Elbasvir/grazoprevir in children aged 3-18 years with chronic HCV genotype 1 or 4 infection: a pharmacokinetic modeling study.

BACKGROUND: Approximately 3.5 million children and adolescents worldwide are chronically infected with HCV. This study uses pharmacokinetic modeling to identify pediatric doses of elbasvir/grazoprevir (EBR/GZR) that achieve plasma concentrations similar to those seen in adults receiving the approved fixed-dose combination regimen of EBR/GZR. PATIENTS AND METHODS: We conducted a nonrandomized, single-arm, multicenter, open-label phase 2b trial in children and adolescents aged 3 to <18 years with chronic HCV genotype 1 or 4 infection (NCT03379506). Pharmacokinetic data were used to bridge efficacy and safety data from adults to children in a stepwise (oldest to youngest) manner. A total of 57 participants were enrolled: cohort 1 (aged 12 to <18 y), n=22; cohort 2 (aged 7 to <12 y), n=17; and cohort 3 (aged 3 to <7 y), n=18. RESULTS: Steady-state plasma exposures were achieved by week 4 for EBR and GZR in all cohorts and daily dosing achieved geometric mean steady-state area under the concentration-time curve at 0-24 hours that fell within comparability bounds established for adults. All participants achieved sustained virologic response 12 weeks after completing treatment (ie, undetectable HCV RNA 12 wk following completion of treatment). Headache (n=4), fatigue (n=4), and nausea (n=2) were the most common treatment-related adverse events (all mild or moderate); no participant discontinued because of an adverse event. CONCLUSIONS: Pediatric EBR/GZR pharmacokinetic models were successfully developed based on complex adult population pharmacokinetic models. At appropriate age-related doses, EBR/GZR is safe and effective in pediatric and adolescent participants with HCV infection.

Wide spectrum of clinical picture of COVID-19 in children - From mild to severe disease.

INTRODUCTION: Children account for a relatively small proportion of laboratory-confirmed SARS-CoV-2 infections. In children, COVID-19 usually has a relatively mild course. However, in rare cases, severe disorders can be observed, and clinical manifestations may differ from adults. PURPOSE: The aim of this study is to analyse the frequency, clinical picture and outcome of COVID-19 in children based on the experience from the tertiary care centre and regional sanitary-epidemiological office. METHODS: We report a study regarding 106 cases of confirmed SARS-CoV-2 infection cases in PCR from a nasopharyngeal swab (age range 1-month - 17-years). In all cases, history was taken. In children who required hospital admission, physical examination and laboratory test were performed according to clinical indications. RESULTS: Twelve of the patients required admission to the hospital. The most common symptoms were anosmia and dysgeusia (75%) and headaches (49%) in outpatients and fever in hospitalised children (75%). Three children from the hospitalised group developed a severe course with increased inflammatory indexes. The clinical picture was more severe in younger children from the hospitalised group. Treatment options were regarded individually in all cases. CONCLUSION: Our study is the first tour knowledge regarding the clinical course of COVID-19 in Polish children. In general, the clinical course of COVID-19 was mild with anosmia and dysgeusia as the most common symptoms. However, in hospitalised children, a severe progression of the disease and less typical signs as aplastic anaemia may be developed.

Estimation of the risk of fibrosis in children with nonalcoholic fatty liver disease.

AIM OF THE STUDY: Assessment of liver fibrosis as a predictive factor of liver-related mortality in children with nonalcoholic fatty liver disease (NAFLD) is crucial. This study aims to estimate the risk of fibrosis using noninvasive markers. MATERIAL AND METHODS: The study group of 49 children with NAFLD (age range 3-16, mean 10.51 ±3.18 years) was created. The diagnosis was based on clinical picture, abdominal ultrasound, and laboratory tests; four children underwent liver biopsy. Then homeostatic model assessment (HOMA-IR) and noninvasive hepatic fibrosis scores were calculated, and patients were divided into four groups depending on body mass index (BMI, obese vs. lean) and aminotransferases. RESULTS: 71.43% of patients were obese, and 14.29% were overweight. We found that overweight children had lower mean corpuscular volume (MCV) than lean patients. In a group of patients with a high risk of fibrosis or significant fibrosis due to pediatric NAFLD fibrosis score (PNFS), higher alanine aminotransferase (ALT) to platelet ratio (APRI) values were observed. The highest values of APRI were found in a group of lean patients with elevated aminotransferases and the highest value of PNFS - among obese patients with elevated aminotransferases. A strong significant correlation between APRI and PNFS was found (r = 0.88). CONCLUSIONS: Apart from aminotransferase activity, complete blood count should be assessed looking for lower MCV caused by iron deficiency. In contrast to FIB-4 (fibrosis score), PNFS and APRI proved to be more accurate in our group. PNFS seems to be appropriate to evaluate fibrosis in a noninvasive diagnostic algorithm.

Skin lesions caused by Orthopoxvirus in children.

INTRODUCTION: The global eradication of smallpox and abandonment of mandatory smallpox vaccination has led to an increased proportion of the population who are immunologically naïve to infections caused by Orthopoxviruses (OPV). AIM: To present the different courses of OPV infection in children and to highlight the diagnostic difficulties in their differentiation from the other inflammatory processes. MATERIAL AND METHODS: We retrospectively evaluated the medical documentation of 5 children with OPV infection. Clinical diagnosis of OPV infection was based on evaluation of animal contact and skin symptoms, characterised by either a single ulcer or disseminated lesions. In all five cases, blood samples and skin swabs were collected from the lesion(s) to identify specific OPV DNA fragments (Vgf, b9R and D11L genes) using PCR. RESULTS: Two children presented with high fever, a single ulcer on the skin and local lymphadenopathy. The three other patients were in good general health and their skin lesions presented as a disseminated vesicular rash. Using the Vgf gene as the target for PCR, OPV infection was confirmed in material collected from skin lesions of all children and in blood samples of 4 children. The B9R and d11L genes tested positive in the skin material of 2 children and blood samples of 2 children. All analysed patients presented a history of ineffective antibiotic therapy. CONCLUSIONS: In the case of unclear necrotising skin lesions in children, the primary diagnosis always includes bacterial dermatitis. However, if the patient has come into contact with animals, diagnosis of OPV infection should also be considered.

Serum proteome assessment in nonalcoholic fatty liver disease in children: a preliminary study.

OBJECTIVES: Nonalcoholic fatty disease (NAFLD) affects 3-10% of the pediatric population, making it the most common chronic liver disease among children. The aim of the study is to identify potential biomarkers enabling the diagnosis of NAFLD and monitoring the course of the disease. METHODS: Proteome analysis was performed in a group of 30 patients (19 boys and 11 girls) in total, of whom 16 children had previously diagnosed NAFLD based on the abdominal ultrasound after excluding other diseases of this organ. RESULTS: A total of 297 proteins have been identified. Thirty-seven proteins (responsible for inflammation, stress response, and regulation of this process) differentiating both experimental groups were identified. Up-regulated proteins included afamin, retinol-binding protein-4, complement components, and hemopexin; while serum protease inhibitors, clusterin, immunoglobulin chains, and vitamin D binding protein were found in the down-regulated group. The correlation between selected proteins and indicators of noninvasive assessment of liver fibrosis (APRI, FIB-4) as well as differences between the serum proteome of patients with normal weight, overweight, and obesity were also assessed. CONCLUSION: The plasma protein profile is significantly altered in nonalcoholic liver disease in children and may prove to be a valuable source of biomarkers to evaluate the extent of liver disease.

First case of convalescent plasma transfusion in a child with COVID-19-associated severe aplastic anemia.

We present the case of a six-year-old girl with severe COVID-19, in whom SARS-CoV-2 was successfully eliminated after convalescent plasma transfusion. Children show a variable clinical course of COVID-19, from asymptomatic to critical. In our patient, we diagnosed COVID-19-associated aplastic anemia with severe pancytopenia. The correlation between SARS-CoV-2 infection with aplastic anemia remains unclear. At the beginning of the disease, we used antiviral drugs and immune modulators as therapy but without any positive results. After providing a transfusion of convalescent plasma, the elimination of SARS-CoV-2 was observed. We did not observe any adverse events of this treatment. The girl still has a diagnosis of aplastic anemia and requires specialist therapy.

Clinical pathology of larval toxocariasis.

Human toxocariasis is a worldwide helminth zoonosis caused by roundworms of the genus Toxocara. Toxocariasis is the most common helminth infection in many countries. Disease caused by Toxocara can be classified into five clinical forms: generalised, neurological, ocular, covert, and asymptomatic. The clinical pathology of toxocariasis largely depends on the form of infection, the intensity of the infection, the larvae localisation, and the age of the host. Because histological and molecular examination of toxocariasis is limited by difficulties in obtaining material to analyse, clinical diagnosis is often based on nonspecific tests, such as the detection of eosinophilia and hyperimmunoglobulinemia E (Hyper-IgE). Specific analysis uses an initial ELISA test to detect anti-Toxocara IgG and requires confirmation for all positive results via Western blot. This strategy does not distinguish between actual and recent infections, making the monitoring of disease a challenge for clinicians. Additional research will be required to distinguish active disease from the presence of recent infection.

Epstein-Barr virus infection with acute acalculous cholecystitis in previously healthy children.

BACKGROUND: Acute acalculous cholecystitis (AAC), an inflammatory process of the gallbladder (GB) in the absence of gallstones, typically occurs in seriously ill patients. AAC can complicate primary Epstein-Barr virus (EBV) infection, but it is an atypical clinical presentation. AIM: The aim of our study was to analyse AAC occurrence in children with primary symptomatic EBV infection who had been admitted to the hospital. METHODS: We retrospectively evaluated the medical documentation of 181 children with EBV infection who were diagnosed based on the presence of viral capsid antigen IgM antibodies. All EBV-positive patients underwent transabdominal ultrasonography of the liver in the supine and right anterior oblique positions. Fifteen children who presented with AAC symptoms, including abdominal pain and a positive Murphy's sign, were analysed as a subsample and re-evaluated after 2-3 months. RESULTS: The incidence of AAC in children hospitalised with infectious mononucleosis (IM) was estimated at 8.3%. Analysis of the laboratory results confirmed that the C-reactive protein (CRP) concentration was the only parameter which was higher in children who presented with AAC symptoms. The mean number of leucocytes and monocytes and liver enzyme activities were not significantly higher. The radiological findings of AAC were evident: increased GB wall thickness, non-shadowing echogenic sludge and pericholecystic fluid collection. CONCLUSION: AAC during primary EBV infection appears to be a more common pathology than previously suspected. Its relatively mild nature and the lack of laboratory abnormalities mean that ultrasonographic examination is required for diagnosis. This might explain why the prevalence in children is underestimated.

Autoimmune encephalitis with GABAA receptor antibodies in a 10-year-old girl.

Recent studies have indicated that some cases of nonparaneoplastic autoimmune encephalitis in children can be caused by a systemic autoimmune disorder that generates autoantibodies to cell membrane proteins. We describe the clinical features of a 10-year-old girl with autoimmune encephalitis with autoantibodies against the GABAA receptor in whom type 1 diabetes mellitus developed during the course of the disease. The diagnosis was based on the progressive course of disease, pleocytosis in the cerebrospinal fluid (CSF), inflammatory changes in the brain and autoantibodies against the GABAA receptor detected in serum (absent in CSF). The treatment of encephalitis included intravenous immunoglobulins, intravenous methylprednisolone, oral prednisolone, cycles of plasmapheresis; this led to temporary remission. Finally, rituximab was applied as a second-line therapy with positive results.

Higher expression of inhibitory CD158b and CD158e NK cell receptor and age predicts treatment response in children with chronic hepatitis C.

Treatment with pegylated interferon-α and ribavirin (PEG-IFN/RBV) is the only choice for chronic hepatitis C (CHC) in children. Natural killer (NK) cells were described to play a vital role in CHC. The aim of this study was to analyze the expression of peripheral blood NK cell receptors in their relation to PEG-IFN/RBV treatment response. Study included 26 children with CHC-13 boys, age range 13.42 ± 3.28 years. Blood for biochemical, virological and cytometric testing was taken for evaluation prior to the antiviral treatment. NK cell receptors were detected by flow cytometry and the results were presented as proportion of cells and mean fluorescence intensity (MFI). Therapy consisted of PEG-IFNα-2b (60 µg/m2 s.c 1×/week) and RBV (15 mg/kg p.o. daily). Treatment duration was response-related and varied from 12 to 72 weeks. Rapid virological response (RVR) was evaluated in the 4th week and sustained virological response (SVR) 6 months after completion of the therapy. RVR children were younger (11.67 ± 3.74 vs 15.35 ± 2.42; p = 0.001) and displayed higher CD158b (3.58 ± 0.16 vs 3.45 ± 0.13; p = 0.038) and CD158e expression (4.33 ± 0.21 vs 4.03 ± 0.16; p = 0.039). Density of CD158b (logMFI = 3.68 ± 0.22 vs 3.36 ± 0.16; p = 0.036) and CD158e expression was significantly higher (4.37 ± 0.14 vs 4.12 ± 0.21; p = 0.046) and NKG2D expression significantly lower (97.50 ± 3.46 vs 94.92 ± 5.93; p = 0.049) in SVR children. SVR children were also significantly younger (12.40 ± 3.66 vs 15.13 ± 2.83; p = 0.003). Significance of the age of patients, and expression of CD158b and CD158e were confirmed in univariate and multivariate analysis. Age of patients is negatively related to RVR and SVR. NK cell phenotype with higher expression density of CD158b and CD158e receptor was a positive predictor of SVR.

Expression of Natural Killer Cell Inhibitory Receptors is Associated with Significant Liver Injury in Chronic Hepatitis C in Children.

INTRODUCTION AND AIM: Natural Killer (NK) cells play an important role in innate immune response to viral infections and their high proportion is situated in the liver. The aim of this study was to analyze possible relation between the expression of NK cell receptors and varied intensity of liver lesions in chronic hepatitis C (CHC) in children. MATERIAL AND METHODS: Study included 105 children with CHC - 54 boys and 51 girls, age 13.62 ± 3.48 years. Blood specimens were taken at the day of the liver biopsy. Histological evaluation was performed according to METAVIR scoring system. Circulating NK cells were evaluated by flow cytometry. The results were shown as a proportion of cells expressing evaluated receptor and its' mean fluorescent intensity (MFI). RESULTS: In 58 children with CHC (55.2%) significant liver fibrosis was observed ( ≥F2). Higher proportion of cells expressing CD158e inhibitory receptors was observed in the group of children with ALT > 2UNL (21.11 ± 14.60 vs. 12.22 ± 8.99%; p = 0.037). While higher proportion of cells expressing inhibitory CD158b receptor was observed in children with significant fibrosis (F ≥ 2) compared to minimal fibrosis (F < 2) - (34.14 ± 12.44 vs. 27.48 ± 8.71%; p = 0.049). Children with advanced fibrosis (F ≥ 3) had higher MFI of NK cell CD 158b receptor than children with fibrosis scored F < 3 - (5344.20 ± 3407.49 vs. 2979.67 ± 1190.64; p = 0.049). Proportion of NK cells expressing CD158b was found a predictor of significant fibrosis in univariate analysis - [OR 1.065; 95%CI (1.07-1.15); p = 0.046]. CONCLUSIONS: Higher proportion of NK cells expressing inhibitory CD158b and CD158e receptors is associated with significant liver injury.

Active hospital-based surveillance of invasive pneumococcal disease and clinical pneumonia in infants and young children in two Polish counties.

INTRODUCTION: Invasive pneumococcal disease (IPD) incidence, serotype distribution, and antibiotic susceptibility of Streptococcus pneumoniae were estimated in children aged 28 days to < 60 months. MATERIAL AND METHODS: One-year prospective, hospital-based surveillance was conducted starting on February 15, 2008, at two children's hospitals serving the city and surrounding county of Poznan and Poznanski, Poland. Eligible children had fever ≥ 39.0°C or physician-suspected IPD. Blood cultures were obtained from all children, cerebrospinal fluid in suspected meningitis cases, and chest radiographs (CXRs) in suspected pneumonia cases. RESULTS: Seven of 1,581 eligible children had confirmed IPD. Estimated IPD incidence per 100,000 children was 11.89 (95% CI: 4.78-24.50) overall and 20.1 (95% CI: 6.52-46.84) in subjects aged 28 days to < 24 months. One S. pneumoniae isolate of each of the following serotypes was obtained: 6B, 14, 23A, 23F, and 33F. Two isolates were resistant to both trimethoprim-sulfamethoxazole and erythromycin. Clinical pneumonia incidence among children aged 28 days to < 24 months and 24 months to < 60 months was 3,151.3 (95% CI: 2934.7-3379.7) and 962.7 (95% CI: 861.2-10,072.9) per 100,000 children, respectively. CXR-confirmed pneumonia rates in the same groups were 1,035.7 (95% CI: 913.2-1,170.1) and 379.8 (95% CI: 317.1-451.3) per 100,000 children, respectively. CONCLUSIONS: IPD is an important cause of morbidity in Poznan and Poznanski county, Poland. Among participants aged < 5 years with fever or suspected IPD, pneumonia was the most common diagnosis and was highest in children aged < 24 months.

Neurologic Complications Caused by Epstein-Barr Virus in Pediatric Patients.

We retrospectively analyzed the medical documentation of 194 children infected with Epstein-Barr virus. The diagnosis was based on clinical symptoms and the presence of the viral capsid antigen IgM antibody. Patients with severe neurologic complications also underwent neurologic examination, magnetic resonance imaging (MRI), and electroencephalography (EEG). There were 2 peaks in incidence of infection; the first one in young children aged 1 to 5 years represented 62.0% of cases. The second peak (24.6% of patients) occurred in teenagers. Febrile seizures were confirmed in 3.1% of affected children younger than 5 years and headaches in 24.2% patients, mostly older children. Ten children presented severe, neurologic complications: meningoencephalitis, acute encephalitis, acute cerebellitis, transverse myelitis, and myeloradiculitis. Our study identified a variety of Epstein-Barr virus-related neurologic complications. Epstein-Barr virus should be routinely tested for when a child presents with an apparent neuroinfection as it is a common pathogen that can induce a wide variety of signs and symptoms.

Polish consensus guidelines on the use of acyclovir in the treatment and prevention of VZV and HSV infections.

A physician has to perform a benefit-risk assessment each time acyclovir is prescribed "off label" for children. A group of Polish infectious disease experts was created to develop evidence-based guidelines on the use of acyclovir in the treatment and prevention of varicella zoster and herpes simplex infections. In primary varicella zoster virus infections, oral acyclovir treatment is recommended in children over 12 years of age and should be considered in younger children who fall into one of the groups at risk of severe varicella. Intravenous acyclovir therapy in varicella is recommended in patients with immune deficiencies, newborns and in complicated cases. When there is a justified need for prevention of varicella, oral acyclovir prophylaxis may be considered if immunoglobulin cannot be administered, and if it is too late for vaccination. Oral acyclovir treatment of herpes zoster may be beneficial to otherwise healthy patients with a rash in places other than the trunk and in patients over 50 years of age. In immunocompetent patients with herpes simplex infections, indications for treatment with oral acyclovir include primary (genital herpes, skin herpes in children with atopic dermatitis, ocular herpes simplex, severe gingivostomatitis, paronychia and pharyngitis) and recurrent infections. Intravenous acyclovir should be administered for herpes infections in neonates, immunocompromised patients and patients who develop complications including neurological.

Successful outcome of therapy of acute hepatitis C following sexual and parenteral exposure - report of two cases.

Acute hepatitis C (AHC) remains difficult to diagnose due to its asymptomatic course. The manuscript presents two children with AHC after known sexual and parenteral exposure, which allowed for close monitoring. Both developed increased aminotransferase activity, though the viral load was significantly higher after parenteral exposure. Lack of hepatitis C virus (HCV) clearance led to therapy with recombinant interferon-α with good toleration and response. The conclusion is that treatment of AHC was effective and well tolerated.

The significance of Bartonella henselae bacterias for oncological diagnosis in children.

BACKGROUND: Cat-scratch disease (CSD) is a common infection in children; however, the wide spectrum of its clinical picture may lead to delayed diagnosis. An unusual presentation of CSD includes in the differential diagnosis malignant diseases, Epstein-Barr and cytomegalovirus infections, tuberculosis, and mycobacterioses. The diagnostic procedure is difficult, and it is important to consider CSD as the etiology of untypical lesion. PATIENTS AND METHOD: We present the analysis of 22 immunocompetent children treated with the clinical diagnosis of CSD in our hospital. Their ages were 2 to 16 years (mean 9.15 ± 2.2 years). Four of them presented classical papulas at admission time. Asymmetric, local lymphadenopathy was present in 16 patients. Five children, who presented an untypical course of CSD mimicking the oncological process, were analysed carefully. There were 3 patients with skull osteomyelitis, 1 with inflammation of the parotid gland, and 1 with an extra peripharyngeal mass. The diagnosis in these children was based on epidemiological, radiological, serological, and histological factors. RESULTS: About 25 % of children with bartonellosis present an untypical spectrum of symptoms, including the lack of documented cat contact, primary lesions, or peripheral lymphadenopathy. Radiological methods like USG, CT, MRI present the unspecific masses, but they are not enough to distinguish the Bartonella inflammatory and oncological process. The final diagnosis was based on a histological method with additional polymerase chain reaction test. CONCLUSION: CSD should be considered in differential diagnosis of any patient with untypical lesions located on the head, neck, and upper extremities.

Cat-scratch disease: a wide spectrum of clinical pictures.

The aim of this review is to present an emerging zoonotic disease caused by Bartonella henselae. The wide spectrum of diseases connected with these bacteria varies from asymptomatic cases, to skin inflammation, fever of unknown origin, lymphadenopathy, eye disorders, encephalitis and endocarditis. The reservoirs of B. henselae are domestic animals like cats, guinea pigs, rabbits and occasionally dogs. Diagnosis is most often based on a history of exposure to cats and a serologic test with high titres of the immunoglobulin G antibody to B. henselae. Most cases of cat-scratch disease are self-limited and do not require antibiotic treatment. If an antibiotic is chosen, however, azithromycin has been shown to speed recovery.

Pulmonary presentation of Toxocara sp. infection in children.

INTRODUCTION: The aim of this study was to investigate the associations between radiological findings, blood eosinophilia, hyperimmunoglobulinemia E and G and Toxocara seropositivity in Polish children with newly diagnosed pulmonary infiltration. MATERIAL AND METHODS: We retrospectively analyzed the documentation of 119 patients, aged 1 to 18 years (mean age: 7.21 ± 4.82), who were seropositive in Toxocara sp. antibodies. In all cases, peripheral blood eosinophils and leukocyte counts, serum total IgE, IgG levels and specific IgG antibodies against excretory and secretory Toxocara sp. antigens were measured at the first presentation. After the confirmation of seropositivity, all children had a routine radiological examination. RESULTS: In the documentation of 23 children (mean age 3.58 ± 2.63 years) we found abnormalities in the radiological examination of their lungs. Fifteen children who had abnormalities in radiological findings presented clinical respiratory complaints such as chronic cough, wheezing, asthma and haemoptysis. Eight children were asymptomatic. The analysis of peripheral eosinophils and leukocyte number, the level of IgE and specific anti-Toxocara IgG presented significantly higher values in children with radiological lesions than in children who had correct radiology. The concentrations of total IgG and gamma globulins were not significantly different. In 10 patients CT showed irregular round nodules with and without halo ranging from 1 to 13 mm. The number of nodules varied from a single lesion to multiple, disseminated ones. All nodules were located in peripheral areas of the lungs. None of them were found in the central areas. In 13 patients, CT images showed ground-glass opacities with ill-defined margins. None of the CT images presented lymphadenopathy and pleural effusion. CONCLUSION: The pulmonary lesions in small children with high eosinophilia and hyperimmunoglobulinemia E could be related to toxocariasis and for this reason they are eligible to undergo therapy with prolonged observation for several months, rather than start invasive malignancy investigations.

Transient lesion in the splenium of the corpus callosum due to rotavirus infection.

Transient signal changes in magnetic resonance imaging (MRI) of the splenium of the corpus callosum (SCC) can result from many different reasons, including encephalitis and encephalopathy caused by infection, seizures, metabolic disorders and asphyxia. We report a case of a 6-year-old Polish girl with rotavirus infection demonstrating a reversible SCC lesion on diffusion-weighted MRI images. She presented six episodes of generalized tonic seizures with mild acute gastroenteritis. Stool test for rotavirus antigen was positive. At the time of admission imaging showed the hyperintense region in T2-weighted and fluid-attenuated inversion-recovery MRI, a well-defined lesion in the splenium of the corpus callosum with restricted diffusion in diffusion-weighted MRI and no enhancement in post contrast T1-weighted imaging. Her first EEG showed slow brain activity in the posterior occipitotemporal portion, consisting mainly of theta waves with a frequency of 4.5-5.5 Hz and amplitude of 40 uV. The lesion had completely disappeared on follow-up MRI 10 days later. The patient recovered fully without any sequelae.