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Objective:To compare the efficacy of combination therapy on cyclic vomiting syndrome(CVS)in children, and improve the efficacy of CVS treatment in the future.Methods:This study retrospectively analyzed patients′ medical records of CVS, which were admitted to Digestive Department of Beijing Children′s Hospital from 2012 to 2019.The treatment regimen was A(Cyproheptadine+ Doxepin+ Valproate), B(Propranolol+ Cyproheptadine), or C(Propranolol+ Amitriptyline). Meanwhile, the patients should take drugs more than three months.The clinical data of 42 cases were analyzed retrospectively, and the treatment effect after discharge was followed up by telephone until October, 2020.Results:Among the 42 cases, 17 were male and 25 were female, whose mean age of onset was (4.65±3.23) years, and the age of diagnosis was (6.79±3.58) years.The main accompanied symptoms were abdominal pain and upper gastrointestinal bleeding.Forty-two patients were moderate/severe CVS.The regimens A, B and C were observed in 7, 11, and 24 patients, respectively.The age at improvement was(8.17±4.12)years.The course of treatment was(1.37±0.96)years.The age at follow-up was(10.32±4.03)years.During the 1-year follow-up, 35 cases were effective, and the efficiency was 83.3%.Among them, 23 cases had no paroxysmal vomiting and 7 cases had no effect.There was no significant difference in therapy effects among group A, B and C. Between the effective group and non-effective group, there were statistical differences in the personal history of hiatus hernia( P=0.024), the weight at follow-up ( P=0.042), and the course of medication( P=0.020). Conclusion:The combination regimen has a higher effective rate in the treatment of CVS.There was no significant difference among the three regimens in the treatment of CVS.For children with refractory CVS, who can not be treated with combination therapy, individualized therapy should be further developed.
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Cyclic vomiting syndrome(CVS)is a functional gastrointestinal disorders, which the pathophysiology remains unclear.CVS usually occurs during childhood.With the increasing recognition of the diagnosis of CVS in children, therapeutic regimens become crucial.Therefore, according to the current research progress, this review summarized the therapeutic strategies of the four phases of CVS: the prodromal phase, the emetic phase, the recovery phase, and the inter-episodic or asymptomatic phase, including drugs dose and the modes of administration, which would help pediatricians to optimize the therapeutic regimes.
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Background: Cyclic vomiting syndrome is an increasingly recognized disorder with sudden, repeated episodes of severe nausea, vomiting, and physical exhaustion that occur with no apparent cause. It is more common in children than adults. However, we don't often see a diagnosis of cyclic vomiting syndrome being made. Hereby we report 7 cases of cyclical vomiting.Methods: This is a retrospective study. Medical records of 5 years were review and consecutive paediatric patients discharged with a diagnosis of cyclic vomiting syndrome were identified, data collected and analysed.Results: Total of 7 cases were found, all of which were adolescents. The mean age was 13.28. 57.14% (4) were females and 42.86% (3) were boys. 42.86% (3) presented with complications. 14.28% (1) had an association with menstrual cycles and 14.28% (1) had an association with psychological stress.Conclusions: Cyclic vomiting syndrome should be kept in mind when a child presents with multiple episodes of vomiting, especially when repeated admissions have been made for the same. Early diagnosis and treatment can improve the quality of life.
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Patients with cyclic vomiting syndrome usually have comorbid psychological disorders,the trigger and aggravating factors of gastrointestinal symptoms.It may decrease the quality of life and the response to the conventional therapies,bring the patients to seek medical care frequently and perform unnecessary examinations,result in the waste of medical resources.We reported a 20-year-old woman with complaint of recurrent vomiting since infant,and less response to symptomatic and supportive treatment.Her vomiting relieved with antidepressant after consultation with gastroenterological specialist and psychologist.Physicians should pay more attention to recognize the comorbid psychological disorders in patients with functional gastrointestinal disorders (FGIDs),including cyclic vomiting syndrome.It is important to refer the patients with refractory symptoms to the psychologists for further professional evaluation and antidepressants.
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RESUMO Os autores relatam um caso da enfermaria psiquiátrica do Hospital Geral Santa Casa de Misericórdia de Sorocaba-SP. Paciente gestante, de 19 anos, usuária crônica de maconha que apresenta náuseas e vômitos intensos não responsivos aos antieméticos, associados a dor abdominal, agitação psicomotora e hábito compulsivo de tomar banhos quentes para alívio dos sintomas, quadro que caracteriza a SHC. Trata-se de uma síndrome rara, com efeito paradoxalmente emetogênico da maconha. É subdiagnosticada e relacionada ao uso crônico e intenso de maconha. Destacamos que não foi encontrada descrição de caso na literatura brasileira. A conclusão deste relato reporta a importância do reconhecimento e categorização da síndrome e sua correlação com a dependência de maconha, pois o tratamento implica a suspensão do uso de maconha, tratamento da dependência, além da prevenção de suas complicações clínicas.
ABSTRACT The authors report a case from the psychiatric department of a general hospital (Santa Casa de Misericordia at Sorocaba city, São Paulo, Brazil). A patient, 19-year-old, pregnant woman, marijuana chronic user, presenting abdominal pain, psychomotor agitation, unmanageable nausea, severe vomiting, not responsive to antiemetic drugs, associated with compulsive hot water showering. Cannabinoid hyperemesis syndrome is sub-diagnosed and rare, characterized by those three symptoms: heavy marijuana use, vomiting and repeated hot showering. There is no prior report in Brazilian medical literature. This paper aims to emphasize the importance of recognizing and categorizing this syndrome and its correlation to marijuana use. Main treatment is supportive care, withdrawing substance and supportive carries to suspension of marijuana use as well as clinical complications prevention.
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<p>A 19-year-old man was referred to our clinic for frequent nausea and vomiting. At age 16, he started to have periodic bouts of nausea and vomiting. During an attack, he would experience vomiting more than ten times a day and was unable to eat, which resulted in hospitalization for a week. Inpatient investigations did not reveal any abnormalities except dehydration. Between attacks, he was asymptomatic. Initially, he had attacks a few times a year. However, beginning at age 19, the attacks occurred almost every month. At our clinic, routine physical examination and laboratory tests were unremarkable. On Kampo medical examination, he had <i>qi </i>stagnation and <i>qi </i>counter-flow. He was diagnosed with cyclic vomiting syndrome. Hangekobokuto was administered with improvement of his symptoms. Hangekobokuto may be effective for cyclic vomiting syndrome with <i>qi </i>stagnation and <i>qi </i>counter-flow as diagnosed with Kampo medicine. This suggests the effectiveness of Kampo medicine in functional gastrointestinal disorders.</p>
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Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction of the stomach. Approximately 20∼40% of patients with a long course of diabetes mellitus and/or other complications, especially neurologic dysfunction, develop diabetic gastroparesis. Diabetic gastroparesis has been thoroughly investigated; however, few reports have considered an associated episodic cyclic vomiting pattern. We present a literature review and report the case of our recent experience with a 29-year-old male patient who presented with a cyclic vomiting pattern associated with diabetic gastroparesis.
Subject(s)
Adult , Humans , Male , Diabetes Mellitus , Gastric Emptying , Gastroparesis , Neurologic Manifestations , Stomach , VomitingABSTRACT
BACKGROUND/AIMS: Cyclic vomiting syndrome (CVS) is a disabling migraine variant manifesting as severe episodes of nausea and vomiting and often refractory to many therapies. Gastric electrical stimulation (GES), which can reduce nausea and vomiting in gastroparesis, may provide symptomatic relief for drug-refractory CVS. This study assessed the utility GES in reducing the symptoms of CVS and improving the quality of life. METHODS: A one-year, non-randomized, clinical study was conducted. Eleven consecutive patients with drug refractory, cyclic vomiting syndrome based on Rome III criteria and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), underwent treatment with temporary GES (Temp GES) and permanent GES (Perm GES). Post-treatment follow up was done up to one year after permanent gastric electrical stimulation therapy. RESULTS: Total symptom score decreased by 68% and 40% after temporary and permanent GES therapies, respectively. Hospital admission events significantly decreased to 1.50 (± 1.00) events from 9.14 (± 7.21) annual admissions prior to treatment with permanent GES. Vomiting episodes fell by 83% post Temp GES and 69% after Perm GES treatments. Mucosal electrogram values also changed after temporary stimulation. CONCLUSIONS: In a small group of drug-refractory CVS patients, treatments with temporary and permanent GES significantly reduced the severity of gastrointestinal symptoms and frequency of hospital admissions.
Subject(s)
Humans , Clinical Study , Electric Stimulation Therapy , Electric Stimulation , Follow-Up Studies , Gastroenterology , Gastroparesis , Migraine Disorders , Nausea , Quality of Life , VomitingABSTRACT
BACKGROUND/AIMS: The aim of this study was to compare the efficacy and tolerability of topiramate and propranolol in preventing pediatric cyclic vomiting syndrome. METHODS: A retrospective medical-record review of patients who underwent prophylaxis after receiving a diagnosis of cyclic vomiting syndrome was performed. Patients who completed at least 12 months of treatment were included in the analysis. Responder rate, and adverse-event rates were also calculated from all patients. Response to treatment was assessed as the total number of vomiting attacks per year. Patients in whom the frequency of vomiting attack reduced greater or equal to 50% were defined as responders, and the remaining patients were classified as nonresponders. RESULTS: A total of 38 patients who were treated prophylactically with either topiramate (16 patients) or propranolol (22 patients) were identified. Fifty-nine percent of the patients in the propranolol group and 81% of the patients in the topiramate group reported freedom from attacks. A decrease of more than 50% in attacks per year occurred in 23% of patients in the propranolol group and 13% of patients in the topiramate group. The responder rates were 81% for propranolol group and 94% for topiramate group (P = 0.001). Despite minor adverse effects (drowsiness, nervousness, and dizziness) observed in a few patients, the adverse event rates were not significantly different between the 2 groups (P = 0.240). CONCLUSIONS: The efficacy of topiramate was superior to propranolol for the prophylaxis of pediatric cyclic vomiting syndrome.
Subject(s)
Humans , Anxiety , Diagnosis , Freedom , Propranolol , Retrospective Studies , VomitingABSTRACT
Cyclic vomiting syndrome is characterized by recurrent episodes of stereotyped vomiting separated by regular symptom-free periods. We describe a case of cyclic vomiting syndrome developed after stroke, which has not been reported to date. A 69-year-old woman experienced recurrent vomiting following left cerebral infarct. The patient's vomiting pattern was consistent with cyclic vomiting syndrome, and the diagnosis of cyclic vomiting syndrome was established by exclusion of other known disorders which could have resulted in vomiting. She was treated with imipramine hydrochloride and her symptom was well controlled.
Subject(s)
Aged , Female , Humans , Imipramine , Stroke , VomitingABSTRACT
Functional nausea and vomiting is a broad term used to be described a subset of individuals who have chronic nausea and vomiting without apparent cause, despite extensive evaluation. According to the Rome III criteria, functional nausea and vomiting can be subdivided into three separate entities: chronic idiopathic nausea, functional vomiting and cyclic vomiting syndrome. Although no specific test can diagnose these diseases, the diagnostic approach requires excellent history taking combined with judicious diagnostic testing to exclude some organic cause of chronic nausea and vomiting. These conditions are probably not psychogenic in origin. Treatment remains empirical for all patients with functional nausea and vomiting. Reassurance and supportive physician-patient relationship, along with use of low-dose tricyclic antidepressants, can be beneficial in caring for patients with chronic idiopathic nausea and functional vomiting. The cornerstones of management for patients with cyclic vomiting syndrome are identifying and avoidance of triggering factors, treatment with prophylactic antimigraine agents, 5-HT3 antagonists, benzodiazepines and 5-HT1 agonists (sumatriptan), with supportive therapy.
Subject(s)
Humans , Antidepressive Agents, Tricyclic , Benzodiazepines , Diagnostic Tests, Routine , Nausea , Rome , Serotonin 5-HT1 Receptor Agonists , Serotonin 5-HT3 Receptor Antagonists , VomitingABSTRACT
The aim of this case report was to evaluate the psychiatric co-morbidity and efficacy of mirtazapine treatment in young subjects with chronic or cyclic vomiting syndromes. This is a case series of 8 young subjects (age range of 6-16 years, 11.12 +/- 3.52 years) who were referred or consulted to child psychiatry department. They were referred or consulted by pediatric gastroenterology or surgery departments for the presence of non-remitting and medically unexplained vomiting. They were investigated for co-morbid psychiatric disorders using a structured psychiatric interview. An open trial of mirtazapine was conducted for the treatment and/or prevention of vomiting. Primary outcome measure was Clinical Global Impression-Improvement scale. Subjects were diagnosed with chronic (n = 5) or cyclic (n = 3) vomiting syndromes. Duration of vomiting ranged from 6 months to 10 years (3.5 +/- 3.2 years). All subjects received multiple psychiatric diagnoses with anxiety disorders being the most frequent. Maximum mirtazapine dosage was 7.5-30 mg/day (16.00 +/- 6.16 mg/day). Three subjects showed complete remission and 5 subjects showed much to very much improvement in vomiting. Most frequent side effects were increased appetite, weight gain and sedation. Young subjects with chronic or cyclic vomiting may frequently suffer anxiety and/or depressive symptoms or disorders. Mirtazapine could be an effective treatment option for the treatment of vomiting and co-morbid anxiety or depressive disorders in these subjects. More systematic research are needed on this topic.
Subject(s)
Child , Humans , Anxiety , Anxiety Disorders , Appetite , Child Psychiatry , Depression , Depressive Disorder , Gastroenterology , Gastrointestinal Diseases , Mianserin , Outcome Assessment, Health Care , Vomiting , Weight GainABSTRACT
Functional gaonic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. The Rome II pediatric criteria for FGIDs were announced in 1999. The Rome III criteria, update and revise the pediatric criteria, included FGIDs criteria of infant and toddler to child and adolescent (aged 4 to 18 years). The aerophagia was classified into abdominal pain-related FGIDs in the ROME II criteria. However, cyclic vomiting syndrome and aerophagia, both were classified into vomiting and aerophagia part in the ROME III criteria. We describe the clinical features, diagnostic criteria, and treatments of cyclic vomiting syndrome and aerophaiga among pediatrstrointestinal disorders (FGIDs) are defined as a chric FGIDs
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Adolescent , Child , Humans , Infant , Gastrointestinal Diseases , Rome , VomitingABSTRACT
There are many causes of chronic and/or recurrent vomiting. The differential diagnosis is sometimes difficult because the clinical manifestations are often similar with each other. In this review, common causes of chronic and/or recurrent vomiting, and a general approach to children with vomiting are described. The involuntary passage of ingested material from the stomach into the esophagus, gastroesophageal reflux (GER), is a common event in infants. GER-disease can arise when the refluxed material causes esophagitis, resulting in pain, impaired esophageal function, poor growth or some respiratory symptoms. Esophageal impedance-pH meter will be the golden standard test in these cases. Parental reassurance and dietary management are expected to be the important components of managing mild GER-disease. Eosinophilic esophagitis is a clinicopathological disease characterized by (1) Feeding intolerance and GER-disease symptoms in children; (2) >15 eosinophils/HPF; (3) Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD. Appropriate treatments include dietary approaches based upon eliminating exposure to food allergens, or topical corticosteroids. Cyclic vomiting syndrome (CVS), a paroxysmal, especially severe, recurrent vomiting disorder, may be second to GER-disease as a cause of recurrent vomiting in children. It is highly incapacitating brain-gut disorder. The different diagnosis of CVS cuts a broad swath across neurologic, gastrointestinal, renal, metabolic, and endocrinologic disorders. Treatment is divided between acute intervention, when a patient is actively and severe vomiting, and prophylactic treatment in their interictal phase, the goal of which is reducing frequency and intensity of subsequent episodes.
Subject(s)
Child , Humans , Infant , Adrenal Cortex Hormones , Allergens , Diagnosis, Differential , Eosinophilic Esophagitis , Esophagitis , Esophagus , Gastroesophageal Reflux , Parents , Stomach , VomitingABSTRACT
Objective To analyze the clinical characteristics of children with cyclic vomiting syndrome (CVS), summarize the clinical experience, and improve the awareness,diagnosis and treatment level of CVS.Methods The clinical data and results of long-term follow-up of the children with CVS were collected and analyzed from 1995 to 2009 in our department.Results Forty-six children were enrolled in the study, including 22 boys and 24 girls.Mean onset age was 4.5 years(ranged from 1 to 11 years)and the mean age at final diagnosis was 8.5 years (ranged from 4.5 to 14.5 years).Sixty-six and seventy-four percent of patients had family history of migraine and motional sickness respectively,whereas 83% patients had triggers.The clinical manifestation of CVS was severe episodic vomiting.The episodes had a rapid onset and sudden ending,persisted for several hours to days,and were separated by symptom-free intervals.The incidental symptoms were pallor, lethargy,intractable nausea,abdominal pain,headache,photophobia and dizzy.Twenty-nine patients diagnosed were followed up for 5 years at average.Five patients were treated with valproate,4 with cyproheptadine, 5 with cyproheptadine and valproate,5 with amitriptyline,cyprohep tadine and valproate,and 3 with cyproheptadine and flunarizine.All treated patients recovered mean 10 months(1.5 months to 2 years) years later and displayed the reduced number of episodes or the severity of episodes except 3 patients.Twenty-eight percent (8/29) of patients progressed to migraine headaches.Conclusion CVS is a relatively common disease in children and awareness of the condition should be increased.CVS should be considered when patients had recurrent vomitting and were completely healthy between the two episodes after excluding other pathological conditions.
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Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder that can occur in both children and adults. Clinical courses of CVS manifesting recurrent severe vomiting episodes and interval illness may affect the long-term quality of life in children with CVS. Therefore, we should be careful in accessing a patient suggestive of CVS. Accurate diagnosis based on diagnostic criteria for CVS and the exclusion from other organic diseases mimicking clinical manifestations of cyclic vomiting is absolutely required. In patients diagnosed as CVS, optimal therapy should be performed to improve symptoms and to reduce complications in prodromal phase and emetic phase, and long-term prophylactic therapy should be tried to prevent the development of vomiting episodes. The identification of triggering factors which induce vomiting episodes might be helpful in preventing vomiting attacks. Systematic approach should be recommended to improve clinical outcome of CVS.
Subject(s)
Adult , Child , Humans , Gastrointestinal Diseases , Quality of Life , VomitingABSTRACT
Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent episodes of incapacitating nausea and vomiting interspersed with symptom free periods. Common triggers of cyclic vomiting include noxious stress, excitement, fatigue and menstrual period. Here, we report a case of cyclic vomiting syndrome in adult patient characterized by stereotypical vomiting attack, occurring in every menstruation period. Recurrent vomiting episodes began 6 years ago and we treated this patient with subcutaneous injection of goserelin, a gonadotropin-releasing hormone analogue (GnRHa) and oral estrogen. After 4 months of therapy, she was symptom free for the following 5 years, even with the resumed normal menstruation. Recurrence of vom - iting attack with same pattern occurred 1 month before readmission. Treatment with intravenous lorazepam aborted vomiting, but could not prevent recurrences of vomiting and epigastric pain. We treated the patient with GnRHa and oral estradiol again which effectively prevented recurrence of the symptoms.
Subject(s)
Adult , Female , Humans , Estradiol , Estrogens , Fatigue , Gonadotropin-Releasing Hormone , Goserelin , Injections, Subcutaneous , Lorazepam , Menstruation , Nausea , Recurrence , VomitingABSTRACT
PURPOSE: To evaluate the clinical features and characteristics of childhood periodic syndromes (CPS) in Korea using the new criteria of the International Classification of Headache Disorders (ICHD)-II. METHODS: The study was conducted at pediatric neurology clinics of five urban tertiary-care medical centers in Korea from January 2006 to December 2007. Patients (44 consecutive children and adolescents) were divided into three groups (cyclic vomiting syndrome [CVS], abdominal migraine [AM], and benign paroxysmal vertigo of childhood [BPVC]) by recurrent paroxysmal episodes of vomiting, abdominal pain, dizziness, and/or vertigo using the ICHD-II criteria and their characteristics were compared. RESULTS: Totally, 16 boys (36.4%) and 28 girls (63.6%) were examined (aged 4-18 yr), with 20 CVS (45.5%), 8 AM (18.2%), and 16 BPVC (36.4%) patients. The mean age at symptom onset was 6.3+/-3.6 yr, 8.5+/-2.7 yr, and 8.5+/-2.9 yr in the CVS, AM, and BPVC groups, respectively, showing that symptoms appeared earliest in the CVS group. The mean age at diagnosis was 8.0+/-3.4 yr, 10.5+/-2.6 yr, and 10.1+/-3.2 yr the CVS, AM, and BPVC groups, respectively. Of the 44 patients, 17 (38.6%) had a history of recurrent headaches and 11 (25.0%) showed typical symptoms of migraine headache, with 5 CVS (25.0%), 2 AM (25.0%), and 4 BPVC (25.0%) patients. Family history of migraine was found in 9 patients (20.4%): 4 in the CVS group (20.0%), 2 in the AM group (25.0%), and 3 in the BPVC group (18.8%). CONCLUSION: The significant time lag between the age at symptom onset and final diagnosis possibly indicates poor knowledge of CPS among pediatric practitioners, especially in Korea. A high index of suspicion may be the first step toward caring for these patients. Furthermore, a population-based longitudinal study is necessary to determine the incidence and natural course of these syndromes.
Subject(s)
Child , Humans , Abdominal Pain , Dizziness , Headache , Headache Disorders , Incidence , Korea , Longitudinal Studies , Migraine Disorders , Neurology , Resin Cements , Vertigo , VomitingABSTRACT
PURPOSE: To evaluate the clinical features and characteristics of childhood periodic syndromes (CPS) in Korea using the new criteria of the International Classification of Headache Disorders (ICHD)-II. METHODS: The study was conducted at pediatric neurology clinics of five urban tertiary-care medical centers in Korea from January 2006 to December 2007. Patients (44 consecutive children and adolescents) were divided into three groups (cyclic vomiting syndrome [CVS], abdominal migraine [AM], and benign paroxysmal vertigo of childhood [BPVC]) by recurrent paroxysmal episodes of vomiting, abdominal pain, dizziness, and/or vertigo using the ICHD-II criteria and their characteristics were compared. RESULTS: Totally, 16 boys (36.4%) and 28 girls (63.6%) were examined (aged 4-18 yr), with 20 CVS (45.5%), 8 AM (18.2%), and 16 BPVC (36.4%) patients. The mean age at symptom onset was 6.3+/-3.6 yr, 8.5+/-2.7 yr, and 8.5+/-2.9 yr in the CVS, AM, and BPVC groups, respectively, showing that symptoms appeared earliest in the CVS group. The mean age at diagnosis was 8.0+/-3.4 yr, 10.5+/-2.6 yr, and 10.1+/-3.2 yr the CVS, AM, and BPVC groups, respectively. Of the 44 patients, 17 (38.6%) had a history of recurrent headaches and 11 (25.0%) showed typical symptoms of migraine headache, with 5 CVS (25.0%), 2 AM (25.0%), and 4 BPVC (25.0%) patients. Family history of migraine was found in 9 patients (20.4%): 4 in the CVS group (20.0%), 2 in the AM group (25.0%), and 3 in the BPVC group (18.8%). CONCLUSION: The significant time lag between the age at symptom onset and final diagnosis possibly indicates poor knowledge of CPS among pediatric practitioners, especially in Korea. A high index of suspicion may be the first step toward caring for these patients. Furthermore, a population-based longitudinal study is necessary to determine the incidence and natural course of these syndromes.
Subject(s)
Child , Humans , Abdominal Pain , Dizziness , Headache , Headache Disorders , Incidence , Korea , Longitudinal Studies , Migraine Disorders , Neurology , Resin Cements , Vertigo , VomitingABSTRACT
PFAPA syndrome is characterized by periodic fevers associated with aphthous stomatitis, pharyngitis, and cervical adenitis and is unusual in infants and children. We report on a case of PFAPA syndrome mimicking cyclic vomiting syndrome in a 42-month-old girl. She had experienced multiple episodes of cyclic vomiting with abdominal pain from age 20 to 30 months. When she was 30 months old, periodic fever with pharyngitis was combined with cyclic vomiting, and when 40 months old, aphthous stomatitis and cervical adenitis were added. These periodic symptoms and signs were not treated with prokinetics or antibiotics. Symptom duration of an episode was 3 days. After cimetidine therapy (150 mg three times daily for 6 months), her febrile and cyclic vomiting episodes ceased. At the time of writing she had not received therapy for 10 months and has remained well without periodic attack.