Tal Eidlitz-Markus

Management of nontuberculous mycobacteria-induced cervical lymphadenitis with observation alone.

Background: Nontuberculous mycobacteria can cause a chronic localized cervicofacial lymphadenitis in immunocompetent children. The recommended treatment is total excision of the affected lymph node. The aim of this study was to describe our experience with an observational approach. Methods: Children with chronic nontuberculous mycobacterial (NTM) cervical lymphadenitis, whose parents opted for conservative treatment, were followed at our center from 1990 to 2004. The diagnosis of NTM was based on mycobacterial culture of lymph node specimens obtained by fine needle aspiration. The clinical laboratory and follow-up data were documented. Results: Ninety-two children with lymph node positive cultures of nontuberculous mycobacterium were included in the study. Mycobacterium avium complex and Mycobacterium hemophilum were isolated in 90% of the cultures. In most cases, the affected lymph nodes underwent violaceous changes with discharge of purulent material for 3–8 weeks. Total resolution was achieved within 6 months in 71% of patients and within 9–12 months in the remainder. At the 2-year follow-up, a skin-colored, flat scar in the region of the drainage was noted. There were no complications. Conclusions: We suggest that the observational approach can be effective for managing NTM lymphadenitis in immunocompetent children.

Effectiveness of Nonpharmacologic Treatment for Migraine in Young Children

(Headache 2010;50:219‐223)

Recurrent facial nerve palsy in paediatric patients

Abstract. The aim of the study was to investigate the clinical presentation and prognosis of recurrent facial nerve palsy (RFNP) in children. The files of 182 patients referred to the Schneider Childrens Medical Centre of Israel for neurological evaluation of isolated peripheral facial nerve palsy between October 1992 and December 1998 were reviewed. RFNP was found in 11 patients (9 females, 2 males), with an incidence of 6%. In two males, the aetiology was traced to Melkersson-Rosenthal syndrome and these patients were separated from the rest of the group. Three children had two episodes of facial nerve paresis which completely resolved clinically within several weeks. Six other children underwent electrophysiological studies. Two of the latter with residual neurological damage, and one child with abnormal blink reflex only, showed decreased facial nerve conduction velocity and abnormal blink reflex. Three children with complete recovery had disturbed blink reflex only with normal nerve conduction. Brain imaging studies as well as laboratory work-up were non-contributory in all cases. Conclusion: the frequency of recurrent facial nerve palsy in children was similar to that in adults. The most significant factors in the evaluation of recurrent facial nerve palsy are medical history and physical findings at diagnosis and after short follow-up. In our patients, electrophysiological studies did not have either clinical or prognostic significance. The rate of full clinical recovery is about 70%, lower than in Bell palsy.

Symptoms of Migraine in The Paediatric Population by Age Group

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

CSF pressure measurement during anesthesia: an unreliable technique

Background:  The measurement of cerebrospinal fluid (CSF) pressure is necessary for many clinical indications. Its accuracy may be compromized in frightened or uncooperative children who find it difficult to relax sufficiently. The aim of the present study was to evaluate possible effects of general anesthesia on CSF pressure values.

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

BACKGROUND Recurrent pain symptoms in children are associated with psychiatric comorbidities that could complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA). METHODS Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n = 32), tension-type headache (n = 32), or recurrent abdominal pain (n = 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments. RESULTS The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003). CONCLUSION Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients.

Migraine and cephalic cutaneous allodynia in pediatric patients.

Allodynia is a central sensitization state characterized by a perception of pain to normally nonpainful stimuli. The objective of this study was to determine the frequency of allodynia in children with migraine and to identify clinical features specific to this patient group.

Comparative Evaluation of Cefixime versus Amoxicilhin-Clavulanate Following Ceftiaxone Therapy of Pneumonia

Preliminary results have recently shown that an early switch from parenteral antimicrobials to an oral substitute provides an effective means of treating pneumonia in pediatric patients. In a controlled randomized study, 62 children with community-acquired lobar/segmental pneumonia were selected to receive 8 days of cefixime or amoxicillin-clavulanate after an initial therapy of two doses of parenteral ceftriaxone. Enrollment criteria included: age 6 months to 5 years, fever >38.5°C, white blood cell (WBC) count >15,000/mm3, and lobar/segmental pneumonia on chest radiograph. Twenty-nine patients were randomized to receive oral cefixime and 33 to oral amoxicillin-clavulanate. The two groups were comparable in the following pretreatment parameters: age, duration of illness, temperature, mean WBC count, erythrocyte sedimentation rate, C-reactive protein, and need for hospitalization. Days of resolution of high fever, tachypnea, cough, grunting, and laboratory test abnormalities were similar in the two groups. Clinical response at the end of treatment showed cure, improvement, and failure in 97%, 3%, and 0%, respectively, in the cefixime group and in 88%, 6%, and 6%, respectively in the amoxicillin-clavulanate group (P=NS). We conclude that young children with community-acquired lobar/segmental pneumonia can be successfully treated with 2 days of parenteral ceftriaxone followed by 8 days of oral cefixime or amoxicillin-clavulanate.

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

Congenital pancreatic lipase (PNLIP) deficiency is a rare monoenzymatic form of exocrine pancreatic failure characterized by decreased absorption of dietary fat and greasy voluminous stools, but apparent normal development and an overall good state of health. While considered to be an autosomal recessive state affecting a few dozens of individuals world-wide and involving the PNLIP gene, no causative mutations for this phenotype were so far reported. Here, we report the identification of the homozygote missense mutation, Thr221Met [c.662C>T], in two brothers from a consanguineous family of Arab ancestry. The observed genotypes among the family members were concordant with an autosomal recessive mode of inheritance but moreover a clear segregation between the genotype state and the serum PNLIP activity was evident. Based on biophysical computational tools, we suggest the mutation disrupts the proteins stability and impairs its normal function. Although the role of PNLIP is well established, our observations provide genetic evidence that PNLIP mutations are causative for this phenotype.

Nonpharmacologic Treatment of Migraine With Low-Dose Propranolol or Amitriptyline

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