Infantile Tremor Syndrome With Movement Disorder: Current Perspective

Although infantile tremor syndrome is considered a rare entity, we present a typical case of this disorder. This case reinforces the association of infantile tremor syndrome with exclusive breastfeeding in infants and the absence of proper complementary feeding. A nine-month-old, irritable, listless, exclusively breastfed female presented with grade 2 malnutrition, tremors, hyperpigmentation, scarce scalp hair, and delayed developmental milestones. Laboratory investigations revealed macrocytic anemia and a low serum vitamin B12 value of 205 pg/dL. Cerebral and mild cerebellar atrophy were noted on the MRI brain scan. Accordingly, the patient was diagnosed with infantile tremor syndrome and treated with vitamin B12 and nutrient supplementation with zinc, magnesium, folic acid, and iron. The tremors improved and the child became responsive and interested in her surroundings. It is essential to recognize this condition at the earliest and initiate treatment. Basic interventions such as the promotion of proper nutrition, timely introduction of complementary feeding, and weaning practices are key factors in decreasing the incidence of this condition.

Visual outcomes of toxic optic neuropathy secondary to Ethambutol: A retrospective observational study from India, an endemic country

Purpose

Ethambutol (EMB) is one of the first-line drugs used for treating tuberculosis. Vision loss due to optic nerve toxicity is a well-known potential side effect of the drug. Our aim was to evaluate the clinical features and visual outcomes of patients with EMB optic neuropathy (EON).

Methods

A retrospective, observational, single-center study of all patients who were diagnosed to have EON during January 2017-December 2019 was done. All these patients were screened in the Department of Neuro-ophthalmology at a referral tertiary eye care institution in India. Clinical features, visual outcomes, and neuroimaging findings of these patients were analyzed.

Results

Two hundred and fifty-six eyes of 128 patients were included. Of these, 73 were male and 55 were female. Mean age was 50.55 ± 15 years. Mean visual acuity at presentation was 1.12 ± 0.45 logarithm of the minimum angle of resolution (logMAR). One hundred and forty three eyes had normal optic disk on presentation, 111 had disk pallor, and two eyes had disk edema. The most common field defect was central/paracentral scotoma (26.2%) followed by temporal defects (24.6%). Magnetic resonance imaging (MRI) brain and orbit showed optic nerve signals in 19.6% and chiasmal signals in 5.2%. At the final follow-up, a ≥2-line vision improvement was noted in 161 eyes (62.9%), which was statistically significant.

Conclusion

Multiple prognostic factors were analyzed to predict the visual recovery of EON. We observed that patients presenting with visual acuity worse than 6/60 had poor visual outcome and long duration of follow-up showed better visual recovery, proving the possibility of a gradual recovery pattern of EON. Interestingly, we found in our study that the chances of favorable visual outcome were directly proportionate to early diagnosis and cessation of EMB.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Magnetic resonance characterisation of primary Raynaud's phenomenon

The objective findings of phalangeal T2-weighted hyperintense and T1-weighted hypointense bone marrow signal on MRI without features of seronegative arthropathy or osteomyelitis may assist clinicians in making a diagnosis in the appropriate clinical context.

Vitamin B12 deficiency: case report and review of literature

Vitamin B12 deficiency in early childhood is an important cause of neurodevelopmental delay and regression. Most of these cases occur in exclusively breast-fed infants of deficient mothers. Symptoms and signs of vitamin B12 deficiency appear between the ages of 2 to 12 months and include vomiting, lethargy, failure to thrive, hypotonia, and arrest or regression of developmental skills. Approximately one half of this cases exhibit abnormal movements, variously described as tremors, twitches, chorea, or myoclonus. Urinary concentrations of methylmalonic acid and homocysteine are characteristically elevated in vitamin B12 deficiency. Hyperglycinuria is sometimes present. The early diagnosis and treatment of vitamin B12 deficiency is crucial for significant neurological impairment and long-term prognosis. Treatment with vitamin B12 corrects these metabolic abnormalities very rapidly (within a few days). Vitamin B12 supplementation of pregnant women may prevent neurological and neuroradiological findings of the infants. Because of the importance of vitamin B12 in the development of the foetal and neonatal brain, vegetarian and vegan mothers should be aware of the severe and not fully-reversible damages caused by insufficient nutritional intake of vitamin B12 during pregnancy and lactation. Therefore, efforts should be directed to prevent its deficiency in pregnant and breastfeeding women on vegan diets and their infants. It is also important to take the nutritional history of both infants and their mothers for the early prevention and treatment. Here an interesting case of vitamin B12 deficiency in a 10-month-old boy presented with psychomotor regression, hypotonia and lethargy.

Epidemiology of Hypoxic Community-Acquired Pneumonia in Children Under 5 Years of Age: An Observational Study in Northern India

BACKGROUND

Community-acquired pneumonia (CAP) is the leading cause of under-five mortality in India. An increased risk of mortality has been reported in cases of hypoxic pneumonia.

METHODS

The primary objective of this study was to assess the proportion of children aged 2-59 months, hospitalized with hypoxic CAP, as well as socio-demographic, clinical, and radiological features associated with it. The secondary objective was to determine the risk of mortality among hospitalized cases of hypoxic CAP. This prospective, observational study was conducted in four districts of Northern India, between January 2015 and April 2021. A hospital-based surveillance network was established. Inclusion criteria were as follows: (a) child between 2 and 59 months, (b) hospitalization with symptoms of WHO-defined CAP, (c) resident of project district, (d) illness of <14 days, and (e) child had neither been hospitalized for this illness nor recruited previously. Children whose chest x-rays (CXRs) were either unavailable/un-interpretable and those that received any dose of pneumococcal conjugate vaccine-13 were excluded. Hypoxic pneumonia was defined as oxygen saturation <90% on pulse oximetry or requiring oxygen supplementation during hospital stay.

RESULTS

During the study period, 71.9% (7,196/10,006) children of severe pneumonia were eligible for inclusion, of whom 35.9% (2,580/7,196) were having hypoxic pneumonia. Female gender and use of biomass fuel for cooking increased the odds of hypoxic CAP. Clinical factors like wheezing, pallor, tachypnea, low pulse volume, presence of comorbidity, general danger signs, severe malnutrition, and radiological finding of primary end-point pneumonia ± other infiltrates (PEP±OI) also increased the odds of hypoxic CAP in a conditional logistic regression model. Adjusted odds ratio for mortality with hypoxia was 2.36 (95% CI: 1.42-3.92).

CONCLUSION

Almost one-third of cases hospitalized with severe CAP had hypoxia, which increased chances of mortality. Besides known danger signs, certain newer clinical signs such as pallor and wheezing as well as PEP+OI were associated with hypoxic CAP. Therefore, objective assessment of oxygen saturation must be done by pulse oximetry in all cases of CAP at the time of diagnosis.

Automatic computer-aided analysis of optic disc pallor in fundus photographs

PURPOSE

Assessment of optic disc pallor in fundus photographs may be frequently misinterpreted due to the subjective nature of interpretation. We developed a fully automatic computer-aided detection (CAD) system for optic disc pallor using colour fundus photographs and evaluated the accuracy of the system.

METHODS

A newly proposed CAD system was developed for automated segmentation and image analysis of optic disc pallor, and a logistic regression model was developed for risk analysis. A total of 230 photographs with variable degree of optic disc pallor, and 123 normal optic discs confirmed by optical coherence tomography were tested for validation of the software. Sensitivity and specificity of the CAD system in automatic detection of optic disc pallor using colour fundus photographs were evaluated. The results of manual detection of optic disc pallor on fundus photographs by two independent ophthalmologists were compared with the efficacy of the CAD system.

RESULTS

The fully automated CAD system achieved a sensitivity of 95.3% and a specificity of 96.7% for detecting optic disc pallor in colour fundus images. The overall accuracy of the CAD system was 96.1%, which was superior to the results of manual detection by individual examiners.

CONCLUSIONS

We developed an automated CAD system that successfully detected optic disc pallor in fundus photographs. The proposed algorithm can assist the clinical judgement of ophthalmologists for detecting optic disc pallor in fundus photographs.

Breath-Holding Spells in Pediatrics: A Narrative Review of the Current Evidence

BACKGROUND

Breath-holding spells are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, evaluation, and management of children with breath-holding spells.

METHODS

A PubMed search was completed in Clinical Queries using the key term "breath-holding spells". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Breath-holding spells affect 0.1 to 4.6% of otherwise healthy young children. The onset is usually between 6 and 18 months of age. The etiopathogenesis is likely multifactorial and includes autonomic nervous system dysregulation, vagally-mediated cardiac inhibition, delayed myelination of the brain stem, and iron deficiency anemia. Breath-holding spells may be cyanotic or pallid. The former are usually precipitated by anger or frustration while the latter are more often precipitated by pain or fear. In the cyanotic type, the child usually emits a short, loud cry, which leads to a sudden involuntary holding of the breath in forced expiration. The child becomes cyanosed, rigid or limp, followed by a transient loss of consciousness, and a long-awaited inspiration and resolution of the spell. In the pallid type, crying may be minimal or "silent". The apneic period in the pallid type is briefer than that in the cyanotic type prior to the loss of consciousness and posture. The episode in the pallid type then proceeds in the same manner as a cyanotic spell except that the child in the pallid type develops pallor rather than cyanosis. In both types, the entire episode lasts approximately 10 to 60 seconds. The spells usually disappear spontaneously by 5 years of age.

CONCLUSION

Although breath-holding spells are benign, they can be quite distressing to the parents. Confident reassurance and frank explanation are the cornerstones of treatment. Underlying cause, if present, should be treated. Interventions beyond iron supplementation may be considered for children with severe and frequent breath-holding spells which have a strong impact on the lifestyle of both the child and family.

Dermatological manifestations in hemodialysis patients in Iran: A systematic review and meta-analysis

BACKGROUND

Dermatologic complications are common in patients with end-stage renal disease and also have a high diversity.

OBJECTIVES

This meta-analysis reviews prevalence of dermatological manifestations among hemodialysis patients in Iran.

MATERIALS AND METHODS

Using PubMed and NLM Gateway (for MEDLINE), Institute of Scientific Information (ISI), and SCOPUS as the main international electronic data sources, and Iran-Medex, Irandoc, and Scientific Information Database, as the main domestic databases with systematic search capability, we systematically searched surveys, papers, and reports on the prevalence of dermatological manifestations (until February 2016). Heterogeneity of reported prevalence's between studies was assessed using the Q test; overall prevalence of dermatological manifestations was estimated using random-effect meta-analysis model.

RESULTS

We found 1229 records; from them, a total of eight studies comprising 917 hemodialysis patients were included. In all of studies, skin discoloration, pruritus and xerosis have the highest prevalence. According to random-effect meta-analysis model, the pooled prevalence of skin discoloration, pruritus, ecchymosis, xerosis, and half-and-half nail in hemodialysis patients were 48.03% (95% CI: 45.09-51.01), 52.85% (95%CI: 49.23-56.47), 19.88 (95% CI: 17.57-22.19), 51.14% (95% CI: 48.25-54.02), and 18.50% (95% CI: 16.0-21.0), respectively.

CONCLUSIONS

his study shows that the prevalence of dermatological manifestations seems high among the hemodialysis patients in Iran, and skin discoloration, pruritus, and xerosis are more common.

A life threatening problem in infants: supratentorial epidural hematoma

Traumatic epidural hematoma (EDH) represents a rare head injury complication in infants. Its diagnosis can be quite challenging because its clinical presentation is usually subtle and nonspecific. Authors present a study on 30 infants with epidural hematoma (EDH) admitted in the Pediatric Department of Neurosurgery of the "Bagdasar-Arseni" Clinical Hospital in the period of 1990-2007 (17 years). The most common symptom was irritability, which occurred in 16 cases (53.3%), of our patients. Pallor in all cases (100%) and subgaleal hematoma in 20/30 (66.6%) of the patients. These were the most common clinical signs that occurred upon admission; both of them represent signs of significant clinical importance. Surgical evacuation via craniotomy was required in 26/30 (86.6%) of our patients, while 4/30 (13.3%) of the patients were managed conservatively. The mortality rate was 6.6% in our series, whilst the long-term morbidity rate was 3.3%. EDH in infants represents a life-threatening complication of head injury, which requires early identification and prompt surgical or conservative management depending on the patient's clinical condition, the size of EDH, and the presence ofa midline structure shift on the head's CT scan.