is reported. Clinically, she had microcephaly, psychomotor arrest, deterioration of communication, autistic behaviour, loss of language development, gait apraxia and stereotyped hand washing movement. Amino acid and organic acid analysis were normal. An abnormal rise in serum lactate was noted 120 minutes after oral glucose loading. Muscle biopsy was performed and there was no specific finding noted under light microscope. Electron microscopic evaluation revealed mild accumulation of mitochondria at subsarcolemmal area with abnormal tubular cristae. The cause of Rett syndrome remains obscure. Several articles concerning abnormal mitochondrial morphology or respiratory enzymes have been reported. The exact pathogenesis requires further investigation.

Intramyelin splitting in the spongiform lesions of Leigh syndrome

A 5-month-old male infant, diagnosed as Leigh syndrome, presented with developmental delay, episodic apnea, metabolic acidosis, and myoclonic seizures. The magnetic resonance image of brain showed multiple symmetric low signals over the putamen in the T1-weighted axial view and linear high signal over the brainstem in the T2-weighted sagittal view. On electron microscopy, subsarcolemmal aggregation of abnormal mitochondria in muscle cells were found via biopsy. Small samples of myocardium, liver and brainstem, obtained via necropsy, were subjected to pathological examinations. On light microscopy, vacuoles were found in the myocardium and hepatocytes, while spongiform lesions in the neuropils, round cell infiltration, and vascular proliferation were observed in the brainstem. On electron microscopy, intramyelin splittings were observed in the spongiform lesions. We believe that intramyelin splitting must play an important role in the pathogenesis of spongiform lesions in Leigh syndrome.

Clinical manifestation of mitochondrial diseases in children

Fourteen patients (10 boys, 4 girls) aged from 4 months to 14 years old were diagnosed with mitochondrial disease based on the clinical manifestations together with abnormal muscle mitochondrial morphologies. Their clinical diagnoses included Leigh syndrome, three; Menkes' syndrome, three; Kearns-Sayre syndrome, two; myoclonic epilepsy with ragged fibres, one; and infant-onset progressive myoclonic epilepsy, one; fatal infantile mitochondrial myopathy, one; fatty acid oxidation defect, two; and myopathy with cardiopathy, one. Organs involved other than muscles included central nervous system, ten; heart, six; eye, two; liver, two; and kidney, two. Clinical manifestations varied to include hypotonia, seizures, myoclonus, mental retardation, nystagmus, ataxia, ptosis, ophthalmoplegia, retinal degeneration, muscle atrophy, spasticity etc. Nine had an abnormal rise in lactate after glucose loading. Ragged-red fibres were found in four patients. Abnormal mitochondrial morphology included abnormal accumulation, abnormal cristae pattern of tubular, concentric, or parallel form, some contained osmiophilic inclusion bodies. One patient of Leigh syndrome had had brain necropsy which showed intramyelin splitting of myelinated axons.

Congenital tracheal stenosis: a report of two cases

Congenital tracheal stenosis (CTS) is a rare, potentially lethal condition. Two cases were diagnosed in this hospital between 1986 and 1992. Diagnosis was confirmed by endoscopy and radiography. These two cases were noted to have symptoms of airway obstruction after an infectious process. Their outcomes were quite different. The first patient, a victim of CTS diagnosed at two years old, still lives well and has been asymptomatic for subsequent six years, though he has received no surgical intervention. The second patient, a three-month-old female, exhibited an exacerbation after bronchoscopy and died in spite of intensive care. Prompt recognition of symptoms and a thorough evaluation of airway, as well as other anomalies, is essential for proper management of children with CTS. The diagnostic modalities, management and risk factors are discussed.

Clinical studies of Henoch-Schönlein purpura in Chinese children

Over a 9-year period from 1983 to 1992, 50 patients with Henoch-Schönlein purpura were admitted to the Department of Pediatrics, Taichung Veterans General Hospital. There were 33 boys and 17 girls, with a male to female ratio of 2:1. Their ages ranged from 2 to 14 years with a mean of 6.3 years. Seventy percent of the patients were over the age of five. The months of peak incidence were October to December (48%). Fifty-four percent of the patients had evidence of preceding infections. The main clinical features were skin rashes (100%) followed by gastrointestinal symptoms (66%), joint symptoms (58%), soft tissue edema (30%) and renal involvement (30%). Hemograms showed leukocytosis, thrombocytosis, and elevated erythrocyte sedimentation rate in about half of these patients. Serological examinations were nonspecific; anti-streptolysin O titers were elevated in 40% of the patients. Forty-two percent of our patients had elevated serum IgA levels which bore no relationship to the symptomatology and duration of the illness. One patient had a complication of intussusception requiring surgical reduction. Another patient who had renal involvement progressed to end-stage renal disease. Eighty-two percent of our patients received prednisolone therapy at a dose of 1-2 mg/kg/day, with good response. Seventy-two percent of the patients recovered completely within one month after the onset of the malady. The overall prognosis remains good.

Choledochal cysts: a nine-year review

Hospital records of 24 Chinese infants and children (7 males and 17 females) with choledochal cysts were reviewed. The patients were aged 1 day to 17 years. Abdominal pain, palpable abdominal mass and jaundice, either alone or in combination, accounted for most of the initial presentations. Twenty-two patients were classified as type I with surgery, while the other two patients were type V without surgery. Ultrasonography is a rapid and accurate diagnostic method in the initial evaluation. Cyst excision with Roux-en-Y hepaticojejunostomy was the treatment of choice in this series. Chronic cholecystitis with or without inflammation of choledochal cyst was the most common pathological finding. Five patients underwent liver biopsies, showing four biliary cirrhosis and one portal fibrosis. So far, there is no evidence of malignancy in any patient.

Neonatal Candida albicans meningitis: report of one case

Candida meningitis is a growing problem today. We report a 21-day-old male baby who was a victim of Candida albicans meningitis with the initial presentations of fever, mild stiff neck, poor feeding and activity. He had been treated with intravenous antibiotics and ventilator therapy prior to admission Initially, he was treated as a case of bacterial sepsis after admission with intravenous antibiotics. Due to positive cultures of cerebrospinal fluid for Candida albicans twice, intravenous amphotericin B was started from the 13th hospital day and was continued for 38 days. The successive three sets of CSF fungus culture yielded negative results and the patient was doing well without fever. Meanwhile, the brain sonogram revealed normal findings and he was discharged in a stable condition. We report this case and review some literature in an attempt to know more about this unusual disease, which is becoming more frequent as progress in intensive care grows.

Oral glucose lactate stimulation test in mitochondrial disease

We selected 23 patients with neurologic diseases, including 15 boys and 8 girls from 1 month to 10 years of age, who were divided into mitochondrial and nonmitochondrial disease groups. All patients were required to fast and rest for at least 4-10 hours before the test. Glucose was administered orally using a 50% glucose:water solution at a dose of 1.75 mg/kg. Blood samples then were drawn from a retained heparinized venous line at 0, 30, 60, 120, and 180 min and tested for lactate and glucose levels. Of the mitochondrial disease group, 10 of 11 patients had an upward sloping curve of lactate metabolism; the one who had a flat line response was a patient who suffered from a free-fatty-acid metabolic defect presenting with a recurrent Reye-like syndrome. There was a relatively flat line response in the nonmitochondrial disease group except in a patient with alternating hemiplegia whose symptoms responded well to flunarizine therapy. A significant increase in blood lactate content at 60 min after glucose loading occurred in the mitochondrial disease group, in contrast to that of the nonmitochondrial group. Sensitivity and specificity of a 5 mg/dl increase in blood lactate concentration at 60 min was 72.7% vs. 91.7% Moreover, all 4 patients whose blood lactate increased by 13 mg/dl at 60 min were in the mitochondrial disease group.

[Infantile bilateral necrosis of the striatum of corpus: report of four cases]

The designation of "Infantile Bilateral Striatal Necrosis" (IBSN) was first given by Friede in 1975. However, this unusual condition was first described by Paterson and Carmichael in 1924. The disease is rare with uncertain etiology. The clinical picture includes choreoathetosis, abnormal eye movements, seizures and mental dullness. These circumstances often follow symptoms such as fever, vomiting and impaired consciousness. The final diagnosis is confirmed by pathological examination, which reveals symmetrical degeneration of bilateral basal ganglia. With present technology IBSN can be well demonstrated in the brain Ct scans or MRI scans nowadays. This article reports four cases with clinical manifestations which had appeared before the age of one year. Three cases had prodromal upper respiratory tract infection symptoms with vomiting, while seizure and impaired consciousness ensued. One case had several bouts of pneumonitis followed by seizures, impaired consciousness and abnormal eye movement. Brain sonogram of one of these cases showed hyper-echoic basal ganglia, while CT scans or MRI scans revealed symmetrical hypodensity or signal change over bilateral basal ganglia, respectively. All of these led to a bedridden life. These four cases are reported based on their clinical presentations and brain imaging findings, in spite of the absence of pathological confirmation. Some of the literature are also reviewed. To sum up, IBSN should be kept in mind in the differential diagnosis of symmetrical bilateral basal ganglia lesion after the exclusion of other disorders such as neurometabolic disorders, central nervous system infection, carbon monoxide intoxication, hypoxic-ischemic encephalopathy, tumors and cerebrovascular disorders etc.