Congenital continuous retrograde basilar flow suggests type B interrupted aortic arch in a neonate: A case report

Reversed flow in the basilar artery can be acquired or congenital. Acquired reversed flow in the basilar artery can result from acute thrombosis of the basilar artery or retrograde vertebral artery flow. Congenital continuous retrograde basilar artery flow has not been described. We report a 2-day-old male presenting with hypocalcemic seizures which led us to obtain a Duplex echoencephalogram. An echocardiogram was subsequently ordered. In the coronal plane through the anterior fontanelle, retrograde flow was seen in the basilar artery and the right vertebral artery. In the axial plane through the temporal window, the flow was anteroposterior in both posterior communicating arteries. In the posterior cerebral arteries, the flow was retrograde in the P1 segment and anterograde in the P2 and P3 segments. An interrupted aortic arch was suspected. The echocardiogram showed a large perimembranous ventricular septal defect with bidirectional shunting, a hypoplastic and bicuspid aortic valve, an aortic arch interrupted between the left common carotid artery and the left subclavian artery (type B interrupted aortic arch), and a 5 mm patent ductus arteriosus with predominant right to left flow. Because of the patency of the large patent ductus arteriosus, our patient showed no sign of posterior circulation insufficiency. Prostaglandin E1 therapy was initiated immediately. Diagnosis of DiGeorge syndrome was proven. The infant underwent interrupted aortic arch repair and anterograde flow was established in the basilar artery. We conclude that congenital asymptomatic continuous retrograde flow in the basilar artery and left vertebral artery is a medical emergency as it implies the presence of type B interrupted aortic arch with large patent ductus arteriosus in a neonate.

The Impact of Phenobarbital on the Ability of Electroencephalogram to Predict Adverse Outcome in Asphyxiated Neonates during Therapeutic Hypothermia

OBJECTIVE

 Classification of electroencephalogram (EEG) background has been established to predict outcome in neonates with hypoxic ischemic encephalopathy (HIE). However, the impact of phenobarbital therapy on the predictability of EEG background has not been studied. Our objective is to determine if EEG background after treatment with phenobarbital during therapeutic hypothermia (TH) remains a good predictor for brain injury in neonates with HIE.

STUDY DESIGN

 This is a single-center, retrospective study of consecutive neonates with HIE who underwent TH and EEG monitoring from October 2017 to March 2021. Per institutional protocol, all infants received a dose of prophylactic phenobarbital and bumetanide therapy at the onset of TH for sedative and neuroprotective measures. The initial 3 hours of EEG background activity was classified based on national guidelines. Infants were separated into two groups based on EEG background scores: group 1 (normal-mild, n = 30) and group 2 (moderate-severe, n = 36). Brain magnetic resonance imaging (MRI) results were scored based on the National Institute of Child Health and Human Development (NICHD) criteria. Adverse outcomes were defined as death before MRI or NICHD brain injury score > 1A.

RESULTS

 Infants in group 2 had lower Apgar scores at 5 minutes of age, severe acidemia, moderate to severe encephalopathy score, and earlier initiation of EEG monitoring than infants in group 1. Moderate to severe EEG background score was associated with presence of brain injury on MRI or death (p = 0.003), and this association remained significant even after adjustment for independent risk factors (odds ratio = 56.24 [95% confidence interval = 1.841-1718], p = 0.021).

CONCLUSION

 Phenobarbital therapy does not affect the ability of EEG to predict adverse outcome in infants with perinatal asphyxia during TH.

KEY POINTS

· EEG has a clinical utility for predicting outcome in neonates with hypoxia-ischemia.. · Phenobarbital therapy is commonly used in neonates, and may impact EEG background findings.. · In spite phenobarbital therapy, moderate to severe EEG background abnormalities in infants with perinatal asphyxia during TH remain an excellent predictor for poor outcome..

Echoencephalography of Möbius sequence: A congenital cranial dysinnervation disorder with brainstem calcifications

BACKGROUND AND PURPOSE

Möbius sequence (MBS) previously known as Möbius syndrome is a rare nonprogressive developmental defect of the rhombencephalon leading to congenital abducens (VIth) and facial (VIIth) nerve palsy. Echoencephalography is the first, safe, noninvasive, and cost-effective imaging modality available at bedside. No study on the use of echoencephalography in neonates for the diagnosis of MBS has been previously reported.

METHODS

In this single tertiary center study, more than 18,000 neonates underwent echoencephalographic imaging over the span of two decades. Imaging was performed through the anterior, posterior, and lambdoid fontanelles. All neonates found to have calcifications of brainstem tegmental nuclei underwent additional imaging studies. Each neonate with MBS was carefully examined by the same investigator.

RESULTS

Five neonates were shown to have punctate, bilateral, symmetrical tegmental pontine calcifications through all three acoustic windows. These calcifications extended caudally in most patients, and rostrally in 2 patients. Brainstem hypoplasia was best seen through the posterior fontanelle. Three out of five infants were noted to have brainstem hypoplasia with straightening of the floor of the fourth ventricle. In two children, facial collicular bulges and hypoglossal eminences were present. All five infants fulfilled clinical diagnostic criteria of MBS. In addition, a wide array of cerebral defects is identified. Echoencephalographic findings were confirmed by other imaging modalities.

CONCLUSION

Knowledge of echoencephalographic features of MBS should improve its early recognition. A detailed description of the various imaging phenotypes of MBS is necessary to characterize the etiology of this heterogeneous congenital cranial dysinnervation disorder.

Use of duplex echoencephalography to evaluate brain death in children: A novel approach to the diagnosis

BACKGROUND AND PURPOSE

Brain death is defined as the irreversible cessation of brain function with a known etiology. This study aims to establish the value of duplex echoencephalography (DEG) in children fulfilling clinical brain death diagnostic criteria.

METHODS

DEG must show intracranial brain structures. Power Doppler is used to assess venous flow when feasible. Color Doppler patterns in all major arteries are assessed. Spectral analysis of arterial flow is divided into four grades: grade 1: inverted flow during entire diastole with time average peak velocity (TAPV) less or equal to zero; grade 2: disappearance of the inverted diastolic flow at the end of diastole; grade 3: oscillating pattern in early diastole; and grade 4: no diastolic flow with systolic blip. To fulfill diagnosis of brain death, brain perfusion must be lost for 30 minutes.

RESULTS

DEG is performed in 41 pediatric patients. In infants, loss of venous flow occurs regardless of the etiology. Grade 1 is the most common arterial color flow pattern and TAPV is always below zero. A pulsatile color flow is associated with three other types of flow patterns (grades 2-4). TAPV is not calculated, when there is loss of diastolic flow. Diagnosis of brain death is validated using nuclear brain scan in 4 patients. Two have a grade 1 flow pattern, while the other two have a grade 4 flow pattern.

CONCLUSIONS

In children, DEG following a strict protocol can be used to confirm diagnosis of brain death in the appropriate clinical setting.

The Novel Use of a Synthetic Amino Acid Analog in the Management of Menkes' Disease

Menkes' disease is a rare X-linked neurodegenerative disorder due to an ATPA7 mutation. This mutation results in a defective copper transport into the lumen of the trans-Golgi network (TGN) of all tissues, except the liver. As the liver remains effective in transporting copper into the TGN, parenteral copper administration is successful in normalizing copper and ceruloplasmin levels. In addition, such treatment improves function of cuproenzymes in the nucleus, cytosol, and mitochondria. However, ATPA7 mutation results in a deficient dopamine β-hydroxylase, a cuproenzyme needed to convert dopamine to norepinephrine (NE). Here, we present the novel use of the synthetic amino acid analog, droxidopa, a prodrug to NE in the management of Menkes' disease. In our 6-year-old Menkes' disease patient treated with daily parenteral copper infusion, we studied clinical features and urine catecholamines levels at baseline and after initiating droxidopa therapy. NE deficiency at baseline was associated with inattention, hypothermia, and dysautonomia. After correction of NE deficiency, the child's symptoms improved. Epinephrine levels remained low. In Menkes' disease, NE deficiency persists after normalization of copper and ceruloplasmin levels. Droxidopa therapy is successful in correcting NE levels and improving quality of life. Further studies are needed.

A Curious Case of Progressive Respiratory Failure Due to Anterior Spinal Cord Infarction in an Adolescent Boy: A Case Report and Review of the Literature

Clinical features of cervical spontaneous spinal cord infarctions (SSCIs) remain poorly described in the literature. The goal of this article was to improve recognition of cervical SSCI, a rare but life-threatening condition. We presented a 15-year-old adolescent male patient who developed neck pain with weakness and numbness in all four limbs half an hour after returning from a hike in the late afternoon. The next morning, he was brought to the emergency room due to persistent weakness, vomiting, and progressive respiratory distress. He was promptly intubated for airway protection. Pupils were 2 mm, sluggishly reactive, and all four extremities were flaccid. He was found to have anterior spinal cord syndrome. Light touch (brush) was normal down to the posterior aspect of shoulders. Cervical magnetic resonance imaging (MRI) showed increased T2/short-tau inversion recovery and decreased T1 signal of the anterior spinal cord from C3 to C7. Four days later, MRI of the spinal cord showed restricted diffusion of anterior spinal cord consistent with radicular artery territory infarction. The work-ups for infection, thrombosis, and cardioembolism were all negative. Three months later, he still had incomplete Brown-Séquard's syndrome, as position sense was preserved. There was in addition bilateral loss of pain and temperature sensations below the clavicles. MRI showed cervical myelomalacia most severe between C3 and C5. Furthermore, MRI showed changes in C3–C4 intervertebral disc, consistent with a fibrocartilaginous embolism via retrograde arterial route into the anterior spinal artery. This article demonstrates the importance of recognizing subtle clinical clues leading to cervical SSCI diagnosis.

Fulminating Autoimmune Demyelination with Optic Neuropathy in a Case of Pediatric Cerebral Adrenoleukodystrophy: Case Report and Review of the Literature

X-linked adrenoleukodystrophy (ALD) is a leukodystrophy characterized not only by progressive loss of myelin in the central nervous system due to dysmyelination, but also by acute, subacute, or chronic inflammatory demyelination. This results in the phenotypic variability of cerebral ALD (cerALD), which is independent of the genotype. In this article, we reported a fulminant presentation with fluctuating encephalopathy and visual loss in a patient with childhood onset cerALD. Brain MRI showed symmetric confluent occipito-temporal demyelination with severe disruption of the blood–brain barrier and prechiasmal optic neuropathy. The patient's cerebral spinal fluid (CSF) demonstrated an elevated IgG index, myelin basic proteins, and oligoclonal bands. Within 48 hours of receiving immunomodulating therapy, the patient's symptoms of psychomotor slowing, visual impairment, and areflexia partially resolved. High plasma C26:0 levels and high ratios of C24/22 and C26/22 were diagnostic of ALD. It has been shown that environmental factors play an important role in the inflammatory demyelination responsible for the severe phenotypes of cerALD.

Acute Arterial Ischemic Stroke in a Treated Child with Hunter's Syndrome: A Case Report and Review of the Literature

Enzyme replacement therapy (ERT) has limited therapeutic effects on neurologic, skeletal, and cardiovascular pathophysiology. We report an acute right-sided flaccid hemiparesis in an 11-year-old boy with the severe neuronopathic phenotype of Hunter's syndrome who was receiving weekly idursulfase ERT. Due to his psychomotor regression and epilepsy, his presentation to the hospital was delayed. Computed tomography scan of brain showed no acute changes or hemorrhage. Stroke code was not called as patient was already outside of the time window for tissue plasminogen activator (tPA) therapy. Brain magnetic resonance imaging (MRI) showed diffuse cortical and deep atrophy consistent with his baseline neurological status and restricted diffusion in the territory of the left-middle cerebral artery (MCA) consistent with recent infarction. T1-weighted MRI revealed low signal intensity of the left insular cortex, as well as volume loss, consistent with previous undiagnosed stroke in the same vascular territory. In addition, MR angiogram (MRA) demonstrated left terminal M1 segment MCA occlusion. Echocardiogram showed aortic root dilation and moderate aortic valve insufficiency. Patient was also noted to have bacteremia related to port infection. ERT is limited by blood–brain barrier and the underlying glycosaminoglycans (GAGs) extracellular tissue accumulation which produces a proinflammatory state. GAG and bacterial lipopolysaccharide (LPS) are known to activate toll-like receptor 4 (TLR-4). GAGs released in the extracellular space of intracranial vessels induce inflammation by activating the TLR-4 pathway which is exacerbated by bacterial LPS contributing to focal arteritis. Our case suggests the importance of GAGs in the activation of the TLR-4 pathway as a cause of stroke in Hunter's syndrome.

Gratification Disorder as an Early Marker of Rett Syndrome: Two Pediatric Case Reports

Gratification disorder (GD) is a form of stereotyped posturing with mechanical pressure applied to the genitalia without manual manipulation and is generally considered benign. Here, we describe two patients who exhibited GD. Both were later diagnosed with Rett syndrome via genetic sequencing. In both patients, GD preceded the onset of the hallmark hand stereotypies of Rett syndrome. We therefore conclude that GD is not as benign as previously assumed and in fact can be an early sign of Rett syndrome. Further studies are needed to evaluate the prevalence of GD in Rett girls with the MECP2 genotype.

Low function of natural killer cells in treated classic Menkes disease

BACKGROUND

Menkes disease (MD) is a rare lethal X-linked, multisystem disorder of copper metabolism resulting from mutations in the ATP7A gene. Features such as Ehlers- Danlos syndrome, trichopoliodystrophy, urologic and skeletal changes have been reported. We present a case of classic MD treated with copper infusions who suffered from persistent natural killer (NK) cell dysfunction.

CASE

A 2-year-old, Caucasian male child presented at 8-month-old of age with persistent hypotonia, kinky hair and developmental regression. Diagnosis of MD was based on low serum levels of copper [5 mg/dl (18-37)] and ceruloplasmin [18 ug/dl (75-153)] and gene-targeted deletion/duplication analysis performed by the reference laboratory. Brain MRI showed mild hypoplasia of the cerebellar vermis and vascular tortuosity typical of MD. Copper chloride treatment was immediately initiated. The child became more alert with excellent eye contact and purposeful movements. The child was hospitalized for recurrent respiratory infections, each time caused by enterovirus as confirmed by multiplex polymerase chain reaction (PCR). Extensive immunologic studies were negative, except for a severe NK cell dysfunction on multiple occasions (0.6 NK lytic Units; N > 2.6).

CONCLUSION

We postulate that NK cell dysfunction in a classic MD can be explained by the deficient incorporation of copper in the endoplasmic reticulum resulting in an abnormal Fenton chemistry within phagosomes.

Guillain-Barré syndrome with unilateral peripheral facial and bulbar palsy in a child: A case report

Guillain-Barré syndrome is characterized by progressive motor weakness, sensory changes, dysautonomia, and areflexia. Cranial nerve palsies are frequent in Guillain-Barré syndrome. Among cranial nerve palsies in Guillain-Barré syndrome, facial nerve palsy is the most common affecting around half of the cases. Facial palsy in Guillain-Barré syndrome is usually bilateral. We describe a pediatric Guillain-Barré syndrome variant presenting with unilateral peripheral facial palsy and dysphagia. A 5-year-old boy had progressive lower extremity weakness and pain 3 days prior to onset of unilateral peripheral facial palsy. On presentation, diagnosis of Guillain-Barré syndrome was supported by areflexia and albuminocytologic dissociation. His condition deteriorated with a decline in his respiratory effort and inability to handle secretions. He was given non-invasive ventilation to prevent worsening of his acute respiratory failure. Brain and spine magnetic resonance imaging scans showed enhancement of the left bulbar nerve complex and anterior and posterior cervical nerve roots with gadolinium. Treatment with intravenous immunoglobulin led to an uneventful clinical course with partial recovery within 2 weeks. In summary, Guillain-Barré syndrome should be considered as a possible cause of unilateral peripheral facial palsy. Guillain-Barré syndrome patients with facial nerve and bulbar palsy require close monitoring as they are at risk of developing acute respiratory failure. Early intervention with intravenous immunoglobulin may benefit these patients. Magnetic resonance imaging findings may lend support to early intervention.

Infantile Lhermitte-Duclos Disease Treated Successfully With Rapamycin

Lhermitte-Duclos disease is a rare hamartomatous tumor of the cerebellum resulting from a mutation in the phosphatase and tensin homolog (PTEN) gene: it has been reported in fewer than 10 infants. Rapamycin treatment has not yet been described in Lhermitte-Duclos disease. The infant underwent shunt placement shortly after birth for aqueductal stenosis. Her clinical progression included failure to thrive, seizures, episodes of decerebrate posturing, loss of respiratory drive, and pituitary insufficiency from mass effect. The characteristic "tiger stripe" sign on imaging prompted diagnosis. Rapamycin therapy was initiated at 18 months. Within 5 months, our patient has become responsive to her surroundings and had return of spontaneous breathing. Repeat magnetic resonance imaging (MRI) reveals lack of brainstem compression or distortion of pituitary stalk. Rapamycin should be considered in cases of Lhermitte-Duclos disease where surgical removal may not be an option, as in our case where the cerebellum was entirely involved.

Intermediate filament protein accumulation in motor neurons derived from giant axonal neuropathy iPSCs rescued by restoration of gigaxonin

Giant axonal neuropathy (GAN) is a progressive neurodegenerative disease caused by autosomal recessive mutations in the GAN gene resulting in a loss of a ubiquitously expressed protein, gigaxonin. Gene replacement therapy is a promising strategy for treatment of the disease; however, the effectiveness and safety of gigaxonin reintroduction have not been tested in human GAN nerve cells. Here we report the derivation of induced pluripotent stem cells (iPSCs) from three GAN patients with different GAN mutations. Motor neurons differentiated from GAN iPSCs exhibit accumulation of neurofilament (NF-L) and peripherin (PRPH) protein and formation of PRPH aggregates, the key pathological phenotypes observed in patients. Introduction of gigaxonin either using a lentiviral vector or as a stable transgene resulted in normalization of NEFL and PRPH levels in GAN neurons and disappearance of PRPH aggregates. Importantly, overexpression of gigaxonin had no adverse effect on survival of GAN neurons, supporting the feasibility of gene replacement therapy. Our findings demonstrate that GAN iPSCs provide a novel model for studying human GAN neuropathologies and for the development and testing of new therapies in relevant cell types.

Pediatric gliomatosis cerebri mimicking acute disseminated encephalomyelitis

Gliomatosis cerebri (GC) is a diffuse infiltrating glial neoplasm of astrocytic origin. GC in children is rare and difficult to diagnose, often presenting with a variety of signs and symptoms that may mimic encephalitis. We discuss here the presentation and diagnosis of GC in 2 children who were initially suspected to have acute disseminating encephalomyelitis. In this report we underscore the limitations of relying on clinical presentation and neuroimaging as well as the essential role of pathologic evaluation for the diagnosis of GC in children.

A novelRSK2 (RPS6KA3) gene mutation associated with abnormal brain MRI findings in a family with Coffin–Lowry syndrome

Coffin-Lowry syndrome (CLS) is an X-linked mental retardation syndrome caused by defects in the RSK2 gene. We have identified a CLS family with four patients in two generations. The patients in this family, a mother and her three children (a male and two females), all have severe mental retardation with the typical CLS phenotype. In addition, brain MRI studies on the three siblings revealed abnormalities in deep subcortical white matter, thinning of the corpus callosum, hypoplastic cerebellar vermis, and asymmetry of the lateral ventricles. The degree of severity of the MRI findings correlated with the severity of mental retardation in the patients. Extensive mutation screening was performed on the entire RSK2 gene in this family. Twenty-two exons including the intron/exon junctions were amplified by PCR and subsequently sequenced on both strands. A novel mutation, a two-nucleotide insertion (298 ins TG), was identified. The insertion creates a stop codon at codon 100, resulting in a 99 amino acid truncated RSK2 protein. All patients tested have the same mutation, and no other mutation could be found in the RSK2 gene from the proband. The mutation was confirmed by PCR/RFLP. X-chromosome inactivation assay on the female patients revealed significant skewing toward inactivation of the normal RSK2 allele. Thus, this novel mutation is likely to be responsible for the unusual clinical presentation in this family, which includes full phenotypic expression in females and unique brain MRI abnormalities. The pathological function of the mutation and genotype/phenotype correlation between the mutation and this unusual clinical presentation await further clarification.

Cardiofaciocutaneous syndrome (CFC) with congenital peripheral neuropathy and nonorganic malnutrition: an autopsy study

Many phenotypic manifestations have been reported in cardiofaciocutaneous (CFC) syndrome, but none, to date, are pathognomonic or obligatory. Previous histopathological studies reported findings in skin and hair; no autopsy studies have been published. We report the clinical and autopsy findings of a 7-year-old boy with severe CFC syndrome and malnutrition of psychosocial origin. Manifestations of CFC, reported previously, included macrocephaly and macrosomia at birth; short stature; hypotonia; global developmental delays; dry, sparse thin curly hair; sparse eyebrows and eyelashes; dilated cerebral ventricles; high cranial vault; bitemporal constriction; supraorbital ridge hypoplasia; hypertelorism; ptosis; exophthalmos; depressed nasal bridge; anteverted nostrils; low-set, posteriorly-rotated, large, thick ears; decayed, dysplastic teeth; strabismus; hyperelastic skin; wrinkled palms; keratosis pilaris atrophicans faciei; ulerythema ophryogenes; hyperkeratosis; gastroesophageal reflux; and tracheobronchomalacia. Additional findings, not previously reported, include islet cell hyperplasia, lymphoid depletion, thymic atrophy and congenital hypertrophy of peripheral nerves with onion bulb formations. Although the islet cell hyperplasia, lymphoid depletion, and thymic atrophy are nonspecific findings that may be associated with either CFC or malnutrition, the onion bulb hypertrophy is specific for a demyelinating-remyelinating neuropathy. These findings implicate congenital peripheral neuropathy in the pathogenesis of the developmental delays, feeding difficulties, respiratory difficulties, ptosis and short stature in this case. Additional studies of other cases of CFC are needed.

Elevated plasma gamma-aminobutyric acid (GABA) levels in autistic youngsters: stimulus for a GABA hypothesis of autism

BACKGROUND

Autistic Disorder is an early-onset developmental disorder with severe lifelong impact on social functioning, communication, and behavior. There is currently no marker or cure. The pathophysiology and etiology are obscure. Evidence for abnormal gamma-aminobutyric acid (GABA) function in Autistic Disorders is limited. A few case-reports and small studies have reported differences in GABA levels in plasma, platelets, and urine, compared to controls. Further studies on abnormalities of GABA function in Autistic Disorder are warranted.

MATERIAL/METHODS

Plasma GABA levels were measured using a new and sensitive technique, based on gas chromatography/mass spectrometry, in a small group of youngsters with Autistic Disorder and Attention-Deficit/Hyperactivity Disorder. Participants were outpatients between ages 5-15, satisfying modern criteria for these disorders.

RESULTS

Elevated plasma GABA levels were found in youngsters with Autistic Disorder. Psychotropic medications did not seem to affect plasma GABA levels in this study. Plasma GABA levels decreased with age.

CONCLUSIONS

Elevated plasma GABA levels may be a biochemical marker of Autistic Disorder. This study supports the hypothesis that GABAergic mechanisms play a role in the etiology or pathophysiology of Autistic Disorder. However, the hypothesis remains unspecified owing to lack of research. Future studies on the clinical associations of seizure disorders, mood disorders, and catatonia in autistic people may provide the necessary data to formulate a coherent theory of GABA dysfunction in Autistic Disorder. More trials of medication with known or suspected effects on GABA function are warranted.

Pontine cryptococcoma in a nonimmunocompromised individual: MRI characteristics

The case of a pontine cryptococcoma in a nonimmunocompromised, previously healthy 16-year-old boy is presented. The patient had slowly progressive brainstem signs with right cranial nerves V, VII, and VIII palsies, and contralateral corticospinal and spinothalamic deficits. Magnetic resonance images (MRI) revealed, within the right pons, a 1-cm diameter round mass lesion, hypointense on T1-weighted images, hyperintense on T2-weighted images, and with rim enhancement after infusion of gadopentetate dimeglumine. This is the only report of the MRI findings in an isolated pontine cryptococcoma in an immunocompetent patient. Early recognition of this specific MRI pattern is essential, because complete recovery can be achieved with prompt antifungal treatment.

Altered antioxidant enzyme activities in children with a serious adverse experience related to valproic acid therapy

Specific oxidative metabolites of valproic acid (VPA) have been associated with the clinically defined toxicity of the drug. To investigate the role of enzymatic detoxification in clinical toxicity, we compared activities of five antioxidant enzymes in 15 patients with a serious adverse experience (SAE) related to VPA therapy, to enzyme activities measured in 35 patients with good clinical tolerance of VPA, and 50 healthy, age-matched subjects. These enzymes included glutathione peroxidase (GSH-Px), glutathione reductase (GSSG-R), glutathione transferase, superoxide dismutase, and catalase in erythrocytes; and GSH-Px in plasma. We also determined levels of Se, Cu, and Zn, trace elemental cofactors for these enzymes, in plasma from each individual. In patients with a VPA-associated SAE, GSH-Px was significantly depressed and GSSG-R was significantly elevated relative to values for the other groups. Selenium and zinc concentrations were lower in SAE patients than in controls. These findings may indicate a role for selenium dependent antioxidant activity in individual susceptibility to an SAE related to VPA therapy.

Clinical manifestations of mitochondrial DNA depletion

OBJECTIVE

We studied five new patients with mitochondrial DNA (mtDNA) depletion to better define the clinical spectrum of this disorder.

BACKGROUND

mtDNA depletion has been associated with myopathy or hepatopathy, or both, in infants and young children. Involvement of the CNS and peripheral nervous system has not been clearly established.

METHODS

We reviewed the clinical course and performed morphologic, biochemical, and genetic analyses of muscle samples from five patients.

RESULTS

Age at onset ranged from 3 months to 5 years, and one patient survived until age 10 1/2 years. Two patients had laboratory and clinical features reminiscent of dystrophinopathy, two had evidence of brain involvement, and two had peripheral neuropathy. Muscle biopsy specimens in all patients showed abundant ragged-red fibers. Biochemistry showed cytochrome c oxidase deficiency in all patients tested and decreased activities of other respiratory chain complexes in some.

CONCLUSIONS

Inheritance appeared to be autosomal recessive, suggesting that mutations in nuclear DNA are responsible for mtDNA depletion. mtDNA depletion should be considered in children with mitochondrial disorders of uncertain etiology, and criteria for diagnosis are proposed.

Mitochondrial encephalopathies

Although no single neurological manifestation is specific of mitochondrial encephalopathies, several neurological syndromes are clearly suggestive of the diagnosis. Muscle biopsy for histochemicals, biochemical, and mitochondrial DNA studies is frequently necessary to establish diagnosis of mitochondrial encephalopathy presenting with such neurological syndromes. Mitochondrial encephalopathies most frequently result from nuclear gene defects and biochemical studies are frequently helpful in reaching a specific diagnosis. Various therapeutic interventions are beneficial in selected cases.

Cellular distribution of lesions in Batten disease

One of the characteristic manifestations of chronic neuronal lipofuscinosis (Batten disease) is a marked predisposition for epileptic seizures. The management of these seizures is very difficult. The present study was initiated to determine what mechanisms could account for the seizure disorder. Tissue was examined from a patient with a history of Batten disease that was histologically verified. Reduced silver and Golgi impregnations were done on the parietal cortex of the patient. There was no evidence of the marked dendritic abnormalities seen in classic epileptic foci. Instead there was marked swelling and dilatation of the axon hillock and initial segment. This finding suggested that inhibition of these pyramidal neurons was markedly attenuated due to disruption of initial segment inhibitory synapses. Studies are continuing to determine if the GABA decreases seen in Batten disease may in part be due to trophic sequences brought about by loss of these critical inhibitory synapses.

Free radicals, anticonvulsants, and the neuronal ceroid-lipofuscinoses

The relationship between free radicals and scavenger enzymes, and the disorders called the neuronal ceroid-lipofuscinoses, has long been an argumentative one. Recent evidence would seem to support the fact that such a relationship might exist but that it is indirect. The relationship does not seem due to an inborn error of free radical scavenger enzyme metabolism. Anticonvulsants play a role, as they influence free radical generating systems. At this juncture, no one has studied the relationship of anticonvulsant therapy, neuronal ceroid-lipofuscinosis, and the free radical-scavenging enzyme system, and their interplay. We have studied a large number of patients with epilepsy who are on either monotherapeutic or polytherapeutic regimens of most of the common anticonvulsants. We have found excessive free radical production in many of these patients, ranging from minor effects in the simpler anticonvulsants when used monotherapeutically, to more complex changes in polytherapeutic combinations. Likewise, we have found subtle and inconsistent findings in the free radical-scavenging enzyme system in a variety of examples of neuronal ceroid-lipofuscinosis. When refractory seizure disorders stimulate the vigorous use of polytherapy with a variety of free radical-facilitating anticonvulsants, free radical production becomes deleterious. Likewise, in certain types of neuronal ceroid-lipofuscinosis, polypharmacy with anticonvulsants, by enhancing the production of free radicals or suppressing scavenging enzymes, tends to be deleterious and induces a worsening in the disease process.

Cerebellar infarct: late complication of the Fontan procedure?

Cardiac disease is present in approximately 30% of children with stroke. Other case reports have documented stroke in patients who have previously undergone the Fontan procedure for correction of tricuspid atresia. Most of these strokes have occurred in the immediate postoperative period. There has been one report of a cerebral infarction 3 1/2 months after surgery. We report a child with superior cerebellar artery distribution infarction after undergoing the Fontan procedure 24 months previously. Previous reports of stroke in patients having undergone the Fontan procedure and possible etiologies for these strokes are discussed. We believe our patient had the longest procedure-to-stroke interim yet reported.

Glutathione peroxidase deficiency and childhood seizures

4 children with intractable seizures, repeated infections, and intolerance to anticonvulsants had evidence of glutathione peroxidase deficiency. 2 had low intracellular enzyme activity but normal blood selenium and high plasma glutathione peroxidase concentrations. The other 2 had low intracellular glutathione peroxidase activity with low circulating glutathione peroxidase and selenium concentrations. The clinical state of the children improved after discontinuation of anticonvulsant medication and selenium substitution.

Maternal-fetal transport of vitamin K1 and its effects on coagulation in premature infants

We conducted a prospective study to determine (1) the maternal-fetal vitamin K1 transport in premature infants after vitamin K1 was given to the mothers antenatally and (2) the vitamin K1 effects on blood coagulation in the babies. Women in labor at less than or equal to 34 weeks of gestation were randomly selected to receive antenatal vitamin K1, 5 mg given intramuscularly (vitamin K1 group), or no vitamin K1 (control group). Eight infants, including one set of twins, were in the vitamin K1 group and six in the control group. Vitamin K1 concentrations were higher in the vitamin K1 group than in the control group (p = 0.06). Activated partial thromboplastin time was prolonged, and factor II coagulation activity and factor II antigen were proportionately decreased in cord plasma in both groups. The average ratio of factor II coagulation activity to antigen was not decreased in either group. Protein induced by vitamin K absence-II (PIVKA-II) was not detectable in any cord plasma sample in either group. These findings support previous reports that the decreased vitamin K-dependent coagulation activity in premature infants is the result of reduced synthesis of precursor proteins, rather than the result of vitamin K deficiency, and suggest that additional vitamin K1 is not likely to improve coagulation activity. Among those infants who underwent cranial ultrasonography, all four in the vitamin K1 group and one of five in the control group had mild intraventricular hemorrhage. Studies of a larger number of patients are necessary before it can be established that maternal antenatal administration of vitamin K1 results in improvement of coagulation and the prevention of intraventricular hemorrhage in premature infants.

Stimulation and inhibition of prolactin release from rat pituitary lactotrophs by the cholinomimetic carbachol in vitro. Influence of hormonal environment and intercellular contacts

The prolactin (PRL) response of perifused rat pituitary tissue to the cholinomimetic agent carbachol (CARB) was studied under various in vitro conditions. Perifusion of freshly removed hemipituitaries from 14-day-old rats with CARB did not affect basal PRL release. When established in organ culture for 3 days in a serum-free chemically defined medium, there was a significant increase of PRL release in response to CARB. This PRL releasing activity of CARB depended on the hormonal environment of the culture medium: supplementation of the culture medium with triiodothyronine (T3) and the glucocorticoid dexamethasone (DEX) completely reversed the PRL releasing activity of CARB into an inhibition of PRL release. In dispersed pituitary cells from immature rats, cultured as three-dimensional reaggregates, a similar reciprocal responsiveness to CARB existed which was also determined by T3 and DEX. This reciprocal responsiveness to CARB was preserved in adult female rats but was shifted to a more prominent inhibition in adult male rats. Tumoral PRL secreting GH3 cells, cultured as aggregates, always responded in an inhibitory way, irrespective of the hormonal environment. The expression of the reciprocal responses, in particular of the inhibitory pathway to CARB was dependent on close cellular contacts, as the inhibitory response of normal and tumoral pituitary cells, cultured as isolated cells on Cytodex beads, was completely absent. The stimulatory response of normal lactotrophs, cultured as isolated cells was, although attenuated, still preserved. The present data suggest that there exists a reciprocal responsiveness of normal lactotrophs to cholinomimetics depending on the hormonal environment and close cellular associations. In contrast, only inhibitory PRL responses occur in GH3 tumoral lactotrophs, which are not dependent on thyroid and glucocorticoid hormones.

Imaging through the posterior fontanelle

Sonography of the posterior fontanelle is easily performed and yields exquisite details of the outline of the major structures of the posterior fossa and the tentorium. These structures are more clearly outlined through the posterior fontanelle than via the traditional anterior fontanelle approach, probably because the longitudinal axis of the sonographic beam passing through the posterior fontanelle is nearly perpendicular to the outline of the aqueduct of Sylvius, the fourth ventricle, the brain stem, the cerebellar vermis, and the tentorium. Several cases are presented briefly to illustrate the sonographic appearance of the normal and abnormal infratentorial anatomy via a posterior fontanelle approach.

History of the cerebrohepatorenal syndrome of Zellweger and other peroxisomal disorders

The history of the peroxisomal disorders (PDs), including the most frequent variant, the cerebrohepatorenal syndrome of Zellweger, can be divided into four phases. During the first phase, lasting from 1964 to 1972, the clinical and pathologic manifestations of Zellweger's syndrome (ZS) were explored and delineated. In 1973 it was found that ZS is due to the absence of peroxisomes in hepatocytes and renal tubular epithelial cells. With this discovery the second phase of ZS was initiated, which in subsequent years led to discovery of various defective peroxisomal functions. During the third phase, beginning in 1980, various other peroxisomal disorders were discovered, among them infantile Refsum's disease, hyperpipecolic acidemia, neonatal adrenoleukodystrophy, and rhizomelic chondrodysplasia punctata. During 1986 the etiology of the various PDs was identified by complementation studies, marking the beginning of the fourth phase of the history of the peroxisomopathies. It was found that ZS, neonatal adrenoleukodystrophy, and rhizomelic chondrodysplasia punctata represent different genetic entities, while Refsum's disease and hyperpipecolic acidemia are alleviated variants of ZS. Moreover, results of preliminary studies indicate that cells of one case of ZS may complement the cells of another ZS case, which could indicate genetic heterogeneity of ZS.

Intracranial hemorrhage and cerebral angiopathic changes in a suicidal phenylpropanolamine poisoning

A 27-year-old man had an intracerebral hemorrhage and angiographic evidence of cerebral vasculitis after suicidal ingestion of 13 nasal decongestant tablets containing phenylpropanolamine (PPA). Toxicology screen and gas chromatography demonstrated PPA in the urine. Phenylpropanolamine is found in many over-the-counter preparations, but physicians should be aware of PPA's side effects and should be cautious about prescribing this potentially hazardous drug to suicidal patients.

Alpha-adrenergic stimulation of growth hormone release in perifused rat anterior pituitary reaggregate cell cultures

It has been previously shown that beta-adrenergic agonists stimulate growth hormone (GH) release from perifused rat anterior pituitary cell aggregates cultured in serum-free defined medium for 5-6 days. The present data show that the natural beta-agonist epinephrine (EPI) stimulates GH release through an additional alpha-adrenergic mechanism. The involvement of this mechanism was suggested by the following findings. The intrinsic activity of EPI, at concentrations greater than 10 nM, was significantly higher than that of isoproterenol (ISO) in stimulating GH release. Phenylephrine (PHE), a specific agonist of alpha 1-adrenergic receptors, provoked a significant rise of GH release. The effect was concentration dependent between 100 nM and 10 microM. The stimulatory effect of EPI and PHE was lowered, respectively blocked, by low concentrations of the potent alpha 1-adrenergic antagonist prazosin. The EPI-induced GH release could be totally blocked only by administration of both alpha- and beta-receptor antagonists. Under the same conditions and using concentrations up to 1 microM, the alpha 2-agonist clonidine had no or only a slight stimulatory effect; dopamine had no effect. Administration of both PHE and ISO resulted in a more than additive stimulation of GH release. The effectiveness of PHE but not clonidine, together with the high potency of the alpha 1-blocker prazosin suggest that the alpha-adrenergic receptor is predominantly of the alpha 1-subtype. When tested on days 1, 3, 6 and 8 in culture, both alpha- and beta-adrenergic responses appeared to be higher in the presence of the glucocorticoid dexamethasone compared to the responses in the absence of dexamethasone.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of neuropsychological evaluation in the medical management of subdural empyema

Subdural empyema is in itself an uncommon complication of infection in childhood and localization of the infection to the parafalcine area is rare. This paper presents a case study of a teenager with subdural empyema resulting from paranasal sinusitis, who presented as a parafalcine syndrome and was treated successfully without neurosurgical intervention. Results of repeat neuropsychological evaluation (premorbid, 17 days into treatment, and after six months), correlated with changes seen on serial CT scanning during treatment and follow up. More importantly, the neuropsychological evaluation was clinically more sensitive than the traditional neurological examination in assessing changes in cortical integrity during the course of recovery. Thus, neuropsychological evaluation proved to be a valuable supplement to the neurological examination in exploring morbidity and assisting in treatment decision making in the management of subdural empyema.