A novel missense variant at the NKX2-1 homeodomain prevents the transcriptional rescue by TAZ

Background Brain-Lung-Thyroid syndrome (BLTS) is caused by NKX2-1 haploinsufficiency, resulting in chorea/choreoathetosis, respiratory problems and hypothyroidism. Genes interacting with NKX2-1 mutants influence its phenotypic variability. We report a novel NKX2-1 missense variant and the modifier function of TAZ/WWTR1 in BLTS. Methods A child with BLTS underwent NGS panel testing for thyroid disorders. His family was genotyped for NKX2-1 variants and screened for germline mosaicism. Mutant NKX2-1 was generated and transactivation assays were performed on three NKX2-1 target gene promoters. DNA binding capacity and protein-protein interaction were analyzed. Results The patient had severe BLTS and carried a novel missense variant c.632A>G (p.N211S) in NKX2-1, which failed to bind to specific DNA promoters, reducing their transactivation. TAZ co-transfection did not significantly increase transcription of these genes, although the variant retained its ability to bind to TAZ. Conclusions We identify a novel pathogenic NKX2-1 variant that causes severe BLTS and is inherited through germline mosaicism. The mutant lacks DNA binding capacity, impairing transactivation and suggesting that NKX2-1 binding to DNA is essential for TAZ-mediated transcriptional rescue.

Mechanical Thrombectomy for Acute Stroke in a 2-Month-Old Patient and Review of the Literature in Infancy

Mechanical thrombectomy (MT) in pediatric stroke is supported by studies in adults, but there is controversy regarding younger patients. The main growth of intracranial vessels occurs up to 2 years when there can be more difficulties in MT.Description of the MT performed in a 2-month-old patient-the youngest infant published to date. We also review the literature on MT for stroke in infants.A 2-month-old patient presented with an awakening stroke secondary to an occlusion of the M1 segment of the left middle cerebral artery. A successful MT was performed with an aspiration device without clinically significant complications. An etiological study was completed, and neuroimaging showed focal cerebral arteriopathy. The 3-month outcome was excellent: the pediatric modified Rankin score was 0.Including this case, MT for acute stroke has been reported in only 10 infants. MT was successful in 90%, mostly using adult conventional stent retrievers. There were complications only in patients with mechanical circulatory support (MCS) devices; three patients died due to hemorrhagic transformation after MT and one patient died due to recurrent ischemic stroke.MT seems effective and safe in infants similarly to other pediatric ages. In children under 2 years of age, the presence of comorbidities requiring MCS devices is the main factor underlying poor prognosis.

Carey-Fineman-Ziter Syndrome: A MYMK-Related Myopathy Mimicking Brainstem Dysgenesis

Carey-Fineman-Ziter syndrome is a congenital myopathy associated with mutations in the MYMK gene. It is clinically defined by the combination of hypotonia, Moebius-Robin sequence, facial anomalies and motor delay. Historically it was considered a brainstem dysgenesis syndrome. We provide detailed information of a Spanish boy with compound heterozygous variants in MYMK gene. A muscle biopsy performed as a toddler only disclosed minimal changes, but muscle MRI showed severe fatty infiltration of gluteus muscles and to a lesser extent in adductors magnus, sartorius and soleus muscles. Clinical course is fairly static, but the identification of new well characterized genetic cases will help to delineate the complete phenotype.

Rare Variants in 48 Genes Account for 42% of Cases of Epilepsy With or Without Neurodevelopmental Delay in 246 Pediatric Patients

In order to characterize the genetic architecture of epilepsy in a pediatric population from the Iberian Peninsula (including the Canary Islands), we conducted targeted exome sequencing of 246 patients with infantile-onset seizures with or without neurodevelopmental delay. We detected 107 variants in 48 different genes, which were implicated in neuronal excitability, neurodevelopment, synaptic transmission, and metabolic pathways. In 104 cases (42%) we detected variant(s) that we classified as pathogenic or likely pathogenic. Of the 48 mutated genes, 32 were dominant, 8 recessive and 8 X-linked. Of the patients for whom family studies could be performed and in whom pathogenic variants were identified in dominant or X-linked genes, 82% carried de novo mutations. The involvement of small copy number variations (CNVs) is 9%. The use of progressively updated custom panels with high mean vertical coverage enabled establishment of a definitive diagnosis in a large proportion of cases (42%) and detection of CNVs (even duplications) with high fidelity. In 10.5% of patients we detected associations that are pending confirmation via functional and/or familial studies. Our findings had important consequences for the clinical management of the probands, since a large proportion of the cohort had been clinically misdiagnosed, and their families were subsequently able to avail of genetic counseling. In some cases, a more appropriate treatment was selected for the patient in question, or an inappropriate treatment discontinued. Our findings suggest the existence of modifier genes that may explain the incomplete penetrance of some epilepsy-related genes. We discuss possible reasons for non-diagnosis and future research directions. Further studies will be required to uncover the roles of structural variants, epimutations, and oligogenic inheritance in epilepsy, thereby providing a more complete molecular picture of this disease. In summary, given the broad phenotypic spectrum of most epilepsy-related genes, efficient genomic tools like the targeted exome sequencing panel described here are essential for early diagnosis and treatment, and should be implemented as first-tier diagnostic tools for children with epilepsy without a clear etiologic basis.

TAZ/WWTR1 Mediates the Pulmonary Effects of NKX2-1 Mutations in Brain-Lung-Thyroid Syndrome

CONTEXT

Identification of a frameshift heterozygous mutation in the transcription factor NKX2-1 in a patient with brain-lung-thyroid syndrome (BLTS) and life-threatening lung emphysema.

OBJECTIVE

To study the genetic defect that causes this complex phenotype and dissect the molecular mechanism underlying this syndrome through functional analysis.

METHODS

Mutational study by DNA sequencing, generation of expression vectors, site-directed mutagenesis, protein-DNA-binding assays, luciferase reporter gene assays, confocal microscopy, coimmunoprecipitation, and bioinformatics analysis.

RESULTS

We identified a mutation [p.(Val75Glyfs*334)] in the amino-terminal domain of the NKX2-1 gene, which was functionally compared with a previously identified mutation [p.(Ala276Argfs*75)] in the carboxy-terminal domain in other patients with BLTS but without signs of respiratory distress. Both mutations showed similar protein expression profiles, subcellular localization, and deleterious effects on thyroid-, brain-, and lung-specific promoter activity. Coexpression of the coactivator TAZ/WWTR1 (transcriptional coactivator with PDZ-binding motif/WW domain-containing transcription regulator protein 1) restored the transactivation properties of p.(Ala276Argfs*75) but not p.(Val75Glyfs*334) NKX2-1 on a lung-specific promoter, although both NKX2-1 mutants could interact equally with TAZ/WWTR1. The retention of residual transcriptional activity in the carboxy-terminal mutant, which was absent in the amino-terminal mutant, allowed the functional rescue by TAZ/WWTR1.

CONCLUSIONS

Our results support a mechanistic model involving TAZ/WWTR1 in the development of human congenital emphysema, suggesting that this protein could be a transcriptional modifier of the lung phenotype in BLTS.

LAMA2-related congenital muscular dystrophy complicated by West syndrome

BACKGROUND

Mutations in the LAMA2 gene cause autosomal recessive laminin α2 related congenital muscular dystrophy. In patients with partial laminin α2 deficiency the phenotype is usually milder than in those with absent protein. Apart from the typical white matter abnormalities, there is an increased risk of cerebral complications such as epilepsy and mental retardation, despite a structurally normal brain.

METHODS/RESULTS

We present a patient with primary partial laminin α2 deficiency due to a homozygous novel LAMA2 missense mutation who developed West syndrome in his first year of life. To our knowledge, this combination has not previously been reported. A 5 year-old boy exhibited global hypotonia with generalized muscle weakness from birth. At 8 months of age he presented infantile spasms and an EEG finding of hypsarrhythmia. Seizures were controlled in a few weeks with intramuscular synthetic ACTH, followed by valproic acid. Two years later antiepileptic medication was withdrawn. He achieved unsupported walking at the age of 4, but his cognitive status corresponded to a 2 year-old child. Epilepsy has not recurred and brain MRI showed the typical white matter abnormalities without associated neuronal migration defects.

CONCLUSION

This report widens the clinical spectrum of cerebral manifestations related with mutations in LAMA2. The beginning of a severe epileptic encephalopathy modifies the natural history of the disease.

Clinical features and molecular characterization of a patient with muscle-eye-brain disease: a novel mutation in the POMGNT1 gene

Muscle-eye-brain disease is a congenital muscular dystrophy characterized by structural brain and eye defects. Here, we describe a 12-year-old boy with partial agenesis of corpus callosum, ventriculomegaly, flattened brain stem, diffuse pachygyria, blindness, profound cognitive deficiencies, and generalized muscle weakness, yet without a clear dystrophic pattern on muscle biopsy. There was no glycosylation of α-dystroglycan and the genetic screening revealed a novel truncating mutation, c.1545delC (p.Tyr516Thrfs*21), and a previously identified missense mutation, c.1469G>A (p.Cys490Tyr), in the protein O-mannose beta-1,2-N-acetylglucosaminyltransferase 1 (POMGNT1) gene. These findings broaden the clinical spectrum of muscle-eye-brain disease to include pronounced hypotonia with severe brain and eye malformations, yet with mild histopathologic changes in the muscle specimen, despite the absence of glycosylated α-dystroglycan.

Levetiracetam-induced reversible autistic regression

Levetiracetam is a commonly prescribed antiepileptic drug, and is generally well tolerated, but can eventually cause behavioral disturbances. These disturbances seem more frequent in children and in patients with a previous psychiatric history. We report on reversible autistic regression induced by levetiracetam in a 6-year-old girl with spastic cerebral palsy, mild cognitive deficiency, and focal epilepsy. She was diagnosed with pervasive developmental disorder, and demonstrated mild to moderate impairment in pragmatic language and interactions with peers. After the introduction of levetiracetam, she developed stereotypies, and her social and communicative skills deteriorated severely. She also exhibited mood lability. When the medication was discontinued, a dramatic response occurred, with a complete resolution of new abnormal findings. Levetiracetam can provoke unusual behavioral adverse effects in certain patients who are biologically more vulnerable.

Cognitive and behavioral profile in females with epilepsy with PDCH19 mutation: two novel mutations and review of the literature

Mutation in the protocadherin 19 (PCDH19) gene is an increasingly recognized cause of epilepsy in females. This disorder is frequently associated with mental retardation and psychiatric features. We describe two unrelated females with novel PCDH19 missense mutations. One was de novo, and the other was inherited from her unaffected father. Both had mild mental impairment but had remarkable behavioral problems. We reviewed the cognitive and behavioral profiles of previously reported PCDH19-positive cases. Intellectual disability appeared in 75% of patients, ranging from borderline to severe. More than half of the individuals presented behavioral disturbances, which could be divided into two different groups: autistic and non-autistic. The majority of patients with autism already had some degree of cognitive impairment. It appears that seizures tend to diminish or even stop in adolescence, so non-epileptic problems can become the most important and disabling issue in adult patients with PCDH19 mutation.

Dental management of oral self-mutilation in neurological patients: a case of congenital insensitivity to pain with anhidrosis

Hereditary sensory and autonomic neuropathy type IV is a rare disease characterized by fever episodes, mental retardation of different intensity, recurrent episodes of fever secondary to anhidrosis, little or no perspiration and congenital insensitivity to pain. Oral self-mutilation is also a characteristic sign. In this article, we present the case of an infant, aged 22 months, who showed these clinical characteristics and was treated with a dental device to prevent the patient from injuring her tongue. This device consisted of two acrylic splints joined at the back in the posterior sector, it provided an anterior open bite and allowed the infant to breathe through her mouth. The lesions of the patient had improved after using the device but the patient died due to the medical problem. Neuropathies treatment is a great challenge for medical teams. Dentists should form part ot these teams because of the bucal implications that may appear. Different appliances can be designed in order to solve the special problems each case may present.

Syringomyelia secondary to posthemorrhagic hydrocephalus in a preterm infant

Syringomyelia is often associated with hydrocephalus, especially in Chiari malformations, but it has never been described as a complication of posthemorrhagic hydrocephalus after preterm birth. We report on a premature infant who presented this exceptional association. He was born at 29 weeks of gestational age and suffered a grade 3 intraventricular hemorrhage. Progressive ventricular dilatation developed despite repeated lumbar punctures, and a ventricular reservoir had to be inserted for cerebrospinal fluid drainage. Two weeks later he presented a flaccid, areflexic paralysis of his left upper limb. Magnetic resonance imaging disclosed a remarkable tetraventricular hydrocephalus and a cervical hydrosyringomyelia expanding from the C(5) to T(1) segments. After shunt surgery, the cephalic perimeter stabilized, and the infant began to move his arm. On follow-up, a minimal paresis of the left hand persisted. This case highlights an unreported outcome of posthemorrhagic hydrocephalus. In this context, syringomyelia should be included in the differential diagnosis of any infant with who presents segmental signs of acute or progressive onset.

Macrophagic myofasciitis in childhood: a controversial entity

Macrophagic myofasciitis is an unusual inflammatory myopathy, which has been almost exclusively reported in French adults with diffuse arthromyalgias and asthenia. It is characterized by an infiltrate of densely packed macrophages, with granular periodic-acid-Schiff positive content, on muscle biopsies at the site of vaccination. The presence of aluminum inclusions in these macrophages points to an inappropriate reaction to aluminum used as an adjuvant in some vaccines. Although in adults this entity is well defined, less than 15 cases have been reported in children. This study describes seven children, younger than 3 years of age, with typical lesions of macrophagic myofasciitis on quadriceps muscle biopsy. In five cases, biopsies were performed to exclude mitochondrial pathology. All the children developed hypotonia and motor or psychomotor delay, associated with others symptoms. Abnormal neuroimaging was evident in six cases. Spectrometry studies detected elevated levels of aluminum in muscle in three of four cases tested. Despite the wide use of vaccines in childhood, macrophagic myofasciitis was rarely observed in children and its characteristic histologic pattern could not be correlated with a distinctive clinical syndrome.

Clinical and histologic changes in the follow-up of a congenital myopathy

A 19-year-old woman was born with congenital hypotonia, generalized weakness, and dysmorphic features. A muscle biopsy performed at age 18 months found that type I fibers were smaller and more numerous than type II fibers, and she was diagnosed with congenital fiber type disproportion. She grew up with moderate motor impairment, but after a stationary period her weakness progressed gradually and she developed a severe ophthalmoplegia. When she was 18 years old a second muscle biopsy still indicated the predominance of type I fibers but also the presence of central nuclei and strong oxidative enzyme activity in the center of most of the fibers; this was compatible with centronuclear myopathy. The diagnostic reconsideration raises questions about the pathogenesis of these diseases and the recognition of congenital fiber type disproportion as a distinct nosologic entity.

Congenital disorder of glycosylation (CDG) type Ie. A new patient

CDG Ie is caused by a deficiency of dolichol-phosphate-mannose synthase 1 (DPM1), an enzyme involved in N-glycan assembly in the endoplasmic reticulum. Three proteins are known to be part of the synthase complex: DPM 1, DPM2 and DPM3. Only mutations in DPM1, the catalytic subunit, have been described in three families. One was homozygous for the c274C>G (R92G) mutation in DPM1 and two others were compound heterozygous for R92G and a c628delC deletion or a c331-343del13, respectively. Clinical features were a severe infantile encephalopathy, early intractable seizures, acquired microcephaly, and some dysmorphic features. We report a patient with milder symptoms: microcephaly, dysmorphic features, developmental delay, optic atrophy, and cerebellar dysfunction without cerebellar atrophy. The patient is homozygous for a new mutation in exon 9 of the DPM1 gene (c742T>C (S248P)). Our findings extend the spectrum of CDG Ie.

Vertebral artery fibromuscular dysplasia: an unusual cause of stroke in a 3-year-old child

Fibromuscular dysplasia (FMD) is a systemic arteriopathy which tends to affect renal arteries followed by cervicocranial vessels. It can lead to cerebral infarction if cephalic arteries are involved. FMD is an unusual cause of stroke in childhood that generally affects the carotid area. Only four cases of vertebral FMD and subsequent stroke have been reported previously and we present the youngest patient of all. A healthy 3-year-old female was admitted to Hospital Doce de Octubre in Madrid, Spain with cerebellar infarction. Angiography disclosed basilar artery thrombosis and typical signs of FMD in both vertebral arteries. No other angiographic alteration was noted in the other vessels studied. Her phenotype and other investigations were unremarkable. The patient was treated with anti-aggregation therapy (aspirin) and the outcome was excellent. Investigation of the occurrence in childhood of this kind of arteriopathy may lead to clarification of its natural history and speculation about its unclear pathogenesis.

Symptomatic epidural lipomatosis of the spinal cord in a child: MR demonstration of spinal cord injury

We report a case of symptomatic epidural lipomatosis in an 8-year-old girl with Cushing's syndrome secondary to longstanding high-dose steroid therapy for Crohn's disease. MR imaging of the spine revealed massive diffuse epidural fat compressing the entire spinal cord with T2 prolongation in the central gray matter of the cord suggesting ischemic myelopathy. This finding has not been previously demonstrated on imaging. A proposed mechanism underlying these findings is discussed.

Spontaneous carotid and vertebral artery dissection in children

Carotid and vertebral artery dissection is a rarely reported cause of stroke in childhood and adolescence, especially if there is not a direct trauma to the neck. Four patients, under 15 years of age, presented with an internal carotid artery dissection, and one patient presented with a vertebral artery dissection. They were all making a physical effort when the event occurred. The five patients had ischemic symptoms, and in two the events were preceded by transient ischemic attacks. Headache was associated in four patients. The diagnosis was made by magnetic resonance imaging and angiography, which included transfemoral angiography in two patients. All improved before leaving the hospital, and four patients did not suffer recurrent episodes. The diagnostic accuracy of artery dissection has improved because of noninvasive neuroimaging testing, but it should still be suspected in any pediatric ischemic stroke, especially if there is headache or cervical pain associated.

Differences in the composition of the subgingival microbiota of two periodontitis populations of different geographical origin. A comparison between Spain and The Netherlands

The purpose of this study was to compare the subgingival microbiota of two geographically distinct patient populations using identical clinical and bacteriological methods. Adult patients with a diagnosis of periodontitis were consecutively selected according to pre-defined clinical criteria. Microbiological samples were taken from the deepest four sites with bleeding. The samples were plated on blood agar plates, for the determination of the total anaerobic counts and identification of specific bacterial pathogens, and on TSBV and McConkey for isolation of Actinobacillus actinomycetemcomitans and enteric rods, respectively. Thirty-one patients in Spain and 30 patients in The Netherlands were selected. Both patient groups showed similar clinical characteristics, both in terms of age, gender and periodontal clinical variables. A. actinomycetemcomitans was significantly more prevalent (23.3% vs. 3.2%) in the Dutch group, while Porphyromonas gingivalis was significantly more prevalent (64.5% vs. 36.7%) in the Spanish group. Bacteroides forsythus and most commensal periodontal pathogens showed similar prevalences, except Peptostreptococcus micros that was significantly more frequent in the Dutch group (96.7% vs. 74.2%). In summary, the subgingival microbiota from the Spanish group was characterised by a high prevalence of P. gingivalis and low of A. actinomycetemcomitans, while the flora from the Dutch group was characterised by a high prevalence of A. actinomycetemcomitans and P. micros.

[Acute cerebrovascular accident associated with drepanocytosis complicated by pneumococcal meningitis in two children]

INTRODUCTION

Between 6% and 17% of the patients with drepanocytosis will have an acute cerebrovascular accident (ACVA). Precipitating factors have been described including bacterial meningitis, upper respiratory tract obstruction, dehydration, intense exercise, postoperatively, and hypoxia due to altitude.

CLINICAL CASES

We report two Negro children with drepanocytosis who, at the ages of 8 and 20 months, had pneumococcal meningitis complicated by an ACVA. The 20 month old boy had been previously diagnosed as having drepanocytosis; the 8 month old girl was diagnosed when she was admitted to hospital with meningitis. In both cases the clinical features of the ACVA were focal epileptic seizures followed by hemiplegia. On cranial CT and MR regions of focal ischaemia of the hemisphere were observed. The boy of 20 months made an excellent recovery with no long term sequelae. The 8 month old girl had severe permanent sequelae: hemiparesia, blindness, mental deficiency and epileptic encephalopathy.

CONCLUSIONS

We present two Negro children with drepanocytosis who had ischemic ACVAs, a common complication of the disease, during the course of pneumococcal meningitis but with very different clinical courses. Recent increases in immigration will mean that previously rare illnesses will be more commonly seen in our environment, and should be considered in the differential diagnosis.

Mitochondrial diseases in children: neuroradiological and clinical features in 17 patients

Mitochondrial diseases result from structural, biochemical or genetic defects of mitochondria, which contain the respiratory chain. They usually affect children and young adults. We report the CT and MRI findings in 17 patients under 14 years of age, the youngest reported to date, with various mitochondrial diseases. Although imaging studies may be normal negative in the early stages, follow-up usually shows many abnormalities, which depend on clinical status and the disease. We have recognised a spectrum of findings that can be divided into four patterns: nonspecific myelin lesions (8/17); grey-matter nuclei involvement (6/17); a leukodystrophic pattern; and calcification of the brain (1/17), although mixed forms, particularly myelin and grey-matter lesions are frequent.

[Spinal cord infarction/ischemia]

INTRODUCTION

Vascular pathology is considered to be uncommon, with a much lower incidence than cerebral vascular pathology.

PATIENTS AND METHODS

We reviewed the clinical histories of patients with a clinical diagnosis of spinal cord infarction-ischemia attended by the Neurology Department and the Neuropaediatric section at our centre between 1990 and 1997. We analyzed the clinical and investigational findings and compared them with those in the literature.

RESULTS

We studied the cases of 12 patients (nine adults and three children). There was only one case in which no etiological factor of any type was found to justify the spinal vascular condition. All the children had had surgery to repair coarctation of the aorta. The most frequent clinical presentation was of paraparesis-paraplegia with signs of involvement of the anterior spinal artery. MR was done in all cases, except in that of an adult who was diagnosed on arteriography. The adults were studied by means of MR during the first 24-48 hours after onset of the condition. In five cases this was normal. In two of the latter cases, MR was repeated and alterations were seen in one whilst the other was not satisfactory. In the other three cases MR was not repeated since in two there was clinical improvement and in the other excessive technical problems. On discharge the children had not improved at all although the six adults improved completely or almost completely.

CONCLUSIONS

In general, our findings are comparable to those in the literature. We consider that the diagnosis is basically clinical and differential diagnosis should be made with other spinal disorders. MR is helpful, although early use does not show changes which help in diagnosis.

[Gamma-sarcoglycanopathy:two new cases in a gypsy family family in Spain]

INTRODUCTION

Included under the heading of limb girdle muscular dystrophy is a heterogeneous group of myopathies which share the same phenotype characteristics. The illness is of early onset, progressive and basically involves muscles of the shoulder and pelvic girdles. Recent identification of muscle proteins and the genes which codify them has led to new classification of these conditions according to their genetic characteristics. It is currently accepted that there are two major groups: the dominant and recessive forms. The latter includes type 2C limb girdle muscular dystrophy associated with chromosome 13, where the gene for gamma-sarcoglycan is found. This protein belongs to the glycoprotein complex associated with dystrophin. Recently a new mutation has been identified, the C283Y, exclusive to the Gypsy race, which affects this gene and therefore the alterations in gamma-sarcoglycan produced by it.

CLINICAL CASE

We describe two patients, Gypsy brothers, who complained of myopathy, which they had had for some years, compatible with this condition and in whom the C283Y mutation had recently been detected.

CONCLUSIONS

We describe another Spanish Gypsy family, all members of which have the characteristic mutation. We emphasize the importance of genetic studies in all cases of myopathy which have not been fully diagnosed.

[Spinal tumors in infancy. A report of 48 cases]

INTRODUCTION

Spinal tumours in infancy are an infrequent oncological disorder. The clinical features, usually of insidious onset, are alterations in gait and a painful spine.

OBJECTIVE

To analyze the different histological types of spinal tumours seen in infancy and their form of presentation in our series.

PATIENTS AND METHODS

We reviewed the clinical histories of 48 patients with intraspinal tumours, aged under 15 years, whose reports of histological diagnosis had been sent to our centre.

RESULTS

Of the patients studied, 17 were girls (35.4%) and 31 boys (64.6%) with an average age of 7.7 years. The histological diagnoses made most frequently were astrocytomas (22.9%) and lipomas (18.8%) followed by metastases (12.5%), ependymomas (8.3%) and Edwing's sarcoma (8.3%). The clinical features were present prior to diagnosis for between 1 and 6 months in 13 patients, and for less than one month in 9 patients. The presenting symptoms were alterations in gait and back pain in most patients. Exploratory tests were related to the involvement of long vias and second motor-neurone lesions. The main topographical findings were: in the axial plane the lesions were extradural (23 patients) and in the sagittal plane there was dorsal involvement (34 patients).

CONCLUSIONS

Insidious, progressive alterations in gait together with continuous, nocturnal back pain are valuable data when a serious spinal disorder is to be suspected. Early diagnosis should be based on neuroimaging tests, essentially MR, in the patients in whom spinal cord involvement is considered.

[Vascular malformations of the central nervous system in children]

OBJECTIVE

To present the experience of vascular malformations (VM) of the central nervous system (CNS) in children obtained in our centre. Since these lesions do not often present clinically in childhood, there are few series described in the literature.

PATIENTS AND METHODS

We made a retrospective review of the clinical histories of patients with VM of the CNS shown on MR, angiography and/or morbid anatomy, who were aged 15 years or under. Patients with Sturge-Weber or Von Hippel-Lindau syndromes were excluded.

RESULTS

We describe 32 patients with VM of the CNS. Twenty four had arteriovenous malformations (AVM), 5 had cavernous malformations (CM), 2 had malformations of Galeno's vein (MGV) and one patient had a congenital fusiform arterial aneurysm. Twenty two children (68%) presented clinically with hemorrhages. This was the form of presentation in 20 patients with AVM. In 4 of the 5 patients with CM the first sign was epileptic crisis. The two patients with MGV presented with macrocephaly, in one neonate it was associated with heart failure and in on older baby with hydrocephaly. The patient with a congenital arterial aneurysm presented with paroxystic episodes of facial pain.

CONCLUSIONS

The AVM are the VM which most frequently cause symptoms in childhood.

[Ischemic stroke in children]

OBJECTIVE

Ischemic stroke in children and infants is a rare condition. We present a series of 23 pediatric patients of ischemic stroke.

PATIENTS AND METHODS

A retrospective series of 23 patients, aged between 1 month and 13 years, diagnosed by anamnesis, clinical examination and neuroimaging. The clinical picture, neuroimaging findings, etiology, evolution and sequelae are evaluated.

RESULTS

Eighteen of the patients had an ischemic stroke in the carotid territory (78.3%) and 5 in the vertebro-basilar (21.7%). Idiopathic (30.4%), cardiopathy (21.7%) and migraine (17.4%) were the most frequent etiologies. The recovery was complete in 9 patients (39.1%). There was a death as a result of systemic complications caused by dehydration (4.3%), and 13 patients (56.6%) were disabled: 6 with hemiparesis of diverse grades, 5 with epilepsy and hemiparesis, one with epilepsy, and one with mental retardation.

CONCLUSIONS

Ischemic stroke in children and infants is an unusual entity. The causes are multiple, although there is an elevated percentage of idiopathic cases. In our series, we highlight the significative percentage of vertebro-basilar strokes and the finding of three unusual etiologies in ischemic stroke in childhood, such as migraine, Mycoplasma pneumoniae infection and smallpox.

Numb chin syndrome as the initial manifestation of HIV infection

Numb chin syndrome, which consists of focal sensory loss and paresthesias of the chin, occurs with malignant diseases. We report a patient with numb chin syndrome, caused by Burkitt's lymphoma, occurring as the initial manifestation of HIV infection.

A comprehensive knowledge-based system for laboratory hematology

The Coulter FACULTY knowledge-based systems, Professor Petrushka for peripheral blood interpretation, Professor Fidelio for flow cytometry immunophenotyping and Professor Belmonte for bone marrow reporting, have been installed in several hospitals in Spain, Portugal and the United Kingdom. In Spain and Portugal, the systems are part of the IZASA-Coulter CITOTECA workstation, which includes a video camera for capturing microscopic images and a networkable laboratory information system supporting color reports. At the Royal Hospitals Trust (St. Bartholomew's Hospital and The Royal London Hospital, London, UK), networked workstations are available and the system is used daily to generate bone marrow reports in the hematology laboratories. There have been considerable benefits from adopting Coulter FACULTY for bone marrow reporting, including faster turnaround time, improved quality of the reports and cost savings.

[Spontaneous intracranial hemorrhages in childhood]

INTRODUCTION

Spontaneous or non-traumatic intracranial haemorrhages seen in children of under 15 years old are most frequently due to cerebral vascular malformations, followed at a considerable distance by blood disorders, vasculopathies, tumours and the complications of radio-therapy.

OBJECTIVE

To present the cases of spontaneous and non-traumatic cerebral haemorrhage seen at our hospital.

MATERIAL AND METHODS

We reviewed all the paediatric cases of spontaneous cerebral haemorrhage diagnosed in our hospital over the previous sixteen years, excluding bleeding in the neonatal period. Computerized tomography was done in all cases, study of the cerebrospinal fluid, angiography and/or magnetic resonance in some cases.

RESULTS

We selected 44 patients, of who the aetiology could be determined in 30. Of these, 20 cases were due to vascular malformations, 7 were associated with haematological disorders, 2 with cerebral tumours and one case with meningococcal sepsis. The commonest form of presentation was that of an acute intracranial hypertension syndrome, also showing focal deficits, partial crises and meningism.

CONCLUSIONS

The commonest cause of spontaneous intracranial haemorrhage in children is due to rupture of a vascular malformation, namely an arterio-venous malformation. Angiography and/or magnetic resonance are the techniques of choice for diagnosis. The various causes of disorders of haemostasia also are important in giving rise to intracranial bleeding.

[Treatment of refractory infantile epilepsy with vigabatrin in a series of 55 patients]

We present the results of treatment with vigabatrin in the polytherapy of resistant infantile epilepsy. A retrospective review of 55 children with resistant epilepsy aged between 2 months and 15 years was carried out between January 1992 and January 1995. Semiologically, the crises treated were simple partial crises (CPS), complex partial crises (CPC), West's syndrome, the Lennox-Gastaut syndrome and polymorphic crises. The efficacy of the drug (defined as a 50% or more reduction in crises), secondary effects and the reduction in the number of drugs necessary were evaluated. 60% of the children studied improved. 20% became completely free of crises. 34% remained unchanged and 3% became worse. In West's syndrome 100% responded satisfactorily, as did 80% of the cases of partial crises, but only 40% of those with Lennox's syndrome responded. Generalized tonic-clonic crises did not respond, and myoclonic crises became worse. Aetiologically, there was greater improvement in the symptomic cases than in the essential cases, the improvement being 70% while 5 patients with tuberose sclerosis responded particularly well. Medication was stopped in one case because of side-effects, due to a psychiatric disturbance, and in another case vigabatrin caused transitory side-effects. In 10% of the subjects the initial efficacy wore off around 6 months later. We have shown the usefulness of vigabatrin in the polytherapy of infantile epilepsy, which is resistant to conventional epileptic drugs, mainly in simple and complex partial crises and in West's syndrome. Its minimal side-effects and the favourable response in over 50% of cases make it an extremely useful drug.

Miller Fisher syndrome in infancy

Miller Fisher syndrome (MFS) is characterized by the triad of ataxia, areflexia and ophthalmoplegia. It is exceptional for infants to be involved. Two infants, aged 11 and 16 months, developed acute-onset MFS. Both patients had prodromal upper respiratory tract infection. Pupillary responses to light, strength and sensation modalities were preserved. One patient was lethargic for a day; the electroencephalogram disclosed slightly slow background activity that later became normal. The other received high-dose intravenous immunoglobulins for 5 consecutive days starting at once on admission; within the next 7 days he became asymptomatic. Increased cerebrospinal fluid protein content and delayed nerve conduction studies with prolonged distal latencies were encountered in both patients.

[Axilla skin biopsy in the diagnosis of Lafora's disease]

Skin biopsy is the method of choice for the diagnosis of Lafora's disease. The presence of PAS (+) inclusions characteristic of Lafora's disease has been thought to be more evident in aprocrine glands of the axillary skin than in the duct cells of the eccrine glands. We describe 4 patients with Lafora's disease diagnosed by axilla skin biopsy, confirming the usefulness of this procedure.

[Congenital fiber-type disproportion: analysis of a series of 11 cases]

We present 11 patients with congenital fiber type disproportion suggesting the existence of two different clinical groups. The first group not associated with other diseases, presents a uniform clinical picture and a generally good prognosis, although the patients with severe respiratory involvement can die. The second group includes the cases in which CFTD is associated with other congenital diseases such as Lowe's Syndrome, Möbius' Syndrome, hypothyroidism and hydrocephalus. In this group the clinical presentation and prognosis is that of the associated disease added to that of CFTD. The frequent association of CFTD with other congenital diseases suggests that CFTD may not be a specific myopathy but a histological abnormality due to different pathogenic insults which interfere with the normal growth and maturation of the muscle fibres.

[Idiopathic pulmonary hemosiderosis: anatomoclinical study of 2 cases]

Two children with idiopathic pulmonary hemosiderosis are described. Both of them presented initially a clinical picture of recurring iron deficiency anemia, before pulmonary symptoms and signs made it possible to establish correct diagnosis. In one case diagnosis was considered only when an overwhelming pulmonary hemorrhage occurred, leading to the patient's death. At necropsy, areas of fresh alveolar hemorrhage and hemosiderin loaded macrophages were found, as well as moderate to severe interstitial fibrosis and hyperplastic alveolar cells. There was not disruption of the basal alveolocapillary membrane.