Changes in retinal and choroidal capillary dynamics in patients with multisystem inflammatory syndrome in children.

PURPOSE: To evaluate patients with multisystemic inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using optical coherence tomography angiography (OCTA) during and after resolution of inflammation to investigate the effect of this entity on the retinal and choroidal circulation. METHODS: The study included 38 eyes of 19 patients diagnosed as having MIS-C between March 2021 and June 2021. OCTA measurements of choroidal thickness and vessel density in the radial peripapillary capillary plexus (RPCP), superficial capillary plexus (SCP), and deep capillary plexus (DCP) obtained at time of diagnosis and 60 days later were compared. Correlations between C-reactive protein (CRP) levels at diagnosis and retinochoroidal involvement were investigated. RESULTS: Compared to post-recovery follow-up examinations, patients with active MIS-C showed foveal avascular zone enlargement (p = 0.031), decreased vessel density in the temporal parafoveal SCP (p = 0.047) and all parafoveal areas of the DCP (p < 0.05 for all), and increased choroidal thickness (p = 0.021). Correlation analysis between CRP levels and OCTA changes during MIS-C revealed significant negative correlations with all parafoveal sectors of the SCP and DCP and a significant positive correlation with CT. CONCLUSION: There were especially marked effects on the DCP and choroid in MIS-C patients. Our findings also correlate with CRP levels. The use of optical coherence tomography angiography in patients with multisystemic inflammatory syndrome may have potential future implications for detecting ocular microvascular changes that occur before permanent damage develops. Clinical Trial Registration Number and Date: 77/1340; March 1, 2021.

The Relationship between Bronchiolitis Severity and Vitamin D Status.

BACKGROUND/AIM: Acute bronchiolitis is mostly caused by viral agents in children under 2 years of age. The disease mostly has a mild clinical course however severe cases are not uncommon. Vitamin D is known to exert immune-regulatory functions. We aimed to examine the association between the clinical severity of acute bronchiolitis and serum vitamin D levels in infants. MATERIALS AND METHODS: A total of 182 children with acute bronchiolitis were prospectively enrolled. The disease severity was assessed using the Modified Tal Scoring System and their vitamin D levels were evaluated. RESULTS: Vitamin D deficiency or insufficiency was as high as 47.8% in infants with bronchiolitis. Infants with low vitamin D levels comprised a significantly larger proportion of patients with severe bronchiolitis (p = 0.002). Infants admitted to intensive care unit had significantly higher degrees of vitamin D deficiency or insufficiency (p < 0.001). CONCLUSION: Vitamin D deficiency is closely linked with severe bronchiolitis and the need for intensive care unit admission in infants. We believe that assessment of vitamin D levels in infants prior to bronchiolitis season and appropriate supplementation may have a protective effect against severe bronchiolitis.

Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19: A Case Series Experience in a Tertiary Care Hospital of Southern Turkey.

OBJECTIVE: Aim of the study is to assess the clinical characteristics and treatment outcomes of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. STUDY DESIGN: The study comprised 52 children with MIS-C admitted to University of Health Sciences Adana City Training and Research Hospital pediatric wards from September 2020 to April 2021. Demographic characteristics and clinical data were retrospectively collected from patient files. RESULTS: Median age of patients was 9 (5-13) years. Fever (92.3%), abdominal pain (76.9%), rash (48.1%) and vomiting (48.1%) were the most common presenting symptoms. Fever duration was 8 (4.25-10) days in overall. Depressed left ventricular ejection fraction was found in 17.3% of patients. At admission, elevated levels of C-reactive protein, procalcitonine, erythrocyte sedimentation rate, D-dimer and ferritin were found in 98.1%, 96.2%, 75%, 84.6% and 69.2% of the patients, respectively. Lymphopenia, hyponatremia and hypoalbuminemia were found in 76.9%, 59.6% and 42.3% of the patients. Intravenous immunoglobulin was used in 96.2%, corticosteroids in 71.2% and anakinra in 3.8% of the patients. In total, 28.8% of the patients were admitted to pediatric intensive care unit and 17.3% received vasopressor support. Median duration of hospital length of stay was 12.5 days. Comorbidities were present in 19.2% of the patients. No mortality was recorded. CONCLUSIONS: While being rare and treatable, MIS-C is the ugly and mysterious face of the COVID-19 pandemic for children. The increasing number of MIS-C cases shows that this phenomenon is more common than thought. Comprehensive studies are required to understand the pathogenesis of the disease and determine the treatment regimens clearly. LAY SUMMARY: While being rare and treatable, multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is the ugly and mysterious face of the COVID-19 pandemic for children. MIS-C is now thought to be a post-infectious (SARS-CoV2) hyperinflammatory disease secondary to an abnormal immune response, rather than a complete obscurity. The increasing number of MIS-C cases and new case series reports from all over the world show that MIS-C is more common than thought. Despite our increasing experience, we may encounter a new finding every day in MIS-C patients. Therefore, we want to contribute to literature by presenting the MIS-C cases we treated in our clinic in detail. We have experienced that MIS-C patients can apply with similar but also different and unique characteristics. In case of delayed diagnosis or treatment, morbidity and mortality rates may increase. Therefore, the level of awareness and knowledge of all physicians, especially those dealing with pediatric patients, about MIS-C should be increased. Although the early effects of MIS-C are known, we don't have enough information about the long-term consequences yet. Comprehensive studies are required to understand the pathogenesis of the disease and determine the treatment regimens clearly.

Surgical approaches to upper thoracic Pott's disease with spinal instability during childhood: two cases.

PURPOSE: Tuberculosis is a common disease worldwide that is caused by Mycobacterium tuberculosis. Tuberculosis is primarily a pulmonary disease, but extrapulmonary manifestations are not uncommon, especially in children and adolescents. METHODS: We present two pediatric patients who underwent surgery in our clinic for Pott's disease in the upper thoracic region. The patients were investigated to describe their age, complaints, neurological examination results, disease location, surgical procedure, and complications. RESULTS: The patients were 2 and 14 years old and exhibited disease located in the upper thoracic region (T2-T3 and T1-T2). Both patients displayed severe neurological deficits (Frankel B and C). The kyphotic angles were 82.2° and 43.2°. The patients were stabilized by applying fusion using transpedicular screws via a posterior approach. They also underwent anti-tuberculosis treatment for approximately 1 year. One year later, neither patient exhibited any neurological deficit, and their kyphotic angles were measured as 11° and 1°, respectively. CONCLUSIONS: The recommended treatment approach for unstable cases of Pott's disease located in the upper thoracic region who exhibit neurological deficit and severe kyphotic angling or the development of kyphosis on the thoracic vertebrae is surgical. Decompression, stabilization, and fusion and kyphotic correction can be safely performed via a posterior approach. One of the present cases is the youngest patient described in the literature to undergo transpedicular surgery as a result of Pott's disease. Our other case is the first described in the literature who developed ptosis as a result of tuberculosis and underwent a procedure via posterior transpedicular screw.

Treatment of Lyme neuroborreliosis with plasmapheresis.

Lyme disease is a rare tick-borne multisystemic infection caused by Borrelia burgdorferi. Different neurological conditions were reported in the disease. In this article, we present a 15-year-old patient hospitalized with ataxia who was diagnosed with Lyme neuroborreliosis. Intravenous immunoglobulin and ceftriaxone treatment was applied to the patient for 4 weeks. However, ataxia did not recover, upper and lower muscle weakness developed, and deep tendon reflexes diminished during follow-up. The patient was diagnosed with Guillain-Barre syndrome arising from B. burgdorferi. Second dose of intravenous immunoglobulin treatment was started for 5 days but the patient didn't recover. Therefore administration of plasmapheresis was decided. All symptoms relieved following the plasmapheresis. The effect of plasmapheresis in pediatric neuroborreliosis has not been documented before. This study highlights that plasmapheresis could be a useful alternative for pediatric neuroborreliosis cases. J. Clin. Apheresis 31:476-478, 2016. © 2015 Wiley Periodicals, Inc.

Pediatric Lyme Neuroborreliosis: Different clinical presentations of the same agent; Single center experience.

OBJECTIVES: Lyme disease is a vector-associated infectious disease, caused by the agent, spirochete Borrelia burgdorferi. Neurologic findings are observed in approximately 12% of the cases and termed Lyme neuroborreliosis (LNB). Lyme neuroborreliosis may manifest with different clinical neurologic manifestations. METHODS: The study was conducted at tertiary training and research hospital. From January 2014 to September 2015, a total of 75 patients diagnosed with encephalitis, ataxia, Guillain Barre Syndrome (GBS), facial paralysis, acute disseminated encephalomyelitis (ADEM), pseudotumorcerebri were evaluated for inclusion to the study. Among these patients whom investigations of B. burgdorferi antibody IgM and/or IgG ELISA and Western Blot (WB) were detected to be positive, were assessed. Epidemiologic data, tick bite histories, duration of symptoms, clinical findings, radiologic findings, treatment durations and prognosis were investigated. RESULTS: Totally 7 patients had been treated with the diagnosis of Lyme neuroborreliosis. The mean age was 9.14±4.91 years; duration of symptoms before admission was 8.0±4.50 days; and the duration of antibiotic use was 2.85±0.89 weeks. All patients had received ceftriaxone and intravenous immunoglobulin (IVIG); 3 patients had received plasmapheresis (42.9%) and one patient had received pulse corticosteroid therapy. While the patient with the diagnosis of encephalomyeloneuritis and atypical GBS had partially improved, the other patients were completely cured. CONCLUSION: In this article, we report pediatric LNB patients, B. burgdorferi should also be considered in patients with atypical or severe neurologic involvement or a history of tick bite; it is known that the prognosis is good with appropriate and early treatment.

Cerebral salt wasting in pediatric critical care; not just a neurosurgical disorder anymore.

OBJECTIVE: Cerebral salt-wasting syndrome (CSWS) is a hypovolemic hyponatremia caused by natriuresis and diuresis, of which the exact pathogenesis is unknown. Although CSWS has been more commonly described to be associated with neurosurgical disorders, increasing numbers of patients are diagnosed and new etiological factors are being identified as the awareness of it increases. METHODS: The files of the patients who had been hospitalized and treated with the diagnosis of CSWS at the pediatric critical care unit during the last three years were retrospectively reviewed. RESULTS: Totally 9 patients had been treated with the diagnosis of CSWS. The causes of CSWS were identified as tuberculosis meningitis in two patients, status epilepticus in two patients, ketamine infusion in one patient, medulloblastoma in one patient, sepsis in one patient, brain oedema following child abuse in one patient, and cerebral infarct in one patient. All of the patients had received isotonic saline and hypertonic saline while 77.7% of them had received fludrocortisone. The mean time to correction of hyponatremia was 20.37±14.73 days. One patient had died. CONCLUSION: Cerebral salt-wasting syndrome is increasingly described in the etiology of hyponatremia that is commonly seen in children hospitalized especially at critical care units. Serum sodium, urinary sodium and polyuria should be primarily considered in the diagnosis, and supportive laboratory tests such as uric acid and brain natriuretic peptide (BNP) should not be stipulated. At hospitals providing inpatient care services, clinical and laboratory characteristics of CSWS should be known in detail especially at pediatric critical care units.

Cerebral salt wasting in tuberculous meningitis: Two cases and review of the literature. Case Report.

Cerebral salt wasting syndrome (CSWS) is characterized by severe natriuresis and volume depletion in the presence of cerebral pathology. In literature, there are few reports about tuberculous meningitis and cerebral CSWS. In this article, we report two tuberculous meningitis cases with CSWS and present a review of the literature on this topic. Cerebral salt wasting diagnosis was based on hyponatraemia associated with high urinary sodium excretion and inappropriately high urine output in the presence of dehydration. Treatment was made with sodium-fluid replacement plus fludrocortisone therapy in both cases. In agreement with the literature we argue that cerebral salt wasting syndrome might be more common than the syndromes of inappropriate antidiuretic hormone secretion (SIADH) in cerebral disorders. Differentiating the cerebral salt wasting syndrome from the SIADH is very important because unrecognized cerebral salt wasting syndrome can lead to inadequate management and result in unnecessary hyponatremia-related morbidity. The electrolyte and hydration status of patients should be monitored closely in patients with tuberculous meningitis.

Short-term Side Effects of Pulse Steroid Treatment in Children.

This study is aimed to evaluate pediatric patients, who were hospitalised in the Department of Pediatrics, University of Health Sciences, Adana City Training and Research Hospital, Turkey, between January, 2019 and January, 2020, and treated with pulse steroid therapy and the early side effects of their treatment. The fasting blood glucose levels of the patients during treatment were statistically significantly higher than those prior to the treatment. The most common side effects observed in the patients were dermatological (48.5%), psychiatric (31.4%), and gastrointestinal (31.4%). Hypertension was detected in seven patients (20%) after treatment; and continued in three, who subsequently underwent antihypertensive treatment. Pulse steroid treatment was administered for a median of five days (3-11 days). It was found that 24 patients responded to treatment, 11 patients did not respond, and one patient died. There is a shortage of studies in literature on pulse steroid therapy and its side effects, especially focusing on children. Multicentre and randomised controlled studies are needed comprising different patient groups to evaluate the efficacy and complications associated with its use. Key Words: Children, Side effect, Pulse steroid treatment.

Evaluation of Clinical Findings and Treatment Results of Coronavirus Disease 2019 (COVID-19) in Pediatric Cancer Patients: A Single Center Experience.

Objective: The objective of the study is to evaluate the clinical findings and treatment results of COVID-19 in pediatric cancer patients. Study design: The study was designed as a single-center retrospective observational study. Pediatric cancer patients with COVID-19 admitted to the University of Health Sciences Adana City Training and Research Hospital pediatric COVID wards from October 2020 to October 2021 were included. Clinical data and demographic characteristics were retrieved from patient files. Results: A total of 45 pediatric cancer patients diagnosed with COVID-19 were included in the study. The mean age of the patients was 8.68 ± 5.16 years (range 1.5-17.5), 62.2% were men, 37.8% were Turkish citizens, and 62.2% were Syrian refugees. A total of 41 patients (91.1%) had leukemia/lymphoma, while 4 (8.9%) had solid tumors. The most common symptoms were fever (66.7%), respiratory (35.6%), and gastrointestinal symptoms (17.8%). Disease severity was evaluated as mild in 46.7%, moderate in 44.4%, and severe in 8.9% of patients. Patients presented with lymphopenia (88.9%), thrombocytopenia (73.3%), anemia (71.1%), and neutropenia (62.2%). Mean hospital length of stay was 15.18 ± 10.34 (range 6-62) days overall and 9.5 ± 2.39 (range 2 to 28) days in the PICU. Intensive care unit admission rate was 8.9%, and mortality rate was 4.4%. Median viral shedding period was 21 days (range 7-52). Conclusions: Our study reveals that the mortality rate, length of hospital stay, and the need for intensive care of pediatric cancer patients with COVID-19 are higher than those of healthy children. Prospective studies with larger sample sizes are needed to further evaluate the clinical findings and treatment results of COVID-19 in pediatric cancer patients.

MIS-C and Visceral Leishmaniasis Co-occurence: Has the Clinic of Other Diseases Masked in the Pandemia?

At the end of 2019, the newly detected severe acute respiratory syndrome-coronavirus (COVID)-2 in China spread rapidly and caused a global epidemic. It has been observed that the virus, which is the cause of COVID-2019 and can cause severe acute respiratory failure, later causes a hyperinflammatory picture and causes a clinical picture similar to Kawasaki disease. Fever, cardiac involvement and rash are the most common findings in this picture, which is called multisystem inflammatory syndrome (MIS-C). Although its pathophysiology is not fully known yet, the most common cause is thought to be post-infection immune dysregulation. Visceral leishmaniasis (VL) is a zoonosis in which Leishmania infantum and rarely Leishmania donovani are the agents and can cause a similar clinical picture. In this text; we discussed a patient who was followed up with a diagnosis of COVID-associated MIS-C, but without an adequate response in his clinic with MIS-C treatment, and was diagnosed with VL with further examinations. To our knowledge, this is the first MIS-C and VL co-occurence in the literature.

Effect of malnutrition on length of hospital stay in children.

OBJECTIVE: To determine the prevalence of malnutrition in hospitalized pediatric patients, to provide a classification of patients with malnutrition, and to evaluate the effect of malnutrition on length of hospital stay. MATERIAL AND METHODS: The study included patients aged 5 months to 18 years who were hospitalized in the Department of Pediatrics of the Adana City Training and Research Hospital between May 1st, 2018, and December 31st, 2018. Bodyweight, height, mid-upper arm circumference, and triceps skinfold thickness were measured at the time of hospitalization, and age, sex, diagnosis, comorbid conditions, and length of stay for treatment were recorded. RESULTS: Of 1009 patients, 44% were female and 56% were male, and the mean age was 59.9±58.6 (median age 32) months. The mean length of stay was 6.83±4.48 days. Malnutrition was determined in 46.9% of the patients according to the Gomez classification. The mean length of stay in patients without malnutrition was 6.31±3.86 days, compared with 7.39±5.04 days in patients with malnutrition (p<0.001). The length of stay increased with increasing degrees of malnutrition (p<0.001). CONCLUSION: Malnutrition is often overlooked in hospitalized patients. Studies conducted in different years that reported similar malnutrition rates indicated that this condition still existed as a significant health problem. In the evaluation of nutritional status in hospitalized patients, paying attention to malnutrition while addressing the main reason of hospitalization and incorporating nutritional support into the treatment plan will decrease the length of stay and also reduce the rate of complications.

Evaluation of Pediatric Measles Cases Hospitalized in 2019.

OBJECTIVE: Outbreaks of measles were seen throughout the world in 2018-2019, including Turkey. Measles outbreak in Turkey may be attributed to cases imported from European countries and increased rate of unvaccinated children due to the massive influx of refugees from neighboring countries. MATERIALS AND METHODS: The demographic details and clinical and laboratory findings of the patients hospitalized with diagnosis of measles in the Pediatric Clinic of Adana City Hospital in 2019 were evaluated retrospectively. RESULTS: Among the 38 children enrolled, 18 were female (47.4%), the median age was 12 months (3-199 months), 20 were Turkish citizens (52.6%), and 18 (47.4%) were refugees. Twenty-seven children had vaccination data available, with 25 unvaccinated for measles. None of the families declared vaccine hesitancy. Of the unvaccinated subgroup (n = 25), 19 (76%) were younger than 12 months. The mean duration of hospitalization was 5.13 ± 2.67 days, no mortalities occurred. Measles was encountered in the social circle of 10 cases, although only 2 families applied for prophylaxis. CONCLUSIONS: Among the children with measles, 10 of the cases were reported to be within the household of previously diagnosed measles cases, but only 2 of them were given prophylaxis. Awareness regarding use of post-exposure prophylaxis against measles should be increased. Efforts to keep the measles vaccination coverage rate above optimal levels should be encouraged in regions with concentration of irregular refugees.

Post-exposure Rabies Prophylaxis for Children in Southern Turkey.

OBJECTIVE: To evaluate the prophylaxis practices used on children with animal exposures in a major southern city of Turkey, close to the Syrian border. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Emergency and Outpatient departments, Adana City Training and Research Hospital, Turkey between September 2017 and September 2018. METHODOLOGY: The demographic data of the patients, who presented due to animal contact; the interval between animal contact and hospital presentation; species of exposed animals, type, and apparent condition of the animals; risk categories based on national assessment scale; the number of rabies vaccines and anti-rabies immunoglobulin (RIG) administrations; administration of tetanus prophylaxis; adherence of patients to the follow-up schedule; vaccine refusals; and development of rabies disease (if any), were recorded. RESULTS: Of the 2,068 presentations after animal exposure, 906 (43.8%) were children, mostly boys (62%), and the mean age was 97.15 ± 57.68 months. Risky contact was most frequently caused by cats (52.8%) and dogs (45.6%). Exposure to stray animals was the most common (58.5%). For serial prophylaxis vaccinations, 761 (83.99%) families were in full compliance and 145 (16%) families had discontinued vaccinations. The discontinuation rate of the immigrant population was significantly higher (p = 0.001). CONCLUSION: Risky contacts were mostly due to stray animals. Efforts to minimise the stray animal population should be increased. The rate of discontinuation of rabies prophylaxis follow-ups was 16%. Significantly higher prophylaxis discontinuation among the immigrant population was noted. Key Words: Rabies, Vaccines, Prophylaxis, Turkey.

A Paediatric Case of Pulmonary Hydatid Cyst Presented with Mediastinal Lymphadenopathy.

Hydatid cyst is a common zoonosis caused by larval forms of tapeworms called Echinococcus. The problem often occurs in the liver or lung. Cyst rupture and secondary bacterial infection are the most important complications of pulmonary hydatid cyst (PHC). PHC may mimic serious lung diseases such as treatment-resistant pneumonia, tuberculosis, and tumours. This report discusses the case of a paediatric patient with PHC who presented with chronic cough, hilar lymphadenopathies up to 3 cm, and worsening symptoms despite non-specific pneumonia treatment. Hence, PHC should be considered in patients with treatment-resistant pneumonia and mediastinal lymphadenopathy.

Appraisal of the "pediatric ARDS: consensus recommendations from the pediatric acute lung injury consensus conference" with the AGREE II instrument

Background/aim: The ″Pediatric Acute Lung Injury Consensus Conference″ (PALICC) was convened in order to develop a taxonomy to define pediatric acute respiratory distress syndrome (ARDS). The Appraisal of Guidelines for Research and Evaluation (AGREE) assesses the quality of guidelines. The aim of this study is to evaluate the new pediatric ARDS guideline using the AGREE II instrument. To the best of our knowledge, this is the first assessment of the new pediatric ARDS clinical practice guideline in the English literature. Materials and methods: Four appraisers assessed the new pediatric ARDS guideline with the AGREE II instrument. At the end of the evaluation each appraiser rated the overall quality of the guidelines. Results: Results of the assessment were editorial independence 100%, clarity of presentation 94%, scope and purpose 89%, stakeholder involvement 78%, rigor of development 78%, and applicability 78%. Conclusion: The new pediatric ARDS guideline received good scores especially with respect to editorial independence and clarity of presentation. Our overall AGREE II review of the PALICC guideline indicates that it has been created using high quality methodology and should be recommended for use and implementation as currently published.

Platelet Indices in the Diagnosis of Ventriculoperitoneal Shunt Infection in Children.

AIM: Ventriculoperitoneal shunt infection (VPSI) is one of the main causes of mortality and morbidity in hydrocephalus. Platelet indices, mean platelet volume (MPV) and platelet distribution width (PDW) have been evaluated for some infectious diseases. In this study we aimed to investigate whether MPV and PDW values are decisive for the diagnosis of VPSI in children. MATERIAL AND METHODS: Charts of VPSI from 2012 to 2015 were reviewed retrospectively. Twenty-five ventriculoperitoneal shunt infected patients and 25 healthy children as the control group were included in the study. Platelet indices were recorded. RESULTS: A total of 25 VPSI patients and 25 healthy children were enrolled in the study. Significant differences were detected between the MPV and PDW values in the two groups (p < 0.001). ROC curve analysis suggested a cut off point for MPV as below 9.2 fl (smaller values indicate patients) for the diagnosis of VPSI, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 80%, 92%, 91% and 82%, respectively. For PDW, the cut-off point was 12.25 (larger values indicate pathology) for diagnosis of VPSI, with sensitivity, specificity, PPV and NPV of 68%, 80%, 77% and 71%, respectively. CONCLUSION: Our results suggest that MPV and PDW can be used for the diagnosis of VPSI in children with an accuracy of at least 75%. Moreover, MPV"s specificity is higher than the other platelet parameters and leucocyte count.

Concurrency of Guillain-Barre syndrome and acute transverse myelitis: a case report and review of literature.

Guillain-Barré syndrome and acute transverse myelitis manifest as demyelinating diseases of the peripheral and central nervous system. Concurrency of these two disorders is rarely documented in literature. A 4-year-old girl presenting with cough, fever, and an impaired walking ability was admitted to hospital. She had no previous complaints in her medical history. A physical examination revealed lack of muscle strength of the lower extremities and deep tendon reflexes. MRI could not be carried out due to technical problems; therefore, both Guillain-Barré syndrome and acute transverse myelitis were considered for the diagnosis. Intravenous immunoglobulin treatment was started as first line therapy. Because this treatment did not relieve the patient's symptoms, spinal MRI was carried out on the fourth day of admission and demyelinating areas were identified. Based on the new findings, the patient was diagnosed with acute transverse myelitis, and high dose intravenous methylprednisolone therapy was started. Electromyography findings were consistent with acute polyneuropathy affecting both motor and sensory fibers. Therefore, the patient was diagnosed with concurrency of Guillain-Barré syndrome and acute transverse myelitis. Interestingly, while concurrency of these 2 disorders is rare, this association has been demonstrated in various recent publications. Progress in diagnostic tests (magnetic resonance imaging and electrophysiological examination studies) has enabled clinicians to establish the right diagnosis. The possibility of concurrent Guillain-Barré syndrome and acute transverse myelitis should be considered if recovery takes longer than anticipated.

Epstein-Barr virus encephalitis with substantia nigra involvement.

Infectious mononucleosis due to Epstein-Barr virus (EBV) is a usually benign systemic viral illness common in children. Many studies described nervous system manifestations of infectious mononucleosis with a wide spectrum of neurologic deficits. Neurologic complications of EBV are seen in both acute and reactivate infection. Herein, we describe a patient diagnosed by acute EBV encephalitis with substantia nigra involvement and excellent clinical recovery.