Prolonged expiratory apnoea (cyanotic 'breath-holding') in association with a medullary tumour

Rare occurrence of gangliocytoma in the medulla oblongata

Gangliocytoma is an uncommon low-grade neuroepithelial tumour arising in the cerebral hemispheres, with medulla oblongata being extremely rare site of occurrence. We report a case of an 8-year-old female with recurrent vomiting, hypertension and left hemifacial spasms with a dorsally exophytic lesion arising from the medulla projecting into the fourth ventricle. She underwent excision of the lesion with intra operative cranial nerve monitoring guidance. Histopathology revealed clusters of large mature ganglion cells which were labelled by synaptophysin and CD34. Extreme rarity in this location makes clinical diagnosis and management of gangliocytoma challenging, although prompt diagnosis and total excision has a successful outcome. There are only six previous reports of gangliocytoma in the medulla oblongata.

Autopsy case of undiagnosed gangliocytoma in the medulla oblongata complicated with cerebral palsy

A Japanese man in his 30s who had congenital cerebral palsy was found unresponsive in bed. His death was confirmed after resuscitation attempts. He had a history of occasional falling (despite the use of walking sticks and a wheelchair) owing to a slowly progressive gait disturbance, and had a medical examination without full neurological re-examination. Autopsy revealed gangliocytoma in the medulla oblongata, which was diagnosed as the cause of death. Although gangliocytoma is a well-differentiated benign tumor, the almost total replacement of the medulla oblongata by the tumor cells was assumed to result in ataxia via the olivocerebellar tract and secondary cerebellar atrophy, followed by central hypoventilation and death of the patient. The symptoms caused by gangliocytoma may be overlooked owing to long-standing cerebral palsy.

Treatment of cyanotic breath-holding spells with oral theophylline in a 10-year-old boy

Cyanotic breath-holding spells are generally benign and resolve spontaneously by 4 to 5 years of age. Treatment with iron and other drugs has been employed in selected cases with very frequent and severe episodes. We describe a 10-year-old boy with recent-onset cyanotic breath-holding spells that were activity limiting. He was unable to participate in physical activities with his peers as any argument or emotional upset provoked these spells. Treatment with oral iron and piracetam was ineffective. However, treatment with oral theophylline produced dramatic amelioration of symptoms, and he was once again able to participate in play activities with his peers. We believe that general central nervous system stimulant and respirogenic effects of theophylline were instrumental in control of symptoms in our child.

Rare manifestation of a craniovertebral junction anomaly: is blue breath holding always benign?

Breath-holding or reflex anoxic seizures predominantly occur in preschool children and usually resolve by late childhood, rarely persisting through adolescence and into adulthood. Investigations are generally unnecessary. Education and reassurance is the mainstay of management. In this report, the author describes a case in which an infant presented with breath-holding spells due to a significant craniovertebral anomaly, and underwent a C1-C2 posterior stabilization. Following the stabilization of his dislocation the breath-holding spells never reappeared. Authors have previously described a rare manifestation of craniovertebral junction anomaly. Additionally, it is important to recognize that in a subset of patients breath-holding spells may be hazardous and not benign.

Spontaneous remission of a diffuse brainstem lesion in a neonate

We describe here the spontaneous remission of a diffuse brainstem lesion found in an infant at the age of 7 weeks. Clinical and MRI characteristics strongly suggested a diffuse pontine glioma. Repeated MRI studies showed a continuous decrease in the size of the lesion, which was no longer visible by the age of 27 months. Spontaneous remission of diffuse pontine glioma is extremely rare; to our knowledge there are reports of only three similar cases.

Persistence of breath-holding spells into late childhood

Breath-holding spells commonly occur during infancy. The disorder represents a self-limited, benign phenomenon, and breathholding spells almost always resolve by school age. Their continuing occurrence beyond this age is exceedingly uncommon and may create diagnostic confusion. We recently encountered an 8-year-old boy who continues to experience breath-holding spells.

Blue breath holding is benign

In their recent publication in this journal, Southall et al described typical cyanotic breath holding spells, both in otherwise healthy children and in those with brainstem lesions and other malformations. Their suggestions regarding possible autonomic disturbances may require further study, but they have adduced no scientific evidence to contradict the accepted view that in the intact child blue breath holding spells are benign. Those families in which an infant suffers an 'apparently life threatening event' deserve immense understanding and help, and it behoves investigators to exercise extreme care and self criticism in the presentation of new knowledge which may bear upon their management and their morale.

Recurrent cyanotic episodes with severe arterial hypoxaemia and intrapulmonary shunting: a mechanism for sudden death

The pathophysiology of recurrent cyanotic episodes has been investigated in 51 infants and children. Episodes began at a median age of 7 weeks (range 1 day to 22 months, 39 at less than 4 months). They were characterised by the rapidity of onset and progression of severe hypoxaemia with early loss of consciousness from cerebral hypoxia. The most common precipitating factor was a sudden naturally occurring stimulus from pain, fear, or anger. In uncontrolled trials, cyanotic episodes were reduced in frequency and severity by tetrabenazine (n = 15) and additional inspired oxygen (n = 10). Eight patients died suddenly and unexpectedly (four during cyanotic episodes). Twenty eight patients underwent physiological studies during cyanotic episodes. There was no evidence of seizure activity at the onset and although prolonged absence of inspiratory effort with continued expiratory efforts was common, breathing sometimes continued. Episodes were not caused by upper airway obstruction and sometimes occurred during positive airway pressure ventilation. The rapidity of fall in arterial oxygen pressure and continued breathing suggested a right to left shunt of sudden onset. The results of contrast echocardiography and lung imaging studies confirmed that this was occurring within the lungs. These cyanotic episodes included both intrapulmonary shunting and prolonged expiratory apnoea. They are best explained by interactions between central sympathetic activity, brainstem control of respiration and vasomotor activity, reflexes arising from around and within the respiratory tract, and the matching of ventilation to perfusion in the lungs. They are a cause of sudden unexpected death in infancy and early childhood.