[Spinal tumors in infancy. A report of 48 cases]

INTRODUCTION

Spinal tumours in infancy are an infrequent oncological disorder. The clinical features, usually of insidious onset, are alterations in gait and a painful spine.

OBJECTIVE

To analyze the different histological types of spinal tumours seen in infancy and their form of presentation in our series.

PATIENTS AND METHODS

We reviewed the clinical histories of 48 patients with intraspinal tumours, aged under 15 years, whose reports of histological diagnosis had been sent to our centre.

RESULTS

Of the patients studied, 17 were girls (35.4%) and 31 boys (64.6%) with an average age of 7.7 years. The histological diagnoses made most frequently were astrocytomas (22.9%) and lipomas (18.8%) followed by metastases (12.5%), ependymomas (8.3%) and Edwing's sarcoma (8.3%). The clinical features were present prior to diagnosis for between 1 and 6 months in 13 patients, and for less than one month in 9 patients. The presenting symptoms were alterations in gait and back pain in most patients. Exploratory tests were related to the involvement of long vias and second motor-neurone lesions. The main topographical findings were: in the axial plane the lesions were extradural (23 patients) and in the sagittal plane there was dorsal involvement (34 patients).

CONCLUSIONS

Insidious, progressive alterations in gait together with continuous, nocturnal back pain are valuable data when a serious spinal disorder is to be suspected. Early diagnosis should be based on neuroimaging tests, essentially MR, in the patients in whom spinal cord involvement is considered.

[Vascular malformations of the central nervous system in children]

OBJECTIVE

To present the experience of vascular malformations (VM) of the central nervous system (CNS) in children obtained in our centre. Since these lesions do not often present clinically in childhood, there are few series described in the literature.

PATIENTS AND METHODS

We made a retrospective review of the clinical histories of patients with VM of the CNS shown on MR, angiography and/or morbid anatomy, who were aged 15 years or under. Patients with Sturge-Weber or Von Hippel-Lindau syndromes were excluded.

RESULTS

We describe 32 patients with VM of the CNS. Twenty four had arteriovenous malformations (AVM), 5 had cavernous malformations (CM), 2 had malformations of Galeno's vein (MGV) and one patient had a congenital fusiform arterial aneurysm. Twenty two children (68%) presented clinically with hemorrhages. This was the form of presentation in 20 patients with AVM. In 4 of the 5 patients with CM the first sign was epileptic crisis. The two patients with MGV presented with macrocephaly, in one neonate it was associated with heart failure and in on older baby with hydrocephaly. The patient with a congenital arterial aneurysm presented with paroxystic episodes of facial pain.

CONCLUSIONS

The AVM are the VM which most frequently cause symptoms in childhood.

[Polymyositis in childhood]

INTRODUCTION AND OBJECTIVE

Idiopathic inflammatory myopathies are very rare in infancy. We present five cases of polymyositis in children in which the clinical variability and difficulty in diagnosis that occurs with this disorder are clearly seen, and analyze their response to steroid treatment.

CLINICAL CASES

We can distinguish two groups of patients: the first is formed of the case of a two and a half month old baby with generalized hypotonia; and the second includes the other four cases, children of between 2 and 8 years old with weakness, which was mainly proximal. One of the second group later developed juvenile chronic arthritis. In all cases there was a raised CPK and a myopathic EMG, with or without spontaneous muscle activity. Muscle biopsy showed inflammatory myopathy. The first group corresponds to so-called infantile polymyositis which is characterized by generalized hypotonia. The second group includes older children in whom the clinical features of the disorder are similar to those in adults. The association of other autoimmune diseases with infantile polymyositis is exceptional. All cases show more or less improvement with corticosteroids.

CONCLUSIONS

The polymyositis are extremely rare before puberty and have a broad clinical spectrum. Congenital cases have been described in infants and in older children. The biopsy results are usually unexpected. Treatment with corticosteroids leads to clinical improvement which may be only partial and is less favorable than in the dermatomyositis.

Contribution of transvaginal sonography to the evaluation of benign cervical conditions

PURPOSE

We evaluated the role of transvaginal sonography in imaging the normal cervix and its benign changes.

METHODS

This prospective study included 512 postmenopausal women who underwent transvaginal sonography before hysterectomy and within 15 days of a colposcopy examination that showed no malignant findings. The sonographic findings were compared to the pathology report.

RESULTS

Naboth's cysts were the most common sonographic finding (102 cases), followed by cervicitis (43 cases). In 26 cases, endocervical polyps were found sonographically, and in 20 cases myomas were found. In 321 cases, the cervix showed no sonographic abnormality. Pathologic studies showed 104 Naboth's cysts, 25 cases of nonspecific cervicitis, 26 endocervical polyps, 21 myomas, and 336 normal cervices.

CONCLUSIONS

The sensitivity and specificity of transvaginal sonography in diagnosing normal cervices and benign changes of the cervix are high. Transvaginal sonography provides easily obtainable, reliable information about the cervix.

Elevated non-transferrin bound iron in the lungs of patients with Pneumocystis carinii pneumonia

OBJECTIVE

The aim of the present work was to determine the concentrations of iron and iron-binding proteins in the lungs of patients suffering from Pneumocystis carinii (PCP), which is crucial for justifying the treatment with iron-chelating agents in this disease.

PATIENTS AND METHODS

Bronchoalveolar lavage was performed in 10 HIV patients with PCP and five healthy controls. Total iron and iron-binding proteins (transferrin, ferritin and lactoferrin) were measured in acellular bronchoalveolar lavage fluid (BALF) in both groups. Iron was determined by atomic absorption spectrometry; transferrin and lactoferrin were measured using specific enzyme-linked immunosorbent assays (ELISA); and ferritin concentration was quantified by automated immunonephelometry.

RESULTS

Our findings in patients with PCP demonstrated a six- to seven-fold increase of total iron levels and an eight-fold increase of ferritin in bronchoalveolar lavage fluid when compared with controls. No significant differences were found in transferrin or lactoferrin levels. Moreover, our results suggest that this iron is non-transferrin bound.

CONCLUSION

Non-transferrin bound iron is increased in the lower respiratory tracts of PCP patients. This finding would lend experiment support to the use of iron-chelating agents in this disease.

[Ischemic stroke in children]

OBJECTIVE

Ischemic stroke in children and infants is a rare condition. We present a series of 23 pediatric patients of ischemic stroke.

PATIENTS AND METHODS

A retrospective series of 23 patients, aged between 1 month and 13 years, diagnosed by anamnesis, clinical examination and neuroimaging. The clinical picture, neuroimaging findings, etiology, evolution and sequelae are evaluated.

RESULTS

Eighteen of the patients had an ischemic stroke in the carotid territory (78.3%) and 5 in the vertebro-basilar (21.7%). Idiopathic (30.4%), cardiopathy (21.7%) and migraine (17.4%) were the most frequent etiologies. The recovery was complete in 9 patients (39.1%). There was a death as a result of systemic complications caused by dehydration (4.3%), and 13 patients (56.6%) were disabled: 6 with hemiparesis of diverse grades, 5 with epilepsy and hemiparesis, one with epilepsy, and one with mental retardation.

CONCLUSIONS

Ischemic stroke in children and infants is an unusual entity. The causes are multiple, although there is an elevated percentage of idiopathic cases. In our series, we highlight the significative percentage of vertebro-basilar strokes and the finding of three unusual etiologies in ischemic stroke in childhood, such as migraine, Mycoplasma pneumoniae infection and smallpox.

Assessment with transvaginal ultrasonography of endometrial thickness in women with postmenopausal bleeding

OBJECTIVE

The aim of this study was to assess the use of transvaginal ultrasonography in measuring endometrial thickness in postmenopausal women with bleeding, thus to determine the least invasive treatment.

STUDY DESIGN

We evaluated 168 women with postmenopausal bleeding by transvaginal ultrasonography and histological study of the endometrium.

RESULTS

No cancerous or precancerous lesions were found when endometrial thickness was under 10 mm. The mean endometrial thickness in women with cancerous and precancerous lesions was 10.75 +/- 1.63 mm, while in non-pathological lesions it was 1.36 +/- 1.18 mm.

CONCLUSIONS

To diagnose endometrial pathology, an endometrial thickness over 6 mm yields a sensitivity of 88.6%, a specificity of 90.6%, a positive predictive value of 92%, with 4.6% of false-positives and 4.6% of false-negatives (six small polyps and one irregular maturation). Although we are waiting for other prospective and multicentric studies, our present experience leads us to believe that Dilatation and Curettage (D&C) can be avoided in postmenopausal bleeding with endometrial thickness under or equal to 6 mm.

Accuracy of Topcon CM-1000 Videokeratoscope on Spherical Test Surfaces

BACKGROUND

Many videokeratoscopes use mathematical formulas to calculate corneal radii; calculations depend on slope, curvature, coordinate position, or focal properties of the surface. Accuracy of each type of videokeratoscope must be evaluated. A controversy exists about whether axial or tangential methods best provide a precise description of corneal shape; therefore results with the Topcon CM-1000 using both methods were evaluated.

METHODS

Measurements were done on black polymethylmethacrylate (PMMA) spherical calibrated surfaces. Lenses were first aligned and measured and then misaligned in different directions and measured. Results for each position were compared with the zero or alignment position.

RESULTS

Accuracy of the CM-1000 was high even under extreme misalignment conditions. Tolerance to misalignment was high (about 300 mm). Misalignment-induced variations in the output results were small (usually less than 0.05 mm). However, important variations (more than 1.00 diopter [D]) were found for the lowest measured radius (6 mm). In some cases, small differences between axial and tangential radii for the same point could be found.

CONCLUSION

With the exception of extremely low radii of curvature, the CM-1000 was accurate for measuring spherical surfaces. Further investigation remains to be done on aspheric surfaces and in clinical practice.

[Spontaneous intracranial hemorrhages in childhood]

INTRODUCTION

Spontaneous or non-traumatic intracranial haemorrhages seen in children of under 15 years old are most frequently due to cerebral vascular malformations, followed at a considerable distance by blood disorders, vasculopathies, tumours and the complications of radio-therapy.

OBJECTIVE

To present the cases of spontaneous and non-traumatic cerebral haemorrhage seen at our hospital.

MATERIAL AND METHODS

We reviewed all the paediatric cases of spontaneous cerebral haemorrhage diagnosed in our hospital over the previous sixteen years, excluding bleeding in the neonatal period. Computerized tomography was done in all cases, study of the cerebrospinal fluid, angiography and/or magnetic resonance in some cases.

RESULTS

We selected 44 patients, of who the aetiology could be determined in 30. Of these, 20 cases were due to vascular malformations, 7 were associated with haematological disorders, 2 with cerebral tumours and one case with meningococcal sepsis. The commonest form of presentation was that of an acute intracranial hypertension syndrome, also showing focal deficits, partial crises and meningism.

CONCLUSIONS

The commonest cause of spontaneous intracranial haemorrhage in children is due to rupture of a vascular malformation, namely an arterio-venous malformation. Angiography and/or magnetic resonance are the techniques of choice for diagnosis. The various causes of disorders of haemostasia also are important in giving rise to intracranial bleeding.

[Treatment of refractory infantile epilepsy with vigabatrin in a series of 55 patients]

We present the results of treatment with vigabatrin in the polytherapy of resistant infantile epilepsy. A retrospective review of 55 children with resistant epilepsy aged between 2 months and 15 years was carried out between January 1992 and January 1995. Semiologically, the crises treated were simple partial crises (CPS), complex partial crises (CPC), West's syndrome, the Lennox-Gastaut syndrome and polymorphic crises. The efficacy of the drug (defined as a 50% or more reduction in crises), secondary effects and the reduction in the number of drugs necessary were evaluated. 60% of the children studied improved. 20% became completely free of crises. 34% remained unchanged and 3% became worse. In West's syndrome 100% responded satisfactorily, as did 80% of the cases of partial crises, but only 40% of those with Lennox's syndrome responded. Generalized tonic-clonic crises did not respond, and myoclonic crises became worse. Aetiologically, there was greater improvement in the symptomic cases than in the essential cases, the improvement being 70% while 5 patients with tuberose sclerosis responded particularly well. Medication was stopped in one case because of side-effects, due to a psychiatric disturbance, and in another case vigabatrin caused transitory side-effects. In 10% of the subjects the initial efficacy wore off around 6 months later. We have shown the usefulness of vigabatrin in the polytherapy of infantile epilepsy, which is resistant to conventional epileptic drugs, mainly in simple and complex partial crises and in West's syndrome. Its minimal side-effects and the favourable response in over 50% of cases make it an extremely useful drug.

Miller Fisher syndrome in infancy

Miller Fisher syndrome (MFS) is characterized by the triad of ataxia, areflexia and ophthalmoplegia. It is exceptional for infants to be involved. Two infants, aged 11 and 16 months, developed acute-onset MFS. Both patients had prodromal upper respiratory tract infection. Pupillary responses to light, strength and sensation modalities were preserved. One patient was lethargic for a day; the electroencephalogram disclosed slightly slow background activity that later became normal. The other received high-dose intravenous immunoglobulins for 5 consecutive days starting at once on admission; within the next 7 days he became asymptomatic. Increased cerebrospinal fluid protein content and delayed nerve conduction studies with prolonged distal latencies were encountered in both patients.

[Neuroimaging techniques in the Gilles de la Tourette syndrome]

Tourette's syndrome (GdT) is a chronic neuropsychiatric disorder of unclear etiology characterized clinically by the presence of motor and phonic tics as well as a variety of behavioral and cognitive abnormalities such as Obsessive-Compulsive Disorder (TOC) and Attention Deficit Hyperactivity Disorder (ADHD). Dopaminergic pathway and movement control related structures may have some implications for pathogenesis. Neuroimaging techniques may yield relevant data for a better understanding of the symptoms and physiopathology of this disease. Among them, functional isotopic techniques such as PET and SPECT and other like quantitative EEG are the most remarkable. In this article we intend to perform a thorough review of the most recent literature, contributing with our own experience and discuss the pathogenesis of GdT.

[Neurological impairment in children with HIV infection]

We retrospectively checked 53 paediatric patients suffering from infection with human immunodeficiency virus (HIV) registered in our Centre between the years 1987 and 1993, and evaluated the appearance of HIV encephalopathy. We noted important neurological signs in eleven patients (20.7%) ten of whom had HIV infection via vertical transmission and one as a result of contamination from haemoderivatives. In this review we give a detailed description of neurological signs, the moment of onset of these signs and their possible relationship with the state of the HIV infection. We also analyzed the resulting neuroradiological findings as well as any abnormalities in cerebrospinal fluid. Follow-up period ranged from one month to two and a half years from the moment of onset of the appearance of encephalopathy. Although most of our patients showed a clear improvement after oral or intravenous treatment with zidovudine, this improvement generally proved to be short-lived. The mortality rate in our HIV encephalopathy series was 81.8%, this figure being reached two and a half years after encephalopathy. The appearance of neurological signs in HIV patients therefore represents a very gloomy prognostic factor in the evolution of the disease.

[Nitric oxide in the lower respiratory tract]

The aim of this work is to review of the role of nitric oxide (NO) in the lower respiratory tract. This review mainly focuses on the generation of nitric oxide by alveolar macrophages. In the first part of the paper, we summarize the literature on nitric oxide synthesis by different cell types and the effects of this mediator on target cells. Methods for measuring nitric oxide are also analyzed. The core of the paper is a review of the role of nitric oxide in diffuse interstitial lung diseases (both human and experimental models). We include data about the concentration of this mediator in bronchoalveolar lavage fluid and then summarize the knowledge about the regulation of nitric oxide synthesis by animal or human alveolar macrophages. Finally, we review the biological effects of nitric oxide in the lower respiratory tract.

[Neuromuscular gait disorders in pediatric age]

Alterations in gait are a frequent cause of consultation in neuropaediatric units. They have several different causes. One subgroup of special interest concerns those which have their origin in a neuromuscular disease. We studied the experience of the Child Neurology Unit at the Hospital 12 October from 1980 to 1993.

MATERIAL AND METHODS

between 1980 and 1993 a total of 176 were studied because they showed alterations in their gait caused by a neuromuscular disease. Frequency and clinical features were analysed (sex, age at the beginning of the deterioration, duration of the latter etc.).

RESULTS AND CONCLUSIONS

the alterations in gait were separated into two groups: Group I: backward or non-acquired gait. Group II: deterioration in gait. IIa: temporary. IIb: definitive. The most frequent cause in Group I was spinal muscular atrophy and in Group II, muscular dystrophy linked to sex. To sum up, muscular diseases are far more important than the neuropathic ones, except for Group IIa where acute demyelinating motor polyneuritis was to be found at the top of the list of frequent occurrences.

Meningioangiomatosis: advanced imaging and pathological study of two cases

Meningioangiomatosis (MA) is a rare benign intracranial tumour of uncertain pathogenesis, with only 33 cases reported in the literature. Imaging features have been described in 21 cases, only 3 with contrast-enhanced MRI. We present two cases of MA with MRI and/or CT findings and gross, ultrastructural, and immunohistochemical characteristics. MRI is particularly helpful for establishing the origin of the lesion and its anatomical location, while CT shows calcification, if present. The pathological characteristics establish the diagnosis and underline the differences from other entities such as malignant meningioma, one of the most important differential diagnostic considerations.

[Axilla skin biopsy in the diagnosis of Lafora's disease]

Skin biopsy is the method of choice for the diagnosis of Lafora's disease. The presence of PAS (+) inclusions characteristic of Lafora's disease has been thought to be more evident in aprocrine glands of the axillary skin than in the duct cells of the eccrine glands. We describe 4 patients with Lafora's disease diagnosed by axilla skin biopsy, confirming the usefulness of this procedure.

Changes in acid-base balance and calcium metabolism after urinary diversion through ileal segments. II. Treatment with nicotinic acid

Investigations in animals have shown that nicotinic acid, an intestinal cyclic-AMP inhibitor, partially corrects the metabolic changes associated with urinary diversion through intestinal segments. Blood and serum chemistry were studied in patients before and 3 to 5 months after undergoing urinary diversion through ileal segments, both with and without nicotinic acid treatment. It was found that diverted patients had metabolic acidosis, an increased anion gap and increased levels of serum alkaline phosphatase; there were no significant changes in serum PTH and vitamin D levels, calcaemia and phosphoraemia. There was a tendency towards dehydration, hypernatraemia, hyperchloraemia and secondary hyperaldosteronism produced by ileal secretion of a hypotonic fluid. Nicotinic acid 3 g/day significantly reduced the chloraemia but did not correct the metabolic acidosis, although it reduced its severity, since blood pH decreased when treatment was suspended. Nicotinic acid cannot be recommended for routine use in the management of metabolic acidosis after urinary diversion, and patients with a marginal renal reserve should not be considered for trans-intestinal urinary diversion.