Sleep Disorders in Autism Spectrum Disorder Pre-School Children: An Evaluation Using the Sleep Disturbance Scale for Children.

Background and Objectives: Sleep disorders are common in children with Autism Spectrum Disorder (ASD). The aims of this study were to describe the incidence and characteristics of sleep disorders using a questionnaire completed by the caregiver in a sample of preschool-aged children with ASD and to identify possible differences in a control group of peers. Materials and Methods: Sleep disorders were investigated with the Sleep Disturbance Scale for Children (SDSC) in a population of pre-school-aged (3-5 years) ASD children and in a control group. The Autism Diagnostic Observation Schedule-second ed. (ADOS-2) was further used to assess autism symptom severity. A total of 84 children (69 males; mean age 3.9 ± 0.8 years) with a diagnosis of ASD and 84 healthy controls (65 males; mean age of 3.7 ± 0.8 years) that were matched for age and sex were enrolled. Results: ASD children reported significantly higher (pathological) scores than the control group on the SDSC total scores and in some of the factor scores, such as Difficulty in Initiating and Maintaining Sleep (DIMS), disorders of excessive somnolence (DOES), and sleep hyperhidrosis. A total of 18% of ASD children had a pathological SDSC total T-score, and 46% had an abnormal score on at least one sleep factor; DIMS, parasomnias, and DOES showed the highest rates among the sleep factors. Younger children (3 years) reported higher scores in DIMS and sleep hyperhidrosis than older ones (4 and 5 years). No specific correlation was found between ADOS-2 and SDSC scores. Conclusions: Pre-school children with ASD showed a high incidence of sleep disorders with different distributions of specific sleep factors according to their age. We suggest a screening assessment of sleep disorders using the SDSC in these children with a more in-depth evaluation for those reporting pathological scores on the questionnaire.

Mild encephalitis/encephalopathy with reversible splenial lesion (MERS) in twin sisters with two CD36 frameshift mutations.

Mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a clinical radiological syndrome with good prognosis that affects mainly children or young adults. We describe two cases of MERS, associated with echovirus 6 and influenza A infection, in two twin sisters, at the age of 4 years. Genetic analysis was performed; next exome sequencing was performed on twins to disclose the eventual causative gene. Two different frameshift mutations in the CD36 gene [NM_000072] were found in both twins and confirmed by Sanger sequencing. To best of our knowledge, we report an association between CD36 mutation and MERS. We think that this relation between CD36 and inflammation has had a crucial role in the same callosal alteration during viral disease in the twin sister with the same gene mutation.

Attention-deficit/hyperactivity disorder and enuresis: a study about effectiveness of treatment with methylphenidate or desmopressin in a pediatric population.

BACKGROUND: The aim of this study was to evaluate the effectiveness of treatment with methylphenidate or desmopressin (dDAVP) in patients with comorbid attention-deficit/hyperactivity disorder (ADHD) and enuresis. METHODS: We enrolled 103 patients affected by ADHD and 125 patients with monosymptomatic nocturnal enuresis (NE). Data were collected between January 2014 and December 2015. The study was carried out in compliance with the Helsinki Declaration. RESULTS: About children with ADHD, 9/103 (8.7%) were also suffering from NE; of those 8/9 followed treatment with methylphenidate and cognitive behavioral therapy. After 3 months 2/8 (25%, CI 95%: 8-65%) showed improvements, remaining 75% has been increased dosage of methylphenidate. After 6 months a response was achieved in 6/8 (75%, CI 95%: 35-96%) children and 1/8 was lost to follow-up. Furthermore the drug withdrawal showed a recurrence of symptoms both ADHD and NE in 1/7 (14.3%, CI 95%: 0.3-57%) vs. 6/7 (85.7%, CI 95%: 42-99%) that not presented recurrences. About children with NE enrolled at Campus Bio-Medico University it was found that 4/125 (3.8%) children were also suffering from ADHD; 3/4 (75%) treated with dDAVP and motivational therapy, of those 2/3 (66.7%, CI 95%: 9-99%) showed no improvements of symptoms vs. 1/3 (33.3%, CI 95%: 0.8-90%) that showed partial response with a reduction of wet-nights. CONCLUSIONS: It is important the service of recruitment of patients with NE. In fact considering NE in a Child Neuropsychiatry Service where patients belong to a diagnosis of ADHD and NE is an incidental finding, this one is not considered as the addressee of treatment, but the therapy is directed to the neuro-behavioral problem using specific drugs and therapies, which are resolutive in the enuretic disorder.

Vaccine composition formulated with a novel TLR7-dependent adjuvant induces high and broad protection against Staphylococcus aureus.

Both active and passive immunization strategies against Staphylococcus aureus have thus far failed to show efficacy in humans. With the attempt to develop an effective S. aureus vaccine, we selected five conserved antigens known to have different roles in S. aureus pathogenesis. They include the secreted factors α-hemolysin (Hla), ess extracellular A (EsxA), and ess extracellular B (EsxB) and the two surface proteins ferric hydroxamate uptake D2 and conserved staphylococcal antigen 1A. The combined vaccine antigens formulated with aluminum hydroxide induced antibodies with opsonophagocytic and functional activities and provided consistent protection in four mouse models when challenged with a panel of epidemiologically relevant S. aureus strains. The importance of antibodies in protection was demonstrated by passive transfer experiments. Furthermore, when formulated with a toll-like receptor 7-dependent (TLR7) agonist recently designed and developed in our laboratories (SMIP.7-10) adsorbed to alum, the five antigens provided close to 100% protection against four different staphylococcal strains. The new formulation induced not only high antibody titers but also a Th1 skewed immune response as judged by antibody isotype and cytokine profiles. In addition, low frequencies of IL-17-secreting T cells were also observed. Altogether, our data demonstrate that the rational selection of mixtures of conserved antigens combined with Th1/Th17 adjuvants can lead to promising vaccine formulations against S. aureus.

IL-17/IL-10 double-producing T cells: new link between infections, immunosuppression and acute myeloid leukemia.

BACKGROUND: Acute myeloid leukemia (AML) is an incurable disease with fatal infections or relapse being the main causes of death in most cases. In particular, the severe infections occurring in these patients before or during any treatment suggest an intrinsic alteration of the immune system. In this respect, IL-17-producing T helper (Th17) besides playing a key role in regulating inflammatory response, tumor growth and autoimmune diseases, have been shown to protect against bacterial and fungal pathogens. However, the role of Th17 cells in AML has not yet been clarified. METHODS: T cell frequencies were assessed by flow cytometry in the peripheral blood of 30 newly diagnosed AML patients and 30 age-matched healthy volunteers. Cytokine production was determined before and after culture of T cells with either Candida Albicans or AML blasts. Statistical analyses were carried out using the paired and unpaired two-tailed Student's t tests and confirmed with the non parametric Wilcoxon signed-rank test. RESULTS: A strong increase of Th17 cells producing immunosuppressive IL-10 was observed in AML patients compared with healthy donors. In addition, stimulation of AML-derived T cells with a Candida albicans antigen induced significantly lower IFN-γ production than that observed in healthy donors; intriguingly, depletion of patient Th17 cells restored IFN-γ production after stimulation. To address the role of AML blasts in inducing Th17 alterations, CD4+ cells from healthy donors were co-cultured with CD33+ blasts: data obtained showed that AML blasts induce in healthy donors levels of IL-10-producing Th17 cells similar to those observed in patients. CONCLUSIONS: In AML patients altered Th17 cells actively cause an immunosuppressive state that may promote infections and probably tumor escape. Th17 cells could thus represent a new target to improve AML immunotherapy.

Structural and functional characterization of the Staphylococcus aureus virulence factor and vaccine candidate FhuD2.

Staphylococcus aureus is a human pathogen causing globally significant morbidity and mortality. The development of antibiotic resistance in S. aureus highlights the need for a preventive vaccine. In the present paper we explore the structure and function of FhuD2 (ferric-hydroxamate uptake D2), a staphylococcal surface lipoprotein mediating iron uptake during invasive infection, recently described as a promising vaccine candidate. Differential scanning fluorimetry and calorimetry studies revealed that FhuD2 is stabilized by hydroxamate siderophores. The FhuD2-ferrichrome interaction was of nanomolar affinity in surface plasmon resonance experiments and fully iron(III)-dependent. We determined the X-ray crystallographic structure of ligand-bound FhuD2 at 1.9 Å (1 Å=0.1 nm) resolution, revealing the bilobate fold of class III SBPs (solute-binding proteins). The ligand, ferrichrome, occupies a cleft between the FhuD2 N- and C-terminal lobes. Many FhuD2-siderophore interactions enable the specific recognition of ferrichrome. Biochemical data suggest that FhuD2 does not undergo significant conformational changes upon siderophore binding, supporting the hypothesis that the ligand-bound complex is essential for receptor engagement and uptake. Finally, immunizations with FhuD2 alone or FhuD2 formulated with hydroxamate siderophores were equally protective in a murine staphylococcal infection model, confirming the suitability and efficacy of apo-FhuD2 as a protective antigen, and suggesting that other class III SBPs might also be exploited as vaccine candidates.

Staphylococcus aureus FhuD2 is involved in the early phase of staphylococcal dissemination and generates protective immunity in mice.

Iron availability plays an essential role in staphylococcal pathogenesis. We selected FhuD2, a lipoprotein involved in iron-hydroxamate uptake, as a novel vaccine candidate against Staphylococcus aureus. Unprecedented for staphylococcal lipoproteins, the protein was demonstrated to have a discrete, punctate localization on the bacterial surface. FhuD2 vaccination generated protective immunity against diverse clinical S. aureus isolates in murine infection models. Protection appeared to be associated with functional antibodies that were shown to mediate opsonophagocytosis, to be effective in passive transfer experiments, and to potentially block FhuD2-mediated siderophore uptake. Furthermore, the protein was found to be up-regulated in infected tissues and was required for staphylococcal dissemination and abscess formation. Herein we show that the staphylococcal iron-hydroxamate uptake system is important in invasive infection and functions as an efficacious vaccine target.

Status dystonicus: predictors of outcome and progression patterns of underlying disease.

BACKGROUND: Status dystonicus (SD) is a rare, life-threatening disorder characterized by acute worsening of generalized dystonia. METHODS: This study was conducted to characterize the pathogenesis, clinical course, and prognosis of SD. We reviewed the records of six centers and analyzed them together with all the cases previously reported in the literature. RESULTS: Eighty-nine episodes occurring in 68 patients were studied. The majority of patients were males (64.7%), were <15 years of age (58.8%), and had secondary dystonia as the underlying condition (37.8%). The episodes were mainly characterized by tonic muscle spasms (68.5%), with phasic forms more common in secondary forms and among females. Almost all cases needed a multistaged approach, with surgery being the most successful strategy. Neurological conditions preceding the episode worsened in 16.2% of cases (ending in death in 10.3%). CONCLUSIONS: The course and outcome of SD is highly variable; male gender and prevalent tonic phenotype predict a poor outcome.

Nerve ultrasound follow-up in a child with Guillain-Barré syndrome.

INTRODUCTION: Nerve ultrasound has been used increasingly in neurophysiology laboratories, but data on Guillain-Barré syndrome (GBS) are still limited, and no follow-up studies are available. CASE REPORT: An 8-year-old boy was admitted with severe demyelinating GBS. Serial neurophysiological evaluations were performed initially and in follow-up. Ultrasound studies showed diffuse and heterogeneous nerve swelling and focal enlargement of single fascicles inside the nerve. Together with clinical and electrophysiological improvement, progressive normalization of ultrasound changes was seen. CONCLUSIONS: Ultrasound demonstrated structural nerve abnormalities in GBS. These changes normalized as the patient improved clinically and electrophysiologically. Further studies are needed to elucidate the diagnostic and prognostic value of ultrasound in GBS.

Acute necrotizing encephalopathy during novel influenza A (H1N1) virus infection.

A novel swine-origin influenza A (H1N1) virus was recently identified in Mexico. Some cases of infection with neurological complications have been reported to date. We report a case of acute necrotizing encephalopathy associated with the novel H1N1 virus in a 2-year-old European girl who suddenly developed fever, seizures, and altered mental status. Brain and spinal cord magnetic resonance imaging showed bilateral symmetrical lesions of the insulae, thalami, geniculate bodies, and pons tegmentum suggestive of an acute necrotizing encephalopathy. An involvement of meninges and spinal cord was observed configuring an acute necrotizing meningoencephalomyelitis.

Spinal Cord Involvement in Adult Mitochondrial Diseases: A Cohort Study.

The central nervous system is metabolically very demanding and consequently vulnerable to defects of the mitochondrial respiratory chain. While the clinical manifestations and the corresponding radiological findings of the brain involvement in mitochondrial diseases (e.g., stroke-like episodes, signal changes of the basal ganglia, cerebral and cerebellar atrophy) are well known, at present there are few data on the spinal-cord abnormalities in these pathologies, in particular in adult subjects. In this study, we present a cross-sectional cohort study on the prevalence and characterization of spinal-cord involvement in adult patients with genetically defined mitochondrial diseases.

Diagnosis and Therapy of Infectious Encephalitis in Children: A Ten-Years Retrospective Study.

BACKGROUND: Infectious encephalitis represents a rare but potentially severe clinical condition. However, limited international data are available in pediatric age. METHODS: We conducted a retrospective study to review (a) the clinical presentation; (b) laboratory, radiology, and neurophysiology findings; (c) the correlations between these exams and outcome; and (d) the therapy performed. RESULTS: Fifty-six patients were enrolled [22 female (39.6%), mean age 4.7 years, IQR 0.7-8.7 years], 19.6% presented neurologic sequelae. HSV was the single most frequently isolated pathogen (19.6%), although in most cases, the etiology remained undefined. 41.1% children presented prodromal before the development of neurologic signs. Fever was the most frequent constitutional symptom (83.9% of cases). Cerebrospinal fluid was normal in 48.5% of cases and electroencephalograpy in 24.5% cases. Brain computed tomography scans was normal in 33 (91.7%) cases, while cerebral magnetic resonance imaging (MRI) showed pathologic findings in 62.5% of cases. MRI was the only parameter associated with neurologic sequalae [P = 0.01; OR, 8.1 (95% CI: 1.52-42.84)]. CONCLUSIONS: Pediatric encephalitis is a heterogeneous entity with nonspecific clinical and laboratory findings, with undefined etiologies in most times. MRI can play a primary role, both on a diagnostic and prognostic point-of-view, and its role should be implemented and made more accessible. Further studies are needed to define the exact role and timing of steroids.

Cortical Thickness and Clinical Findings in Prescholar Children With Autism Spectrum Disorder.

The term autism spectrum disorder (ASD) includes a wide variability of clinical presentation, and this clinical heterogeneity seems to reflect a still unclear multifactorial etiopathogenesis, encompassing different genetic risk factors and susceptibility to environmental factors. Several studies and many theories recognize as mechanisms of autism a disruption of brain development and maturation time course, suggesting the existence of common neurobiological substrates, such as defective synaptic structure and aberrant brain connectivity. Magnetic resonance imaging (MRI) plays an important role in both assessment of region-specific structural changes and quantification of specific alterations in gray or white matter, which could lead to the identification of an MRI biomarker. In this study, we performed measurement of cortical thickness in a selected well-known group of preschool ASD subjects with the aim of finding correlation between cortical metrics and clinical scores to understand the underlying mechanism of symptoms and to support early clinical diagnosis. Our results confirm that recent brain MRI techniques combined with clinical data can provide some useful information in defining the cerebral regions involved in ASD although large sample studies with homogeneous analytical and multisite approaches are needed.

Verbal short-term memory and cerebellum: evidence from a patient with congenital cerebellar vermis hypoplasia.

The impairment of phonological short-term memory has been reported in adults with cerebellar lesions. At the same time, a role of the cerebellum in speech production has been hypothesized. Cerebellar malformations have been related to developmental problems and language acquisition in children. We describe a 5-year-old male child with cerebellar vermis hypoplasia who presented a severe linguistic deficit. On language testing, verbal production was almost absent, while comprehension was partially spared. Digit span was markedly reduced. An extensive examination of phonological short-term memory confirmed a deficit at this level. Positron Emission Tomography revealed hypometabolism both in the cerebellum and the supratentorial areas involved in language function. This finding supports the hypothesis that the cerebellum is included in a cerebro-cerebellar network, that underlies the phonological short-term memory, whose integrity is necessary for language acquisition.

Mild encephalopathy with reversible splenial lesion associated with echovirus 6 infection: a case report and review of the literature.

BACKGROUND: Mild encephalopathy with reversible splenial lesion (MERS), a clinic-radiological syndrome distinguished by reversible encephalopathy onset, has been increasingly recognized in Caucasian children. CASE: We describe a MERS case in a previously healthy 4-year-old girl admitted to the hospital with abnormal consciousness level, muscle weakness, dysphagia and dysarthria after a 4-day history of diarrhea and fever. Magnetic resonance imaging (MRI) of the brain showed hyperintensity in the corpus callosum splenium. Electroencephalogram was normal and cerebrospinal fluid (CSF) culture negative. The stool sample was positive for Echovirus 6 and serology test confirmed the infection. The child`s condition gradually improved and the MRI, after 15 days, depicted a normal brain. Only a mild speech impairment was persistent at discharge, which disappeared one month later. We performed a literature review about pediatric MERS cases demonstrating that infectious agents have been rarely isolated in CSF. CONCLUSION: MERS has an overall good prognosis independently from the treatment approach; this is confirmed by our case - one of the first reported with an Echovirus 6-related encephalopathy.