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Cabal Herrera AM, Mandle Q, Varma H, Magaña S. Nausea and Vomiting as Initial Manifestations of Pediatric NMOSD. Pediatrics 2024; 153:e2023062269. [PMID: 38477052 PMCID: PMC10979292 DOI: 10.1542/peds.2023-062269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 03/14/2024] Open
Abstract
Intractable nausea and vomiting are commonly attributed to gastrointestinal (GI) conditions but can sometimes be a symptom of an underlying central nervous system disease. One potentially overlooked neurologic cause of intractable nausea and vomiting that is refractory to antiemetics is area postrema syndrome (APS). APS is a condition characterized by lesions of the dorsal caudal medulla and is considered a core clinical feature of neuromyelitis optica spectrum disorder (NMOSD). APS is present in up to 30% of patients ultimately diagnosed with NMOSD and can be the first presenting symptom of NMOSD in 12% of patients, as our case illustrates. Importantly, APS is highly responsive to immunotherapy. We present the case of a 14-year-old female with a history of migraines who presented to the emergency department multiple times for persistent nausea, vomiting, and hiccups. Multiple GI diagnoses were considered until she developed additional neurologic symptoms that prompted further workup and revealed the final diagnosis of NMOSD-APS. We posit that NMOSD-APS should be considered in the differential diagnosis for patients with intractable nausea and vomiting, especially in patients with a negative GI workup result and poor response to antiemetics.
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Affiliation(s)
| | | | - Hersh Varma
- Nationwide Children’s Hospital, Columbus, Ohio
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Tomari Y, Igata Y, Chong PF, Kajiwara K, Hatai E, Sonoda Y, Oba U, Kaku N, Koga Y, Sakai Y, Ohga S. The Etiology and Outcome of Area Postrema Syndrome in Childhood: Two Cases and a Literature Review. Pediatr Neurol 2024; 152:11-15. [PMID: 38176222 DOI: 10.1016/j.pediatrneurol.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/03/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Area postrema syndrome (APS), a rare childhood condition, manifests as intractable nausea and hiccups. APS has high diagnostic significance in neuromyelitis optica syndrome spectrum disorders (NMOSD) and can be the initial presentation of other critical diseases, including brainstem glioma. METHODS We described two representative cases of unrelated Japanese patients with APS. An etiologic evaluation, including a detailed intracranial neuroradiological examination and autoantibodies assessment, was performed. We also reviewed the literature focusing on the prognosis of pediatric APS symptoms. RESULTS A 14-year-old girl with aquaporin-4 antibody-positive NMOSD showed a good prognosis with immunotherapy, whereas another nine-year-old girl with irresectable medullary low-grade glioma had persistent symptoms for more than 10 years. All reported children aged >12 years were diagnosed with NMOSD, and patients aged <13 years showed heterogeneous etiologies. CONCLUSIONS Distinctive time courses and neuroimaging features were key clinical findings for the diagnostic and therapeutic processes in these patients. This literature review highlights the wide spectrum and prognosis of pediatric-onset APS.
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Affiliation(s)
- Yuriko Tomari
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuhei Igata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Pin Fee Chong
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Kenta Kajiwara
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eriko Hatai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuri Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Utako Oba
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noriyuki Kaku
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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McAbee GN, Morse AM, Cook W, Tang V, Brosgol Y. Neurological Etiologies and Pathophysiology of Cyclic Vomiting Syndrome. Pediatr Neurol 2020; 106:4-9. [PMID: 32107138 DOI: 10.1016/j.pediatrneurol.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/05/2019] [Accepted: 12/06/2019] [Indexed: 12/28/2022]
Abstract
Cyclic vomiting syndrome is an idiopathic chronic periodic disorder of childhood which may persist into the adult years. Although cyclic vomiting syndrome is considered a central nervous system disorder, it is often managed by a pediatric gastroenterologist. The practitioner should not assume a gastrointestinal or non-neurological cause of symptoms especially if there are coexisting neurological symptoms and signs or if vomiting does not bring relief; this suggests a possible central nervous system cause, which may necessitate a pediatric neurology consultation. Examples of central nervous system causes of cyclic vomiting syndrome that can have subjective and objective neurological findings include abdominal migraine, certain types of epilepsy, structural lesions (tumors, Chiari malformation, demyelinating disease), mitochondrial disease, autonomic disorders, fatty acid/organic acid disorders, urea cycle defects, and cannabinoid hyperemesis syndrome. Improved familiarity with cyclic vomiting syndrome and its mimics may improve the time to appropriate diagnosis and may reduce morbidity related to cyclic vomiting syndrome.
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Affiliation(s)
- Gary N McAbee
- Division of Child Neurology, Department of Pediatrics, Maimonides Children's Hospital, Brooklyn, New York.
| | - Anne Marie Morse
- Division of Child Neurology, Department of Pediatrics, Janet Weis Children's Hospital, Geisinger Medical Center, Danville, Pennsylvania
| | - Ward Cook
- Division of Child Neurology, Department of Pediatrics, Janet Weis Children's Hospital, Geisinger Medical Center, Danville, Pennsylvania
| | - Vivian Tang
- Division of Pediatric Gastroenterology, Department of Pediatrics, Maimonides Children's Hospital, Brooklyn, New York
| | - Yuri Brosgol
- Division of Child Neurology, Department of Pediatrics, Maimonides Children's Hospital, Brooklyn, New York
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Tenembaum S, Yeh EA. Pediatric NMOSD: A Review and Position Statement on Approach to Work-Up and Diagnosis. Front Pediatr 2020; 8:339. [PMID: 32671002 PMCID: PMC7330096 DOI: 10.3389/fped.2020.00339] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/21/2020] [Indexed: 11/13/2022] Open
Abstract
Neuromyelitis Optica Spectrum Disorder (NMOSD) is an inflammatory demyelinating disease of the central nervous system (CNS) primarily affecting the optic nerves and spinal cord, but also involving other regions of the CNS including the area postrema, periaqueductal gray matter, and hypothalamus. Knowledge related to pediatric manifestations of NMOSD has grown in recent years, particularly in light of newer information regarding the importance of not only antibodies to aquaporin 4 (AQP4-IgG) but also myelin oligodendrocyte glycoprotein (MOG-IgG) in children manifesting clinically with this syndrome. In this review, we describe the current state of the knowledge related to clinical manifestations, diagnosis, and chronic therapies for children with NMOSD, with emphasis on literature that has been published in the last 5 years. Following the review, we propose recommendations for the assessment/follow up clinical care, and treatment of this population.
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Affiliation(s)
- Silvia Tenembaum
- Department of Neurology, National Pediatric Hospital Dr. J. Garrahan, Buenos Aires, Argentina
| | - E Ann Yeh
- Division of Neurology, Department of Pediatrics, SickKids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Sarnat HB, Flores-Sarnat L, Boltshauser E. Area Postrema: Fetal Maturation, Tumors, Vomiting Center, Growth, Role in Neuromyelitis Optica. Pediatr Neurol 2019; 94:21-31. [PMID: 30797593 DOI: 10.1016/j.pediatrneurol.2018.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The area postrema in the caudal fourth ventricular floor is highly vascular without blood-brain or blood-cerebrospinal fluid barrier. In addition to its function as vomiting center, several others are part of the circumventricular organs for vasomotor/angiotensin II regulation, role in neuromyelitis optica related to aquaporin-4, and somatic growth and appetite regulation. Functions are immature at birth. The purpose was to demonstrate neuronal, synaptic, glial, or ependymal maturation in the area postrema of normal fetuses. We describe three area postrema tumors. METHODS Sections of caudal fourth ventricle of 12 normal human fetal brains at autopsy aged six to 40 weeks and three infants aged three to 18 months were examined. Immunocytochemical neuronal and glial markers were applied to paraffin sections. Two infants with area postrema tumors and another with neurocutaneous melanocytosis and pernicious vomiting also studied. RESULTS Area postrema neurons exhibited cytologic maturity and synaptic circuitry by 14 weeks'. Astrocytes coexpressed vimentin, glial fibrillary acidic protein, and S-100β protein. The ependyma is thin over area postrema, with fetal ependymocytic basal processes. A glial layer separates area postrema from medullary tegmentum. Melanocytes infiltrated area postrema in the toddler with pernicious vomiting; two children had primary area postrema pilocytic astrocytomas. CONCLUSIONS Although area postrema is cytologically mature by 14 weeks, growth increases and functions mature during postnatal months. We recommend neuroimaging for patients with unexplained vomiting and that area postrema neuropathology includes synaptophysin and microtubule-associated protein-2 in patients with suspected dysfunction.
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Affiliation(s)
- Harvey B Sarnat
- Departments of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; Pathology (Neuropathology), University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.
| | - Laura Flores-Sarnat
- Departments of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada; Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Eugen Boltshauser
- Department of Paediatric Neurology, Children's University Hospital, Zürich, Switzerland
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Zeiner PS, Brandhofe A, Müller-Eschner M, Steinmetz H, Pfeilschifter W. Area postrema syndrome as frequent feature of Bickerstaff brainstem encephalitis. Ann Clin Transl Neurol 2018; 5:1534-1542. [PMID: 30564620 PMCID: PMC6292382 DOI: 10.1002/acn3.666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/27/2018] [Accepted: 09/10/2018] [Indexed: 01/12/2023] Open
Abstract
Objective Area postrema (AP) syndrome (defined as: nausea and/or emesis and/or singultus at onset of brainstem dysfunction) comprises complex pathophysiologic mechanisms triggered by different entities. The first objective was to assess the frequency of AP syndrome as a clinical feature in brainstem encephalitis (BE). Finding an especially high prevalence of AP syndrome in Bickerstaff brainstem encephalitis (BBE), we also analyzed the frequency of AP syndrome in other autoimmune diseases with anti-ganglioside antibodies (Guillain-Barré syndrome (GBS) and its variants). Methods We systematically evaluated the prevalence of AP syndrome in BE in all patients treated at our university hospital during a 15-year period. In a second step, BBE patients were compared to GBS and Miller Fisher syndrome (MFS) patients as clinical subtypes of a disease continuum without brainstem dysfunction. Results We found AP syndrome in 8 of 21 BE patients, including 3 of 7 BBE and in 4 of 112 GBS/MFS patients. AP syndrome was as a frequent but under-recognized feature of BE with a significant impact on patients' well being. Interpretation Manifestation of AP syndrome in BBE but also in GBS and its subtypes point toward a role of autoimmune antibodies that should be investigated in future studies. Considerable misdiagnosis or nonrecognition complicates diagnostic and therapeutic management. Therefore, AP syndrome should be considered in any episode of otherwise unexplained nausea, emesis, or singultus.
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Affiliation(s)
- Pia S Zeiner
- Department of Neurology University Hospital/Goethe University Frankfurt Schleusenweg 2-16 Frankfurt/Main 60528 Germany.,Dr. Senckenberg Institute of Neurooncology University Hospital/Goethe University Frankfurt Heinrich-Hoffmann-Strasse 7 Frankfurt/Main 60528 Germany
| | - Annemarie Brandhofe
- Department of Neurology University Hospital/Goethe University Frankfurt Schleusenweg 2-16 Frankfurt/Main 60528 Germany
| | - Monika Müller-Eschner
- Institute of Neuroradiology University Hospital/Goethe University Frankfurt Schleusenweg 2-16 Frankfurt/Main 60528 Germany
| | - Helmuth Steinmetz
- Department of Neurology University Hospital/Goethe University Frankfurt Schleusenweg 2-16 Frankfurt/Main 60528 Germany
| | - Waltraud Pfeilschifter
- Department of Neurology University Hospital/Goethe University Frankfurt Schleusenweg 2-16 Frankfurt/Main 60528 Germany
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Baghbanian SM, Asgari N, Sahraian MA, Moghadasi AN. A comparison of pediatric and adult neuromyelitis optica spectrum disorders: A review of clinical manifestation, diagnosis, and treatment. J Neurol Sci 2018; 388:222-231. [DOI: 10.1016/j.jns.2018.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/19/2017] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
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