Transverse Myelitis in the Setting of Enterobius vermicularis (Pinworm) Infection: Case Report.

Myelitis is a rare inflammatory myelopathy, and known associated etiologies only account for a small number of causes. A significant percentage of cases have an unknown etiology and are considered idiopathic. With 64% to 68% of cases fitting into the idiopathic category, helminth infections, and specifically pinworm parainfections, should be considered in cases that would otherwise be classified as idiopathic. This case report outlines a pediatric patient diagnosed with myelitis given her progressive weakness, fussiness, refusal to bear weight as well as magnetic resonance imaging (MRI) demonstrating T2-hyperintense signal and/or T1 gadolinium enhancement, and/or positive cerebrospinal fluid (CSF) inflammatory markers. This patient had a negative evaluation for typical known etiologies for myelitis including no signs of multiple sclerosis and neuromyelitis optica spectrum disorder on brain MRI, oligoclonal banding and aquaporin-4 autoantibodies, and no evidence of bacterial or viral meningitis given normal cell counts and cultures in CSF. She was found to have a pinworm infection, suggesting a parasitic parainfectious etiology of her myelitis. This case outlines the first case noting the correlation between myelitis and pinworm infection in a pediatric patient.

Approach to the Diagnosis of Pediatric Headache.

Headache in children and adolescents is a common symptom that can be worrisome to patients, their parents and clinicians due to the myriad of underlying etiologies, both benign and life-threatening. The evaluation of headache must be directed primarily to exclude secondary causes. A detailed headache history, recognition of headache patterns and red flags and thorough physical and neurological examinations are essential in the diagnosis; and identifies patients requiring further workup. Considerations for neuroimaging and ancillary testing are also discussed.

Decreasing Seizure Treatment Time Through Quality Improvement Reduces Critical Care Utilization.

BACKGROUND: Rapid, effective treatment for status epilepticus reduces associated morbidity and mortality, yet medication delivery remains slow in many hospitalized patients. We utilized quality improvement (QI) methodology to improve treatment times for hospitalized children with status epilepticus. We hypothesized rapid initial seizure treatment would decrease seizure morbidity. METHODS: We utilized QI and statistical process control analysis in a nonintensive care setting within a tertiary care pediatric hospital. We performed Plan-Do-Study-Act cycles including (1) revising the nursing process for responding to seizures, (2) emphasizing intranasal midazolam over intravenous lorazepam, (3) relocating medications and supplies, (4) developing documentation tools and reinforcing correct processes, (5) developing and disseminating an online education module for residents and nurse practitioners, and (6) completing standardization to intranasal midazolam. RESULTS: Seventeen months after starting the project, 66 seizures had been treated with a benzodiazepine in a median (p25-p75) time of 7.5 minutes (5 to 10), decreased from a baseline of 14 minutes (8-30) (P = 0.01). The proportion of patients receiving a benzodiazepine in 10 minutes or less improved from 39% to 79%. The proportion of patients transferred to intensive care decreased from a baseline of 39% to 9% (P < 0.005), resulting in an estimated $2.1 million in mitigated hospital charges. Significant harm did not occur during the implementation of these interventions. CONCLUSIONS: Children with status epilepticus were treated with benzodiazepines more rapidly and effectively following implementation of QI methodology. These interventions reduced utilization of critical care and mitigated hospital charges.

Multifocal Brain Lesions With Extensive Perilesional Edema in a Young Boy Returning From Kenya.

We report the case of an 8-year-old boy who presented with headaches, optic disc edema, and left eye esotropia. He had recently returned to the United States after living in Kenya for approximately 3 years. His brain magnetic resonance imaging showed multifocal lesions with significant perilesional edema seemingly out of proportion to his neurologic examination findings. With appropriate therapy there was remarkable improvement in his symptoms with reduction in size of the lesions and surrounding edema.

Diagnosis and Treatment of Childhood Migraine.

OPINION STATEMENT: While the diagnosis of migraine in children is generally straightforward, treatment can seem complex with a number of medication choices, many of which are used "off label." Patients with intermittent migraines can often be managed with ibuprofen or naproxen taken as needed. Unfortunately, by the time that children present to our practice, they have often tried these medications without improvement. Triptans are frequently prescribed to these patients with good success. It is important to make the patient aware of the possible associated serotonergic reactions. If the patient is having more than one headache per week or the headaches are prolonged, prophylactic treatment is indicated. In our practice, the overwhelming majority of these patients will be treated with amitriptyline or topiramate. We generally allow side effect tolerability to guide our choice of medication. Cyproheptadine is often used in younger patients as it comes in a liquid form. There is evidence supporting the use of propranolol, though the potential worsening of underlying asthma symptoms may limit its use, and sodium valproate, which must be used with caution in female patients of childbearing age due to significant teratogenicity risks. Other prophylactic treatments with less robust evidence include the antiepileptic drugs gabapentin, zonisamide, and levetiracetam; calcium channel blockers such as verapamil and amlodipine; and the angiotensin receptor blocking agent candasartin (not available in the USA). Almost all patients in our practice are advised to take magnesium supplementation. Magnesium is a supplement with relatively few adverse effects and good evidence for improvement of migraine symptoms. We evaluate lifestyle issues and comorbidities in all our patients. Ignoring these will make successful treatment near impossible. Good sleep, adequate hydration, appropriate diet, and exercise are vitally important. Finally, most of our patients benefit from a psychology evaluation with cognitive behavioral therapy. Stress management and biofeedback are tremendously helpful in improving quality of life in migraineurs.

Specific headache factors predict sleep disturbances among youth with migraine.

BACKGROUND: There is a paucity of pediatric data addressing the complex relationship between primary headaches and sleep disturbances. Our study objective was to explore headache-related factors that predict sleep disturbance and to compare sleep complaints with other forms of headache-related disability among youth with migraines. METHODS: A prospective cohort study was conducted in patients 10-18 years old with migraine or probable migraine and without daily sleep complaints. The patients completed a 90-day internet-based headache diary. On headache days, patients rated headache intensity, answered Pediatric Migraine Disability Assessment-based questions modified for daily scoring, and reported sleep disturbances that resulted as a direct effect of proximate headaches. RESULTS: Fifty-two patients generated 4680 diary entries, 984 patients (21%) involved headaches. Headache intensity (P = 0.009) and timing of headache onset (P < 0.001) were predictive of sleep disturbances. Three Pediatric Migraine Disability Assessment-based items were also associated with sleep disturbances: partial school-day absence (P = 0.04), recreational activities prevented (P < 0.001), and decreased functioning during recreational activities (P < 0.001). Sleep disturbances correlated positively and significantly with daily headache disability scores (rpb = 0.35; P < 0.01). CONCLUSION: We conclude that specific headache factors predict sleep disturbances among youth with primary headaches.

PedMIDAS-based scoring underestimates migraine disability on non-school days.

OBJECTIVE: The aim of this study is to compare daily Pediatric Migraine Disability Assessment (PedMIDAS)-based scores for headaches occurring on school days vs non-school days and during the school year vs the summer holiday. BACKGROUND: The PedMIDAS is the only instrument validated to assess migraine disability among school-aged children. However, the PedMIDAS may underestimate disability during prolonged school holidays. METHODS: In a prospective cohort study, migraine patients aged 10-18 years completed a 90-day Internet-based headache diary. For each headache day, they answered PedMIDAS-based questions and rated their headache intensity (scale 1-10). PedMIDAS-based scores, headache intensity ratings, and relative headache frequencies were compared for school days vs non-school days and for the school year vs the summer holiday. RESULTS: Fifty-two patients completed 4680 diary entries comprising 984 headache days. The headache frequencies and intensity ratings did not differ between time periods. However, the mean headache disability scores (as measured from PedMIDAS-based questions) were significantly different for school days (0.85) compared to non-school days (0.45), P < .001, and for the school year (0.73) compared to the summer holiday (0.46), P < .016. CONCLUSION: Given similar headache intensities and frequencies, daily PedMIDAS-based scores significantly underestimate headache disability on non-school days. Accordingly, PedMIDAS scoring during the school year may not be comparable to assessments done during the summer holiday. These potential differences must be considered when using the instrument as an outcome measure for clinical trials.