Levofloxacin-Induced Oromandibular Dystonia in a 9-Year-Old Patient.

Extrapyramidal symptoms (EPS) that include akathisia, dystonia, pseudoparkinsonism, and dyskinesia are abnormal movements commonly induced by antipsychotic medications. These symptoms are also associated with specific non-antipsychotic agents. This case report describes a case of a 9-year-old boy on antibiotics treatment that developed EPS. A 9-year-old boy presented to the emergency department of Imam Hossein Children>s Hospital with chief complaints of trismus, difficulty speaking, and tongue protrusion. One week before these presentations, he had been prescribed Tavanex® (levofloxacin) and clindamycin. His symptoms improved after the withdrawal of antibiotics and administering Biperiden, and he was discharged in good condition. On a follow-up visit one week after discharge, no remaining symptoms were present, and he was in good condition. Based on the questions in the Naranjo criteria, levofloxacin receives a score of 7 and is a probable cause of adverse drug reaction (ADR). Clindamycin, with a score of 6, is also a probable cause for this adverse drug reaction, but clinical judgment was in favor of levofloxacin as the culprit. Clinicians should be aware of the potential EPS of levofloxacin at standard doses. Effective management of adverse events is necessary to ensure patient safety and optimal outcomes.

Autoimmune Encephalitis Due to COVID-19 in a Young Patient.

Autoimmune encephalitis is an inflammatory condition caused by different factors, including viral infections, diagnosed after ruling out other causes of encephalitis. The current study reported novel autoimmune encephalitis in an 11-year-old girl who presented with seizures, cognitive dysfunction, and neurological impairments. During the admission, the researchers observed high levels of anti-N-methyl-D-aspartate receptor (NMDAR) antibodies in the cerebrospinal fluid (CSF). Besides, she had positive anti-COVID-19IgG. Therefore, the diagnosis of COVID-19-induced autoimmune encephalitis was specific. The patient received anti-epileptic, anti-viral drugs, IVIG, and rituximab and was discharged with remission. The case diagnosis was made by anti-NMDAR antibodies, which highlights the importance of this diagnostic tool. Similar cases have been reported earlier, but the point of this case was her younger age compared to the previous cases and her developing neurological deficit before COVID-19 presentations.

Reversible Cerebral Vasoconstriction Syndrome and Multisystem Inflammatory Syndrome in Children With COVID-19.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) involves multiple organs and shows increased inflammatory markers. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, several studies have reported the association between severe COVID-19 and MIS-C. Reversible cerebral vasoconstriction syndrome (RCVS) presents with thunderclap headaches and multifocal reversible vasoconstriction on imaging. RCVS is very rare in children. This article reports two cases of pediatric COVID-19 with severe MIS-C and clinical and imaging features indicative of RCVS. METHODS: Clinical, laboratory, and imaging data of the patients were reviewed. The diagnosis of RCVS was confirmed based on clinical symptomatology and brain magnetic resonance imaging findings. RESULTS: Two pediatric patients with clinical findings compatible with severe MIS-C and hemodynamic compromise presented to the hospital. During their hospitalization course, they developed thunderclap headaches and neurological deficits. Both were receiving vasoactive agents, intravenous immunoglobulin, and immunosuppressants. Imaging studies showed marked multifocal cerebral vasoconstriction in both cases and infarcts in one. The course and management of the patients will be presented. After controlling inflammation and elimination of triggers, both patients were ultimately symptom free upon discharge. Cerebral vasoconstriction had completely resolved on follow-up imaging. CONCLUSIONS: Although a variety of symptoms including headaches may be seen in pediatric COVID-19 patients with MIS-C, RCVS should be considered as a differential diagnosis in cases of thunderclap headache accompanied by neurological signs in these patients. Imaging findings and follow-up are also key in establishing the diagnosis.

Efficacy and Safety of Topical Timolol for the Treatment of Facial Angiofibroma in Children with Tuberous Sclerosis Complex.

Objective: This study aimed to assess the efficacy and safety of topical timolol in treating facial angiofibromas (FAs) in pediatric patients with tuberous sclerosis complex (TSC). Methods: A prospective clinical trial was conducted involving 15 children diagnosed with TSC and presenting with FAs. The participants were administered topical timolol gel 0.5% twice daily. Prior to the intervention, the severity of FAs in each patient was evaluated using the FA severity index (FASI), which assessed erythema, size, and extent of lesions. Clinical response was assessed at weeks 2 and 4 during the intervention period as well as 1 month after discontinuation of treatment. Findings: Four weeks after discontinuing topical timolol 0.5%, statistically significant reductions were observed in the mean FASI score, erythema, size, and extent of lesions (P < 0.0001, P < 0.0001, P = 0.012, P = 0.008, respectively). FASI scores at 4 and 12 weeks postintervention, as well as 4 weeks after treatment cessation, demonstrated a significant decrease compared to baseline (P < 0.001). Erythema and extension scores also exhibited a significant decrease 1 month after treatment cessation compared to baseline (P < 0.05), while the mean size of lesions before and after the intervention did not show a statistically significant difference (P = 0.004). Conclusion: Topical timolol 0.5% represents a cost-effective and readily available treatment option for pediatric patients with FAs associated with tuberous sclerosis.

Nasal dexmedetomidine in sedation of electroencephalogram (EEG) in comparison with chloral hydrate as a clinical trial.

BACKGROUND: An electroencephalogram (EEG) is a test that measures the brain's electrical activity. Here we decided to evaluate and compare the effectiveness of two drugs, hydrate, and nasal dexmedetomidine, in creating sedation during EEG in children. METHODS: This clinical trial was performed in 2020-2022 on 65 children that were candidates for sedation for EEG with the Iranian Registry of Clinical Trials (IRCT) code IRCT20210614051574N8 (https://www.irct.ir/trial/61860). Pediatrics were randomized into two groups. Children in the first group received intranasal dexmedetomidine at a dose of 2-3 µg/kg 10 minutes before the procedure. The second group received 5% chloral hydrate syrup at a dose of 50-100 mg/kg orally 10 minutes before the procedure. For each patient, sleep onset latency and sleep duration were also measured. It should be noted that the patient's level of consciousness and sleepiness were checked by AVPU (alert, verbal, pain, unresponsive) criteria. RESULTS: There was no significant difference between the two groups regarding the mean sleep onset latency (P = 0.59), sleep duration (P = 0.12), heart rate (P = 0.30), respiratory rate (P = 0.26), and SPO2 (P = 0.27). Analysis of covariance by adjusting for age and sex in both groups showed that the mean sleep duration (P = 0.04) and heart rate (P = 0.03) in the oral chloral hydrate group were significantly higher than in the nasal dexmedetomidine group. But the mean of other variables was not significantly different between the two groups (P>0.05). CONCLUSION: The mean sleep duration and heart rate were significantly lower in the intranasal dexmedetomidine group compared to the oral chloral hydrate group.

Longitudinally extensive transverse myelitis as a sign of multisystem inflammatory syndrome following COVID-19 infection: A pediatric case report.

COVID-19 infection can cause inflammatory reactions that could involve several organs. In the pediatric population, Multi-System Inflammatory Syndrome in Children (MIS-C) has been reported as one of the consequences of COVID-19. We report a unique pediatric COVID-19 patient with MIS-C, associated with paralysis of the extremities. MRI showed abnormal signal in the cervical spinal cord compatible with transverse myelitis. Methylprednisolone and IVIG were administered, without significant symptom improvement. As a next step, Infliximab was tried for her, and she responded remarkably well to this treatment. Infliximab may be considered as a treatment option in COVID-19 patients with transverse myelitis.

L-carnitine versus Propranolol for pediatric migraine prophylaxis.

Objective: Carnitine plays a significant role in fatty acid transportation in mitochondria and has been shown to have a prophylactic effect on adult migraine. The aim of this randomized controlled trial was to compare and evaluate the effects of L-carnitine supplementation versus propranolol in the prevention of pediatric migraine. Materials & Methods: A total of 60 pediatric patients with episodic migraine were randomly allocated to 2 independent groups to receive either 50 mg/kg/day L-carnitine or 1 mg/kg/day propranolol as a prophylactic drug. Frequency, severity, and duration of migraine attacks and headache disability based on the Pediatric Migraine Disability Assessment Score (PedMIDAS) were studied at the baseline and after 2, 4, and 12 weeks. Results: A total of 56 patients were evaluated in the study: 23 girls (41%) and 33 boys (59%) with a mean age of 9.7 ± 2.1 years. Frequency of migraine headaches per month reduced from 11.4 ± 7.1 to 5.34 ± 2.4 in the L-carnitine group and from 10.7 ± 6.2 to 4.96 ± 3.9 in the propranolol group by the end of the study. Headache severity score was also reduced from 19.38 ± 14 to 2.88 ± 7.4 and from 12.92 ± 13 to 0.82 ± 1.3 in the L-carnitine and propranolol groups, respectively. We found a significant decrease in frequency, severity, and duration of headache attacks in both groups (P < 0.01). No significant difference was observed between the efficacies of the 2 drugs.This study concluded that L-carnitine supplementation can play a prophylactic role in the management of pediatric migraine.

Epidemiological and clinical features of pediatric-onset multiple sclerosis: A population-based study in Isfahan, Iran, between 1997-2020.

Background: Pediatric-onset multiple sclerosis (POMS) is an autoimmune demyelinating disorder of the central nervous system (CNS), affecting individuals younger than 18 years of age. We sought to characterize the epidemiological and clinical features of patients with POMS in Isfahan, Iran, from April 1997 to March 2020. Methods: The medical records of patients with POMS in the databases of Isfahan Department of Public Health and Isfahan Multiple Sclerosis Society (IMSS) were retrospectively reviewed. The 2006 and 2016 Isfahan Province population censuses were used as reference values for assessing the temporal trend of POMS. Results: From April 1997 to March 2020, 509 individuals under18 years of age were diagnosed with POMS in Isfahan. 404 of these patients (79.4%) were girls, and 105 patients (20.6%) were boys (a female to male ratio of 3.85:1). Most of the patients (83%) were monosymptomatic at onset, with optic neuritis and brainstem-cerebellar disorders being the most frequent initial presentations. Mean ± standard deviation (SD) of age at disease diagnosis was 15.8 ± 2.5 years (ranging from 3 to 18, mode = 18). From April 2019 to March 2020, the crude prevalence and the crude incidence rate of the POMS were 5.42 per 100000 and 1.86 per 100000, respectively. Poisson regression analysis revealed a 3.4% increase in the incidence rate of POMS from April 1997 to March 2020 [relative rate:1.034, 95% confidence interval (CI): 1.021-1.048]. Conclusion: The female to male ratio in our cohort was significantly higher than any other studies conducted previously. The high female to male ratio and increasing incidence of the disease suggest increasing regionalization of care.

Efficacy of Levetiracetam in Treatment of Childhood Stuttering.

BACKGROUND: Stuttering is a kind of speech disorder that affects about 1% of total population. As the origin of this disorder is not obviously diagnosed yet, various remedies have been practiced and among them different medicines have been studied, but unfortunately no significant effective drugs have been recognized yet. As stuttering imposes a great social and mental costs to the patients and their families, finding an effective medicine will help significantly. In this study we have focused on the effects of levetiracetam (LEV) treatment on children suffering from stuttering. METHODS: In this clinical trial study, 30 children aged > 3 years (median 3.8 years) with stuttering and abnormal sleep electroencephalogram (EEG) were treated by LEV and followed-up for a minimum period of 6 weeks. The starting dose of 20 mg/kg/day was increased at an interval of 1 week by 20 mg/kg/day, if necessary, up to maximum dose of 60 mg/kg/day. RESULTS: Overall LEV was effective in 70% of patients, decreasing stuttering to at least 50%. Three children (10%) became stuttering-free and only in one (3.3%) child an increase in stuttering was observed. There were statistically significant differences for efficacy in the presence of variables such as age groups, seizure, stuttering family history, and EEG data. CONCLUSIONS: LEV is an effective drug for treatment of childhood stuttering in those that have abnormal sleep EEG.

Comparing Sedative Effect of Dexmedetomidine versus Midazolam for Sedation of Children While Undergoing Computerized Tomography Imaging.

BACKGROUND: Pediatric anxiety and restlessness may create issues and difficulties in performing accurate diagnostic studies even noninvasive ones, such as radiological imaging. There are some agents that will help to get this goal. This study aimed to compare the intranasal effect of dexmedetomidine (DEX) and midazolam (MID) for sedation parameters of children undergoing computerized tomography (CT) imaging. MATERIALS AND METHODS: A double-blind clinical trial was conducted on 162 eligible children who underwent CT imaging. These patients were divided into two groups including MID (n = 81) with dose of 0.3 mg.kg and DEX (n = 81) with dose of 3 µg.kg, which was consumed intranasally. The mean blood pressure (MBP), respiratory rate (RR), heart rate (HR), and oxygen saturation (O2Sat) in children were recorded. Then, time of initiation, level of sedation, and duration effect of medication were measured at 0, 10, 20, and 30 min. Parents and clinician satisfaction score was asked. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software by t test and chi-square test. RESULTS: Decreasing in MBP and HR was higher in DEX group than MID group (P < 0.001), whereas decrease of O2Sat in MID group was higher than DEX group (0.009). Starting time of sedation (22.72 ± 11.64 vs. 33.38 ± 10.17, P = 0.001) was lower in DEX group. Parents (P < 0.001) and physician (P < 0.001) satisfaction score was higher in DEX group than the MID group. CONCLUSION: Using 3 µg/kg intranasal DEX for sedation of 1-6-year-old children was a suitable method to undergo noninvasive studies such as CT imaging. Intranasal DEX is superior to MID due to higher sedation satisfactory, faster starting effect of sedation, and lower side effects and complications. Nevertheless, in children with hemodynamic instability DEX is not an appropriate choice.

Oral Diazepam in Febrile Seizures Following Acellular Pertussis Vaccination.

BACKGROUND: Febrile seizure is the most common type of seizures among children, which is a terrible and frightening experience for parents who are concerned about its recurrence. The aim of this study was to evaluate the effect of diazepam on preventing the recurrence of febrile seizure following acellular pertussis vaccination. MATERIALS AND METHODS: In this clinical trial, 121 children with a history of febrile seizure that required the pertussis vaccination were enrolled and divided into two groups; the first group was treated with oral diazepam for 48 h after vaccine injection and the control group received antipyretics only if fever occurred after the vaccination and used rectal diazepam for controlling seizure if a seizure occurred. The incidence of fever and seizure after the injection of the vaccine and incidence of febrile seizure were compared. RESULTS: Nearly, 85.7% in the oral diazepam group and 87.9% in the rectal diazepam group had fever after receiving the pertussis vaccine, but the incidence of fever was not significantly different between the groups. Seven children (12.06%) in the rectal diazepam group had a seizure after pertussis vaccination, and none of the children in the oral diazepam group had a seizure after receiving the vaccine at 18 months of age. This difference was significant. CONCLUSION: Prophylaxis with diazepam administration in children with a history of febrile seizure can prevent recurrence of febrile seizure after pertussis vaccination.

Demographic and Clinical Findings in Pediatric Patients Affected by Organic Acidemia.

OBJECTIVE: Metabolic disorders, which involve many different organs, can be ascribed to enzyme deficiency or dysfunction and manifest with a wide range of clinical symptoms. This study evaluated some of the demographic and clinical findings in pediatric patients affected by organic acidemia. MATERIALS & METHODS: This cross-sectional study was part of a larger study conducted in patients with metabolic disorders during a period of 7 years from 2007 to 2014 in Isfahan Province, Iran. Our study covered a wide range of cases from newborn infants (one-week old) to adolescents (children up to the age of 17 years). This study evaluated patients' demographic information, history of disease, developmental and educational status, clinical and general conditions. Phone and in-person interviews were used to gather information. RESULTS: Out of 5100 patients screened in this study, 392 patients were affected by one of the different metabolic disorders and 167 individuals were diagnosed as organic acidemia. Propionic acidemia/methyl malonic acidemia (PA/MMA) was the most prevalent form of this metabolic disorder. The frequency of consanguinity was 84.7% in the group of patients. The mortality rate was 18.8% in patients with organic academia. CONCLUSION: Each of the metabolic diseases, as a separate entity, is rare; nevertheless, in aggregate they have a somewhat high overall prevalence. These diseases result in mental and developmental disorders in the absence of quick diagnosis and initiation of treatment. Furthermore, more mutations should be identified in societies affected by consanguinity. Further research should also be conducted to determine worthwhile and more-efficient screening methods as well as long term neurological prognosis.

Prevalence of Developmental Delay in Apparently Normal Preschool Children in Isfahan,Central Iran.

OBJECTIVE: Developmental delay screening is essential in pediatric medicine. The purpose of this study was to estimate the developmental delay in apparently normal children at entry to kindergarten. MATERIALS & METHODS: In this cross- sectional study conducted in 2013, the developmental status of a sample of children who entered to kindergarten at the age of 4-60 months were evaluated by the Persian version of ages and stages questionnaires (ASQ) in Isfahan county, central Iran. RESULTS: Totally 680 children were enrolled, 11.8% of them were suspected to delayed in at least one domain and 1.3% and 1.2% in two and three domains, respectively. Developmental delay was in the following items: 5% in problem solving; 4.9% in fine motor; 3.2% in gross motor, 2.2% and 1.2% in personal - social and communication domains, respectively. CONCLUSION: Considerable proportions of apparently normal children who are entering kindergarten had developmental delay, which could be detected by evaluation with appropriate screening tools.