Elevated Alpha-Fetoprotein in Infantile-Onset Niemann-Pick Type C Disease with Liver Involvement

Niemann-Pick disease type C (NPC) is a rare autosomal recessive neuro-visceral lipid storage disease. We describe nine cases of infantile-onset NPC with various genetic mutations in the NPC1 gene, which presented with neonatal cholestasis. Serum alpha-fetoprotein (AFP) levels were obtained as part of their workup during the first four months of life. In eight of nine (89%) patients, serum AFP demonstrated elevated levels. Seven infants displayed marked elevations, ranging from 4 to 300 times the upper limit for age-adjusted norms. In most patients, AFP levels peaked during the initial test and declined over time as cholestasis resolved. We conclude that elevated AFP levels are a common, although non-specific, marker for NPC-associated liver disease. These findings demonstrate the benefit of including AFP levels in the workup of neonatal liver disease, especially if there is accompanied cholestasis and if NPC is suspected.

Comparison of Thrombocyte Count Between Pediatric Patients With Migraine or Tension-Type Headache: A Retrospective Cohort Study

Hypercoagulability may explain the increased risk of thromboembolic cerebrovascular events in patients with migraine. Thrombocytes play a crucial part in the coagulation process, and some studies have demonstrated hyperaggregation of thrombocytes in adult migraineurs. We aimed to compare thrombocyte count between pediatric patients with migraine or tension-type headache and to evaluate the correlation of thrombocyte count with headache parameters. The electronic database of a tertiary pediatric headache clinic was retrospectively searched for all children and adolescents diagnosed with migraine or tension-type headache in 2016-2018. Data on thrombocyte counts were collected from the medical files and compared between the groups by parametric and nonparametric statistical tests. The cohort included 299 patients, 176 girls (59.0%) and 123 (412.0%) boys, of mean age 12.2 ± 3.4 years; 198 had migraine and 101 had tension-type headache. Among the laboratory parameters evaluated, a significantly lower mean thrombocyte number was found in the migraine group than in the tension-type headache group (282 ± 60 vs 304±71 ×10³/μL, P = .004). Within the migraine group, there was a significant negative correlation between the thrombocyte count and the duration of headache attacks in hours (P < .05). No significant between- or within-group differences were found in other laboratory parameters. The low relative thrombocyte count in pediatric headache clinic patients with migraine and its negative correlation with duration of migraine suggest that migraine may be associated with a different underlying pathogenesis from tension-type headache.

Thrombophilia Testing in High Pediatric Migraine Risk Children With Migraine

This study sought to investigate the need for thrombophilia screening in pediatric migraineurs. The cohort included 45/824 children (5.5%) aged 3-18 years with migraine who were tested for thrombophilia at a tertiary pediatric headache clinic. Results were analyzed by background factors and indications for screening. Rates of thrombotic factors were compared with a healthy historical control group. At least 1 thrombotic factor was positive in 19/45 patients (42%). The total thrombophilia risk rate was higher in patients with aura (n = 32). Lipoprotein(a) was the factor most often abnormal in the thrombophilia group of all factors tested (8/19, 42%), regardless of migraine type or gender. It was the only factor with a significantly higher prevalence in the migraine than the historical control group. Full thrombophilia testing in migraine in pediatric headache clinics does not seem to be justified. The high prevalence of elevated lipoprotein(a) in children with migraine warrants further investigation.

Cephalic cutaneous allodynia in children and adolescents with migraine of short duration: A retrospective cohort study

BACKGROUND

Allodynia is prevalent in adults with migraine and has been associated with long disease duration and severe course. Studies of the pediatric population are sparse. The aim of this study was to evaluate the rate of cephalic cutaneous allodynia in children and adolescents within the first 6 months of migraine onset and to identify associated clinical and migraine-related parameters.

METHODS

The electronic database of a tertiary pediatric headache clinic from 2014 to 2017 was retrospectively searched for all children and adolescents diagnosed with migraine headache within 6 months or less of symptom onset. Cephalic cutaneous allodynia was identified by validated questionnaire. Demographics, symptoms, and headache-related parameters were compared between patients with and without allodynia.

RESULTS

The cohort included 119 patients, 69 girls (58.0%) and 50 (42.0%) boys, of mean age 11.6 ± 3.6 years. Mean time since onset of migraine disease was 3.6 ± 1.8 months. Cephalic cutaneous allodynia was reported by 31.1% of patients. It was significantly associated with female gender ( p = 0.03), older age at admission ( p = 0.037), older age at onset ( p = 0.042) migraine with aura ( p = 0.002), and higher rate of awakening pain ( p = 0.017).

CONCLUSIONS

Cephalic cutaneous allodynia may occur in children and adolescents already in the first 6 months of migraine onset. Contrary to adult studies, we found no association of allodynia with migraine frequency or long disease duration. Allodynia was significantly associated with migraine with aura, female gender, and awakening pain. A genetic tendency may contribute to the appearance of allodynia in the pediatric age group.

[TRMU MUTATIONS - REVERSIBLE INFANTILE LIVER FAILURE OR MULTISYSTEM DISORDER?]

INTRODUCTION

Bi-allelic mutations in the TRMU gene cause reversible infantile liver failure. Little is known about extra-hepatic manifestations in these patients.

BACKGROUND

Two infants, aged 4 and 5 months, presented with progressive life threatening liver failure, characterized by lactic acidosis, highly elevated alpha-fetoprotein and recurrent hypoglycemia. Both showed significant extra-hepatic findings, including: hypothyroidism, macrocytic anemia and microcephaly. Both were of Jewish Yemenite descent and homozygous for Y77H mutation in the TRMU gene.

CONCLUSIONS

TRMU bi-allelic mutations cause severe life-threatening liver failure. Extra-hepatic involvement is common and should be evaluated. Spontaneous resolution and recovery occurs in most patients with a remarkably good long-term prognosis. Liver failure in a Jewish-Yemenite infant should prompt early genetic testing for TRMU Y77H mutation. Pediatricians should be aware of this disease and the common mutation in Israel.

DISCUSSION

Nineteen additional patients were described in the literature, of whom 13 were from Israel; 6/19 (31%) manifested extra-hepatic involvement, namely: myopathic weakness, cardiomyopathy, renomegaly and proteinuria, bulbar dysfunction, cerebral white matter changes and abnormal growth including microcephaly. Mortality was 24% (5/21). Survivors (16/21, 76%) showed complete recovery and resolution of clinical, laboratory and histologic abnormalities. Most Israeli patients (10/15) were of Jewish-Yemenite ancestry. Homozygous Y77H genotype was exclusive to this patient subgroup and was associated with a 100% survival and recovery rate.

Younger Age of Migraine Onset in Children Than Their Parents: A Retrospective Cohort Study

Migraine is known to run in families and has long been considered a strongly heritable disorder. We sought to investigate the age of onset of migraine between successive generations. Our retrospective cohort included 102 children with migraine who were referred to a pediatric headache clinic and their affected parent(s). Age at migraine onset was significantly lower in the children with a history of maternal or paternal migraine than in their mothers or fathers ( P < .001). In conclusion, data on parental history of migraine showed that children with migraine were significantly younger at first appearance of the disease than their affected parents.

Symptoms and clinical parameters of pediatric and adolescent migraine, by gender - a retrospective cohort study

Background

The available data on gender differences in clinical migraine parameters among pediatric patients are based on relatively few studies, which did not use the current version of the International Classification of Headache Disorders (ICHD) of the International Headache Society. The aim of the present study was to compare between males and females, demographic and clinical characteristics of children and adolescents with migraines diagnosed according to the ICDIII-beta version.

Methods

The electronic database of a tertiary pediatric headache clinic was searched for all children and adolescents diagnosed with migraine headaches in 2010–2016. Data on demographics, symptoms, and headache-related parameters were collected from the medical files. Findings were compared by gender.

Results

The cohort included 468 children and adolescents of mean age 11.3 ± 3.6 years; 215 males (45.9%) and 253 females (54.1%). Migraine without aura was documented in 313 patients (66.9%), and migraine with aura in 127 (27.1%); 28 patients (6.0%) had probable migraines. The female patients had significantly higher values than the male patients for the following parameters: age at admission (p = 0.042, Cohen’s d 0.8303, 95% CI 0.614–0.992); age at migraine onset (p = 0.021, Cohen’s d 0.211, 95% CI 0.029–0.394); rate of migraine with aura (OR 2.01, 95% CI 1.29–3.16, p = 0.0056); headache frequency (p = 0.0149, Cohen’s d 0.211, 95% CI 0.029–0.3940); rate of chronic migraine (p = 0.036, OR 1.54, 95% CI 1.02–2.34); and puberty (OR 3.51, 95% CI 2.01–6.35, p = <0.001). Males had a higher rate of vomiting (OR 0.62, 95% CI 0.41–0.93, p = 0.018). Further analysis by pubertal stage revealed that pubertal females, but not prepubertal females, had a significantly higher rate of migraine with aura than did males (41.1% versus 28.9%; OR 1.42, 95% CI 0.85–2.37, p = 0.039).

Conclusion

Female children and adolescents with migraine treated in a tertiary pediatric headache clinic were characterized by a higher rate of chronic migraine and migraine with aura, a lower rate of vomiting, and older age at onset relative to males. These findings might be influenced by the better description of migraine symptoms by females owing to their better verbal ability.

Long-term Follow-up of Observation-Only Management of Nontuberculous Mycobacterial Lymphadenitis

A total of 21 children with clinically and microbiologically proven craniofacial nontuberculous mycobacterial lymphadenitis managed by observation only at a tertiary medical center in 1993-2005 were evaluated for scar parameters at least 2 years after diagnosis. Parents completed a satisfaction questionnaire. Median follow-up time from presentation was 6.8 years (range = 2.3-16.9 years). In all, 18 patients showed scar formation, for a total of 26 scars; 21 scars (81%) had a maximal length of ≤3 cm. Vascularity was normal in 20 scars (77%), and pigmentation was normal in 18 (69%); 21 scars (81%) had a normal to only mildly uneven surface. Although 8 parents (44%) reported that the presence of the scar disturbed them, all responders but one (94%) expressed overall contentment of observation only as a conceivable management alternative. In conclusion, an observation-only approach to craniofacial nontuberculous mycobacterial lymphadenitis is associated with an acceptable outcome and may be an alternative to patients who wish to avoid surgery.

Comparison of comorbidities of migraine and tension headache in a pediatric headache clinic

Objective To compare comorbidities between migraine and tension headache in patients treated in a tertiary pediatric headache clinic. Methods Files of patients with migraine or tension headache attending a pediatric headache clinic were retrospectively reviewed for the presence of organic comorbidities. Additionally, patients were screened with the self-report Strengths and Difficulties Questionnaire to identify nonorganic comorbidities. If necessary, patients were referred to a pediatric psychiatrist, psychologist or social worker for further evaluation. Results The study cohort comprised 401 patients: 200 with migraine and 201 with tension headache. The main organic comorbidities were atopic disease, asthma, and first-reported iron-deficiency anemia; all occurred with statistical significance more often with migraine than with tension headache (Familial Mediterranean fever was six times more frequent in the migraine group than in the tension headache group, but the difference was not statistically significant. Nonorganic comorbidities (psychiatric, social stressors) were associated significantly more often with tension headache than with migraine (48.3% versus 33%; p = 0.03). Conclusions Children and adolescents with migraine or tension headache treated in a dedicated clinic have high rates of organic and nonorganic comorbidities. In this setting, patients with migraine have significantly more organic comorbidities, and patients with tension headache, significantly more nonorganic comorbidities.

Persistent Headache and Cephalic Allodynia Attributed to Head Trauma in Children and Adolescents

The aim of the study was to investigate clinical features of headache associated with minor versus moderate to severe traumatic brain injury and of posttraumatic versus primary headache in children and adolescents. Study group included 74 patients after mild (n = 60) or moderate to severe (n = 14) traumatic brain injury identified by retrospective review of the computerized files of a tertiary pediatric headache clinic. Forty patients (54%) had migraine-like headache, 23 (31.1%) tension-like headache, and 11 (14.9%) nonspecified headache. Fourteen patients (53.8%) had allodynia. In comparison with 174 control patients, the study group had a significantly lower proportion of patients with migraine-like headache and a higher proportion of male patients and patients with allodynia. There was no statistically significant correlation of any of the clinical parameters with the type or severity of the posttraumatic headache or rate of allodynia. The high rate of allodynia in the study group may indicate a central sensitization in posttraumatic headache.

Defining the Phenotype and Assessing Severity in Phosphoglucomutase-1 Deficiency

OBJECTIVE

To define phenotypic groups and identify predictors of disease severity in patients with phosphoglucomutase-1 deficiency (PGM1-CDG).

STUDY DESIGN

We evaluated 27 patients with PGM1-CDG who were divided into 3 phenotypic groups, and group assignment was validated by a scoring system, the Tulane PGM1-CDG Rating Scale (TPCRS). This scale evaluates measurable clinical features of PGM1-CDG. We examined the relationship between genotype, enzyme activity, and TPCRS score by using regression analysis. Associations between the most common clinical features and disease severity were evaluated by principal component analysis.

RESULTS

We found a statistically significant stratification of the TPCRS scores among the phenotypic groups (P < .001). Regression analysis showed that there is no significant correlation between genotype, enzyme activity, and TPCRS score. Principal component analysis identified 5 variables that contributed to 54% variance in the cohort and are predictive of disease severity: congenital malformation, cardiac involvement, endocrine deficiency, myopathy, and growth.

CONCLUSIONS

We established a scoring algorithm to reliably evaluate disease severity in patients with PGM1-CDG on the basis of their clinical history and presentation. We also identified 5 clinical features that are predictors of disease severity; 2 of these features can be evaluated by physical examination, without the need for specific diagnostic testing and thus allow for rapid assessment and initiation of therapy.

Association of pediatric obesity and migraine with comparison to tension headache and samples from other countries

The link between body weight and headache has hardly been examined in children. The aim was to evaluate the association of obesity and migraine in selected pediatric patients and compare the findings with the literature. Data on clinical symptoms, headache type, and body mass index standard deviation score were derived from the medical files of 245 patients with migraine and 87 with tension headache. Comparison of the 3 subgroups of migraine patients of normal weight, overweight, and obese with the corresponding body mass index standard deviation score subgroups of patients with tension-type headache yielded no statistically significant differences in frequency of headache attacks per month, or duration of headache attacks in hours. These results call into question earlier reports linking headache and obesity in children. Differences in findings between our study and those in the literature highlight several factors that should be addressed in further studies. A larger sample size may reveal more significant results.

Association of age at onset of migraine with family history of migraine in children attending a pediatric headache clinic: A retrospective cohort study

Aim

Migraine is known to run in families and has long been considered a strongly heritable disorder. This study sought to evaluate the relationship between age at onset of pediatric migraine and family history of migraine.

Methods

Review of the medical files of the headache clinic of a tertiary pediatric medical center yielded 344 children with migraine for whom details on migraine in family members were available.

Results

Mean age of the cohort was 11.69 ± 3.49 years, and mean frequency of headache per month, 13.68 ± 11.26. Mean age at migraine onset in patients with a negative parental history was10.48 ± 3.39 years; in patients with one parent with migraine, 8.84 ± 3.72 years; and in patients with both parents with migraine, 7.32 ± 3.22 years ( p < 0.001).The duration of migraine attacks (in hours) was significantly longer in patients with any family member with migraine than in those with no family history ( p = 0.026).

Conclusions

Among children attending a tertiary pediatric headache clinic, migraine appears at a younger age in those with parental history of migraine than in those with a negative family history. The findings suggest that having a genetic background of migraine makes a child more susceptible to migraine earlier in life than a child without a family history.

Occipital and craniocervical pain and brain MRI in children with migraine

BACKGROUND

Both cervical and occipital pain has been reported in pediatric patients with migraine. There are no descriptions of anatomical changes on conventional brain magnetic resonance imaging that can explain the pathophysiology of headache with cervical and occipital pain in this age group. Our aim was to evaluate the frequency of cervical and occipital pain in children and adolescents with migraine as opposed to other types of headache and to seek corresponding anatomic abnormalities on brain magnetic resonance imaging.

METHODS

The cohort included 194 patients with headache attending the ambulatory headache clinic of a pediatric tertiary medical center. Data were collected by medical file review and revision of conventional magnetic resonance scans.

RESULTS

Patients were divided into two groups: migraine headache (n = 125) and other types of headache (n = 69). Occipital pain was reported by 16.4% of the patients and cervical pain by 4.1%; neither type of pain was characteristic of migraine headache in particular. Brain magnetic resonance imaging did not show any anatomic changes specific to migraine or other headache types, regardless of the presence of occipital or cervical pain.

CONCLUSIONS

Occipital and cervical pain are not characteristic symptoms of any headache group in the pediatric age group, and their presence or absence does not correspond to changes on conventional brain magnetic resonance imaging.

Glycogen storage disease type III in Israel: presentation and long-term outcome

Glycogen storage disease type III (GSD III) was found in the past with an unusual frequency among North African Jews in Israel. The aim of this study was to review the long-term clinical course of GSD III's patients in Israel. Relevant pediatric and adult clinical units of all Israeli hospitals were approached to report on their GSD III patients. 21 (14 M/7F) live patients were located. The average age of the patients was nearly twenty years. Eleven patients were older than 18 years of age. 76% of the patients were of Jewish North African origin, 14% of Jewish European origin, and 10% were Arab Muslims. The symptoms at presentation were fasting, hypoglycemia, hepatomegaly slight hypotonia in infancy and delayed growth. Although in most of the patients their signs and symptoms ameliorated after childhood, significant complications were observed in some 20% of the patients. Consequently, a life long follow up of GSD-III patients is required.

Elevated plasma citrulline: look for dihydrolipoamide dehydrogenase deficiency

The E3 subunit of the pyruvate dehydrogenase complex (dihydrolipoamide dehydrogenase/dihydrolipoyl dehydrogenase/DLD/lipoamide dehydrogenase/LAD), is a mitochondrial matrix enzyme and also a part of the branched-chain ketoacid dehydrogenase and alpha-ketoglutarate dehydrogenase complexes. DLD deficiency (MIM #246900), is relatively frequent in the Ashkenazi Jewish population but occurs in other populations as well. Early diagnosis is important to prevent episodes of metabolic decompensation, liver failure, and encephalopathy. The clinical presentations are varied and may include Reye-like syndrome, hepatic failure, myopathy, and myoglobinuria. Laboratory markers, such as elevated urinary alpha-ketoglutarate, blood pyruvate, lactate, and ammonia, are mostly nonspecific and not always present, making the diagnosis difficult. Since we observed elevated plasma citrulline levels in a number of confirmed cases, we retrospectively examined the value of citrulline as a biochemical marker for DLD deficiency. Data was gathered from the files of 17 pediatric patients with DLD deficiency, confirmed by enzymatic and genetic analysis. The control group included 19 patients in whom urea cycle defects were ruled out but DLD deficiency was suspected. Seven of the DLD-deficient patients presented with elevated plasma citrulline levels (median value 205 μM, range 59-282 μM) (normal range 1-45 μM) while none in the control patient group. In five patients, elevated citrulline was associated with elevated plasma glutamine and metabolic acidosis. Interestingly, elevated plasma citrulline was associated with the common G229C mutation. In conclusion, we suggest that elevated plasma citrulline in the absence of urea cycle defects warrants an investigation for DLD deficiency.

Screening for psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain

BACKGROUND

Recurrent pain symptoms in children are associated with psychiatric comorbidities that could complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA).

METHODS

Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n = 32), tension-type headache (n = 32), or recurrent abdominal pain (n = 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments.

RESULTS

The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003).

CONCLUSION

Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients.

Identification of a novel mutation in the PNLIP gene in two brothers with congenital pancreatic lipase deficiency

Congenital pancreatic lipase (PNLIP) deficiency is a rare monoenzymatic form of exocrine pancreatic failure characterized by decreased absorption of dietary fat and greasy voluminous stools, but apparent normal development and an overall good state of health. While considered to be an autosomal recessive state affecting a few dozens of individuals world-wide and involving the PNLIP gene, no causative mutations for this phenotype were so far reported. Here, we report the identification of the homozygote missense mutation, Thr221Met [c.662C>T], in two brothers from a consanguineous family of Arab ancestry. The observed genotypes among the family members were concordant with an autosomal recessive mode of inheritance but moreover a clear segregation between the genotype state and the serum PNLIP activity was evident. Based on biophysical computational tools, we suggest the mutation disrupts the protein's stability and impairs its normal function. Although the role of PNLIP is well established, our observations provide genetic evidence that PNLIP mutations are causative for this phenotype.

Mutations in GMPPA cause a glycosylation disorder characterized by intellectual disability and autonomic dysfunction

In guanosine diphosphate (GDP)-mannose pyrophosphorylase A (GMPPA), we identified a homozygous nonsense mutation that segregated with achalasia and alacrima, delayed developmental milestones, and gait abnormalities in a consanguineous Pakistani pedigree. Mutations in GMPPA were subsequently found in ten additional individuals from eight independent families affected by the combination of achalasia, alacrima, and neurological deficits. This autosomal-recessive disorder shows many similarities with triple A syndrome, which is characterized by achalasia, alacrima, and variable neurological deficits in combination with adrenal insufficiency. GMPPA is a largely uncharacterized homolog of GMPPB. GMPPB catalyzes the formation of GDP-mannose, which is an essential precursor of glycan moieties of glycoproteins and glycolipids and is associated with congenital and limb-girdle muscular dystrophies with hypoglycosylation of α-dystroglycan. Surprisingly, GDP-mannose pyrophosphorylase activity was unchanged and GDP-mannose levels were strongly increased in lymphoblasts of individuals with GMPPA mutations. This suggests that GMPPA might serve as a GMPPB regulatory subunit mediating feedback inhibition of GMPPB instead of displaying catalytic enzyme activity itself. Thus, a triple-A-like syndrome can be added to the growing list of congenital disorders of glycosylation, in which dysregulation rather than mere enzyme deficiency is the basal pathophysiological mechanism.

MRI white matter lesions in pediatric migraine

OBJECTIVES

Studies have reported an association between migraine and white matter hyperintensities on T2-weighted brain magnetic resonance imaging (MRI) in adults. The aim of the present study was to evaluate white matter MRI brain findings in pediatric patients with migraine.

METHODS

The medical files and imaging scans of all 194 patients who underwent brain MRI at the headache clinic of a tertiary medical center in 2008-2011 were reviewed.

RESULTS

Mean age was 10.9 ± 3.5 years. Migraine was diagnosed in 131 patients and other disorders in 63. In the migraine group, findings on physical and laboratory examinations were within normal range. White matter lesions were identified on MRI scan in 14 children with migraine (10.6%) and none of the children with other disorders ( P  = 0.006). In 13/14 patients, the lesions were focal with a variable distribution; in the remaining patient, confluent periventricular hyperintensities were documented.

CONCLUSIONS

In a headache clinic of a tertiary pediatric medical center, white matter lesions are found in about 10% of pediatric patients with migraine.

Recurrent infantile hypoglycemia due to combined fructose-1,6-diphosphatase deficiency and growth hormone deficiency

A 14-month-old female infant presented with recurrent episodes of acute gastroenteritis accompanied by severe metabolic acidosis and hypoglycemia. Physical examination showed hepatomegaly. Laboratory evaluation revealed elevated hepatic enzymes, prolonged prothrombin time, hyperuricemia, and extremely elevated lactate and alanine levels. Glucagon injection during hypoglycemia resulted in a further decrease of blood glucose. She was treated with glucose-containing intravenous fluids, with rapid improvement and normalization of her blood pH and glucose levels. Hormonal assessment during two episodes of hypoglycemia indicated growth hormone (GH) deficiency. However, as isolated GH deficiency could not explain all other concomitant features, such as severe lactic acidosis, hepatomegaly, impaired liver function, and hyperuricemia, the possibility of a combined defect was suggested. Further lymphocytic enzymatic investigation revealed fructose-1,6-diphosphatase deficiency and molecular genetic analysis demonstrated frame shift mutation in the FBP1 gene. This enzyme deficiency causes a rare metabolic disorder not previously described in combination with GH deficiency.

McArdle disease: a novel mutation in Jewish families from the Caucasus region

McArdle disease is caused by a myophosphorylase deficiency consequent to defects in the PYGM gene. A minority of the over-133 known mutations are associated with ethnicity, occurring mainly in patients from western Europe, the United States, and Japan. We identified a novel mutation, c.632delG, in three unrelated families of Jewish descent originating from the Caucasus region. This possibly ethnicity-associated mutation can significantly facilitate the diagnosis in Jews of the Caucasus and contribute to genetic consultations.

Nonpharmacologic treatment of migraine with low-dose propranolol or amitriptyline

This study evaluated the effectiveness of nonpharmacologic measures combined with low-dose propranolol or amitriptyline for treating severe pediatric migraine. Data were collected from the medical files of 118 patients (mean age, 12.54 ± 3.14 years S.D.). All were treated with nonpharmacologic measures. In addition, 93 children received propranolol (mean initial dose, 0.4 ± 0.17 mg/kg/day S.D.), and 25 received amitriptyline (mean initial dose, 0.26 ± 0.1 mg/kg/day S.D.). Twenty patients were switched from propranolol to amitriptyline during treatment. In both groups, headache frequency was reduced by >50% per month in ~80% of patients. Patients without aura responded significantly better to propranolol than patients with aura (P = 0.02). No significant difference was evident in response to pharmacologic treatment by migraine frequency or type (episodic chronic). No significant difference was evident in response to amitriptyline between patients with or without aura. The response rate was higher than previously reported for placebo. Low-dose propranolol and low-dose amitriptyline, when combined with nonpharmacologic measures, are equally effective in reducing the frequency of migraine in children. Propranolol is preferred because of its lower risk of side effects. An additive effect of nonpharmacologic measures may allow for a reduction in drug dose.

Long-term follow-up for ophthalmologic sequelae in children treated with corticosteroids for infantile spasms

The aim of the study was to determine if early steroid treatment of infantile spasms is associated with ocular complications years after its termination. Twenty-five patients with infantile spasms who underwent prolonged treatment with intramuscular synthetic adrenocorticotropic hormone (ACTH) and oral prednisone were evaluated for ocular complications 2 to 33 years after treatment cessation. Patients were followed by an ophthalmic examination that included anterior and posterior segments and measurement of intraocular pressure. Intraocular pressure was normal bilaterally in all patients. Findings on anterior segment examination were unremarkable. On posterior segment examination, 3 patients had an increased cup/disc ratio with normal intraocular pressure. In 2 patients, the increased ratio was considered an anatomical variant. Posterior segment findings in 2 patients were attributed to their background disease. In conclusion, early treatment with high-dose synthetic adrenocorticotropic hormone and oral prednisone for infantile spasm is apparently not associated with a risk of occular complications on long-term follow-up.

Effect of high-dose glucocorticosteroid treatment for infantile spasms on quantitative bone parameters later in life

This study evaluated possible long-term effects of prolonged high-dose glucocorticosteroid administration in infancy. Thirty patients (16 male, 14 female; age 4.8-33 years) who had completed treatment with adrenocorticotropic hormone (ACTH) followed by glucocorticoids for infantile spasms at a tertiary pediatric hospital at least 2 years previously were invited to undergo quantitative bone ultrasound. The mean speed of soundZ score was -1.085 ± 1.079 for the radius and -0.22 ± 1.19 for the tibia on the nondominant side (P = .0022). The difference from the reference mean (0) was statistically significant for the radius (P < .001). There were no significant differences in radial or tibial mean speed of soundZ scores by age (prepubertal versus pubertal/postpubertal). In conclusion, a high percentage of patients treated with glucocorticoids for infantile spasms have a low radial speed of soundZ score later in life. Long-term follow-up can help to prevent and treat impairments in bone density, especially in non-weight-bearing organs.

[Nontuberculous mycobacterial lymphadenitis with an emerging pathogen and a novel management approach]

Nontuberculous mycobacterial infections in immunocompetent children usually presents as chronic lymphadenitis involving the neck and face. Mycobacterium avium complex is the most common pathogen, although recent series found Mycobacterium haemophilum, to be a major cause of chronic lymphadenitis in otherwise healthy children. The authors describe a 9-month-old baby who presented with a 4-month history of preauricular lymphadenitis. Mycobacterial culture yielded Mycobacterium haemophilum. A no-intervention approach was chosen. At the 6-month follow-up, the swelling had ameliorated and the skin showed a small scar with near-normal overlying skin color. A literature review of the clinical manifestations and diagnosis of Mycobacterium haemophilum lymphadenitis and of the different management options for nontuberculous mycobacterial lymphadenitis in otherwise healthy children is presented.

Breast asymmetry during adolescence: physiologic and non-physiologic causes

BACKGROUND

Pathologic breast conditions are rare in childhood and adolescence. The spectrum of breast disease in the pediatric age group is different from that in adults, and most lesions are benign.

OBJECTIVES

To describe the causes and characteristics of breast asymmetry in adolescents with normal endocrine profiles and sexual development.

METHODS

The files of patients with a diagnosis of breast asymmetry referred to a tertiary pediatric center from 1990 to 2007 were reviewed for history and findings on physical examination with or without imaging, treatment and outcome.

RESULTS

Eleven patients aged 12.5 to 18 years were identified. The cause of the breast asymmetry was traced to unpreventable medical factors in eight patients (physiologic, Poland anomaly, scleroderma), preventable/iatrogenic factors in two patients (chest tissue biopsy, thoracic drain), and possible combined medical-iatrogenic factors in one patient (scoliosis treated with a body brace). All patients were referred for breast reconstruction after full breast development.

CONCLUSIONS

Severe breast asymmetry in adolescence may be due to congenital factors, diseases involving the breast tissue, or to the effects of medical treatment, and may have severe adverse psychological and social implications. To prevent iatrogenic breast asymmetry, physicians should be made aware of the sensitivity of the breast tissue and should avoid unnecessary tests/procedures that involve the chest wall. In most cases a precise medical history and physical examination can differentiate between physiologic and non-physiologic causes.

Chronic cheek lesions: an unusual manifestation of nontuberculous mycobacterial cevicofacial infection

The characteristics of nontuberculous mycobacteria cheek lesions in 7 children were reviewed. The lesions usually presented as nontender erythematous nodules and were associated with a positive purified protein derivate tuberculin skin test. Mycobacterium haemophilum was isolated in 4 cases (57%) and Mycobacterium avium complex in 3 (43%). Cytology and imaging were noncontributory. Resolution was prolonged.

Acute infantile liver failure due to mutations in the TRMU gene

Acute liver failure in infancy accompanied by lactic acidemia was previously shown to result from mtDNA depletion. We report on 13 unrelated infants who presented with acute liver failure and lactic acidemia with normal mtDNA content. Four died during the acute episodes, and the survivors never had a recurrence. The longest follow-up period was 14 years. Using homozygosity mapping, we identified mutations in the TRMU gene, which encodes a mitochondria-specific tRNA-modifying enzyme, tRNA 5-methylaminomethyl-2-thiouridylate methyltransferase. Accordingly, the 2-thiouridylation levels of the mitochondrial tRNAs were markedly reduced. Given that sulfur is a TRMU substrate and its availability is limited during the neonatal period, we propose that there is a window of time whereby patients with TRMU mutations are at increased risk of developing liver failure.

Multicenter long-term follow-up of children with idiopathic West syndrome: ACTH versus vigabatrin

BACKGROUND AND PURPOSE

Long-term follow-up of children with idiopathic West syndrome (WS) treated with adrenocorticotropic hormone (ACTH) or vigabatrin.

METHODS

Records of 28 normal magnetic resonance imaging (MRI) WS cases were reviewed for seizure development and cognitive outcome in relation to treatment type and lag.

RESULTS

Average age at disease onset was 5.5 months, and average lag time to treatment was 25 days. Fourteen patients were treated with ACTH (eight early and six late), and 14 with vigabatrin (without delay). Response rates were 88% for ACTH and 80% for vigabatrin. Short-term outcomes for seizure cessation and electroencephalography normalization were identical between the groups. In the long-term, early ACTH treatment was better than the rest combined. Average follow-up time was 9 years. A normal cognitive outcome was achieved in 100% of the early-ACTH group, 67% of the late-ACTH group and 54% of the vigabatrin group (P = 0.03). Seizures subsequently developed in 54% of the vigabatrin group, in 33% of the late ACTH group, and 0% of the early ACTH group (P < 0.05).

CONCLUSIONS

Idiopathic WS with normal MRI is associated with a good cognitive outcome. Early ACTH treatment, administered within 1 month, yields a better cognitive and seizure outcome than vigabatrin or late ACTH.

Mycobacterium haemophilum and lymphadenitis in immunocompetent children, Israel

The database of a major microbiology laboratory in Israel was searched to determine the prevalence of nontuberculous mycobacterial lymphadenitis in immunocompetent children. We observed a 4-fold increase in nontuberculous mycobacteria isolates during 1985–2006, which was attributable mainly to increased detection of Mycobacterium haemophilum starting in 1996.

Symptoms of migraine in the paediatric population by age group

The revised criteria of the International Headache Society (IHS) for paediatric headache do not differentiate among age groups. This study aims to determine if different symptoms of migraine are specific or typical of different age groups of children. The files of 160 children (79 boys, 81 girls, mean age 10.39 +/- 3.71 years) with migraine treated at the paediatric headache clinic of a tertiary centre were reviewed. The diagnosis was based on the criteria of the IHS (ICHD-II). The patients were divided by age into three groups according to educational status, < or =6 years (preschool, group 1), >6 to < or =12 years (elementary school, group 2) and >12 to < or =18 years (secondary school, group 3), and compared by symptoms and signs. Symptoms of migraine with and without aura were also compared. There was no significant difference among the groups in rates of unilateral headache, phonophobia, photophobia, awakening pain, nausea or worsening of pain during physical activity. The parameters found to be statistically significant were dizziness and duration of migraine, and aura which increased with time. Frequency of attacks increased with age. The single statistically significant parameter found to be more frequent in younger age was vomiting. The statistically significant parameters of nausea and duration of migraine were more frequent in migraine with aura compared with migraine without aura. In conclusion, most of the migraine symptoms included in the 2004 recommendations of the IHS are not typical for specific paediatric age groups, probably because brain maturity is a continuous process. A familial history of migraine is a frequent finding among all age groups and should be considered in the paediatric criteria, especially in younger children in whom diagnosis is more difficult. Vomiting may help the diagnosis of migraine in young children with a familial history of migraine.

Pertussis symptoms in adolescents and children versus infants: the influence of vaccination and age

This study compared the influence of age and immunization status on symptoms in pediatric patients with pertussis. The files of 60 children, aged 7 to 18 years and 20 infants aged up to 6 months, admitted to our pediatric hospital with a diagnosis of pertussis were reviewed. There were no between-group differences in day and night cough or vomiting. The older group had a longer mean interval to diagnosis than the infants, and the infant group had more symptoms of whooping cough, facial redness during cough, cyanosis, a higher white blood count, a higher percentage of lymphocytes, and more abnormal chest X-rays. Statistically significant differences were found between vaccinated and unvaccinated older children for whooping cough and white blood cell count. Daytime and nighttime coughs are common symptoms of pertussis in all pediatric age groups, regardless of vaccination status. High white blood count is related to immunization status, and percentage of lymphocytes is related to age. In infants, symptoms are more grave but are typical, leading to early diagnosis.

A novel PEX12 mutation identified as the cause of a peroxisomal biogenesis disorder with mild clinical phenotype, mild biochemical abnormalities in fibroblasts and a mosaic catalase immunofluorescence pattern, even at 40 degrees C

Mutations in 12 different PEX genes can cause a generalized peroxisomal biogenesis disorder with clinical phenotypes ranging from Zellweger syndrome to infantile Refsum disease. To identify the specific PEX gene to be sequenced, complementation analysis is first performed in fibroblasts using catalase immunofluorescence. A patient with a relatively mild phenotype of infantile cholestasis, hypotonia and motor delay had elevated plasma very long-chain fatty acids and bile acid precursors, but fibroblast studies revealed normal or only mildly abnormal peroxisomal parameters and mosaic catalase immunofluorescence. This mosaicism persisted even when the incubation temperature was increased from 37 degrees C to 40 degrees C, a maneuver previously shown to abolish mosaicism by exacerbating peroxisomal dysfunction. As mosaicism precludes complementation analysis, a candidate gene approach was employed. After PEX1 sequencing was unrewarding, PEX12 sequencing revealed homozygosity for a novel c.102A>T (p.R34S) missense mutation affecting a partially conserved residue in the N-terminal region important for localization to peroxisomes. Transfection of patient fibroblasts with wild-type PEX12 cDNA confirmed that a PEX12 defect was the basis for the PBD. Homozygosity for c.102A>T was identified in a second patient of similar ethnic origin also presenting with a mild phenotype. PEX12 is a highly probable candidate gene for direct sequencing in the context of a mild clinical phenotype with mosaicism and minimally abnormal peroxisomal parameters in fibroblasts.

Adolescent pertussis-induced partial arousal parasomnia

The aim of the study was to assess neurologic complications of pertussis infection. A file review of all children (age 7-18 years) in our hospital with serology-positive pertussis infection admitted from 1995 to 2005 yielded six patients with neurologic symptoms in whom electroencephalographic studies were performed. Data were collected on their clinical symptoms, electroencephalographic findings, final diagnosis, and outcome. The six patients accounted for 10% of all children diagnosed with pertussis during the study period. Their ages ranged from 10 to 15.5 years. All the children were referred by their primary physician because of a suspicion of epilepsy on the basis of parental reports of inefficient attempts to breathe during sleep accompanied by high-pitched sounds and sounds of suffocation, and sleepwalking. The children were amnesic for the episodes. However, findings on electroencephalogram taken during sleep were negative in all cases. The final diagnosis was partial arousal parasomnia. The symptoms of parasomnia disappeared with resolution of the symptoms of the pertussis infection. In conclusion, partial arousal parasomnia may be induced by pertussis infection. Further studies in larger groups are required to confirm this association.

Bordetella pertussis as a trigger of migraine without aura

This report describes a 10-year-old child in whom the clinical and serologic appearance of pertussis coincided with new-onset migraine without aura. The child's mother, who had a history of migraine, also complained of exacerbation of symptoms and was found to be positive for Bordetella pertussis. The migraine improved in both mother and child concomitant with the clinical improvement of symptoms of the pertussis infection. The possible molecular basis of pertussis as a trigger for migraine is discussed.

Mitochondrial myopathy, sideroblastic anemia, and lactic acidosis: an autosomal recessive syndrome in Persian Jews caused by a mutation in the PUS1 gene

We report the seventh case of autosomal recessive inherited mitochondrial myopathy, lactic acidosis, and sideroblastic anemia The patient, a product of consanguineous Persian Jews, had the association of mental retardation, dysmorphic features, lactic acidosis, myopathy, and sideroblastic anemia. Muscle biopsy demonstrated low activity of complexes 1 and 4 of the respiratory chain. Electron microscopy revealed paracrystalline inclusions in most mitochondria. Southern blot of the mitochondrial DNA did not show any large-scale rearrangements. The patient was found to be homozygous for the 656C-->T mutation in the pseudouridine synthase 1 gene (PUS1). Mitochondrial myopathy, lactic acidosis, and sideroblastic anemia is an oxidative phosphorylation disorder causing sideroblastic anemia, myopathy, and, in some cases, mental retardation that is due to mutations in the nuclear-encoded PUS1 gene. This finding provides additional evidence that mitochondrial ribonucleic acid modification impacts the phenotypic expression of oxidative phosphorylation disorders.

2-ethylhydracrylic aciduria in short/branched-chain acyl-CoA dehydrogenase deficiency: application to diagnosis and implications for the R-pathway of isoleucine oxidation

BACKGROUND

Isolated excretion of 2-methylbutyrylglycine (2-MBG) is the hallmark of short/branched-chain acyl-CoA dehydrogenase deficiency (SBCADD), a recently identified defect in the proximal pathway of L-isoleucine oxidation. SBCADD might be underdiagnosed because detection and recognition of urine acylglycines is problematic. Excretion of 2-ethylhydracrylic acid (2-EHA), an intermediate formed in the normally minor R-pathway of L-isoleucine oxidation, has not previously been described in SBCADD.

METHODS

Samples from four patients with 2-MBG excretion were analyzed by gas chromatography-mass spectrometry for urine organic acids, quantification of 2-MBG, and chiral determination of 2-methylbutyric acid. Blood-spot acylcarnitines were measured by electrospray-tandem mass spectrometry. Mutations in the ACADSB gene encoding SBCAD were identified by direct sequencing.

RESULTS

SBCADD was confirmed in each patient by demonstration of different ACADSB gene mutations. In multiple urine samples, organic acid analysis revealed a prominent 2-EHA peak usually exceeding the size of the 2-MBG peak. Approximately 40-46% of total 2-methylbutyric acid conjugates were in the form of the R-isomer, indicating significant metabolism via the R-pathway.

CONCLUSIONS

If, as generally believed, SBCAD is responsible for R-2-MBG dehydrogenation in the R-pathway, 2-EHA would not be produced in SBCADD. Our observation of 2-ethylhydracrylic aciduria in SBCADD implies that a different or alternative enzyme serves this function. Increased flux through the R-pathway may act as a safety valve for overflow of accumulating S-pathway metabolites and thereby mitigate the severity of SBCADD. Awareness of 2-ethylhydracrylic aciduria as a diagnostic marker could lead to increased detection of SBCADD and improved definition of its clinical phenotype.

Occult constipation: a common cause of recurrent abdominal pain in childhood

BACKGROUND

An estimated 10% of all children are subject to recurrent attacks of abdominal pain of unknown origin. When no organic cause is found, the working diagnosis is usually functional abdominal pain.

OBJECTIVES

To investigate the possible causative role of occult constipation.

METHODS

We defined occult constipation as the absence of complaints of constipation on initial medical history or of symptoms to indicate the presence of constipation. The diagnosis was made by rectal examination and/or plain abdominal X-ray.

RESULTS

Occult constipation was found to be the cause of RAP in 42.6% of children examined. Treatment consisted of paraffin oil and phosphate enema. In 82.84% of cases the abdominal pain subsided considerably or disappeared within 2 weeks to 3 months of treatment. On telephone interview of the parents at 1-1.5 years after discharge, 96.5% reported that both the abdominal pain and constipation had subsided or disappeared.

CONCLUSIONS

Occult constipation can be easily identified and treated in a large number of children with RAP who were diagnosed as having functional abdominal pain.

Clinical presentations of mitochondrial cardiomyopathies

To determine the clinical manifestations and interfamilial variability of patients diagnosed with a mitochondrial cardiomyopathy, we reviewed the charts of 14 patients with cardiomyopathy out of 59 patients with mitochondrial disorders who attended the mitochondrial disease clinic at Wolfson Medical Center from 1996 to 2001. All patients underwent a metabolic evaluation including blood lactate, pyruvate, carnitine, and amino acids and urine organic acids. Respiratory chain enzymes were assessed in 10 patients. The mitochondrial DNA (mtDNA) was assessed for mutations. The age at presentation ranged between 6 months and 24 years. Six of the patients died, 5 from heart failure. The cardiomyopathy was hypertrophic in 10 and dilated in 4. Conduction and rhythm abnormalities were present in 6. Eleven patients had family members with mitochondrial disorders. All the patients had additional involvement of one or more systems. Seven patients exhibited a deficiency of a respiratory chain enzyme in the muscle. The MELAS mtDNA point mutation (3243) was found in one patient. Blood lactic acid levels were increased in 5. Brain MRI abnormalities were observed in 4.

CONCLUSIONS

Mitochondrial dysfunction frequently affects the heart and may cause both hypertrophic and dilated cardiomyopathy. The cardiomyopathy is usually a part of a multisystem involvement and may rarely be isolated. The course may be stable for many years, but rapid deterioration may occur. Understanding the biochemical and genetic features of these diseases will enable us to comprehend the clinical heterogeneity of these disorders.