Dizziness in children and adolescents

Dizziness in children is a common cause for a visit to the pediatric outpatient department. The reported prevalence is 6% to 8% but evaluating the symptoms in children who cannot clearly explain and describe their experience is challenging.Current Concepts: The most common causes of dizziness in children and adolescents—which account for approximately 35% of the cases—are benign paroxysmal vertigo of childhood and vestibular migraine. These two diseases and head trauma are the primary causes of dizziness in over 50% of the cases. A thorough history-taking is key for the diagnosis of dizziness in children and adolescents. Additionally, a complete physical examination, including ear and neurologic tests, is essential.Discussion and Conclusion: As the department of pediatrics includes children and adolescents, the number of young patients presenting with dizziness is continuously increasing. This article presents the general definition, etiology, diagnosis, treatment strategies, and recommendations for the management of dizziness in children and adolescents. Further studies are warranted to differentiate the cause of dizziness in children. Moreover, drug abuse related to dizziness and headaches shouldn’t be underdiagnosed at schools or in the community.

A Case of Acute Hemorrhagic Encephalomyelitis associated with Mycoplasma Pneumoniae Infection / 대한소아신경학회지

Acute hemorrhagic encephalomyelitis (AHEM) is a severe form of encephalitis characterized by fulminant clinical course and presence of hemorrhagic necrosis of the white matter. Mycoplasma pneumoniae (M. pneumoniae) have severe central nervous syndrome complication with encephalitis as that most common pediatric manifestations, but have been extremely rare report with AHME. A 10-year-old boy was referred to emergency room because of drowsy mental status, weakness of left side extremities and truncal ataxia. His deep tendon reflexes were hyperactive, neck stiffness sign and Babinski sign were both positive. Motor power were decreased on the both left upper and lower extremities. The sequences of T2-weighted and gradient recalled echo (GRE) showed hyper-intense lesions on multifocal white natter areas with hemorrhagic signal. Cerebrospinal fluid (CSF) analysis showed the pleocytosis with neutrophil dominant. The results of deoxyribonucleic acid (DNA) test and culture of M. pneumoniae were reported negative in CSF, but immunoglobulin M (IgM) was positive in blood. He received intravenous high dose corticosteroid and macrolide. After discharge, his neurologic function gradually returned to normal including sitting and standing without support. We reported the previously healthy boy with M. pneumonia related AHEM. The early diagnosis with brain MRI and the aggressive immunosuppressive treatment may be beneficial for recovery.

Recent advances in pediatric headaches

No abstract available.

Surveillance and compensation claims for adverse events following immunization from 2011 to 2016 in the Republic of Korea

PURPOSE: In recent years, research on reported adverse events following immunization (AEFI) and claims filed for compensation has been lacking. We reviewed reported AEFIs and compensation claims in Korea from 2011 to 2016. MATERIALS AND METHODS: We listed all of the AEFI registered in the Integrated Management System of Disease and Public Health and reviewed the list of claims filed and serious AEFIs reported from 2011 to 2016. RESULTS: An average of 278 AEFI cases was reported annually from 2011 to 2016. Of these, 31 deaths were reported. However, there was no association found between these deaths and vaccinations when evaluating vaccine lot, reviewing autopsies, and considering underlying diseases. AEFI reporting rate was as high as 20.8 cases for bacillus Calmette–Guérin (BCG) vaccine, 7.3 cases for 23-valent pneumococcal polysaccharide vaccine (PPV23), and 5.4 cases for human papillomavirus vaccine per 100,000 vaccination doses in 2016. Of the 469 total cases that claimed vaccine injury compensation from 2011 to 2016, the BCG vaccine was most commonly involved, with 235 cases (50%), followed by influenza vaccine and PPV23, with 90 and 55 cases, respectively. Of these cases, 96% of BCG-related AEFI were compensated, while only 31% and 49% of AEFI following influenza and PPV23 vaccination, respectively, were compensated. Common characteristics of uncompensated cases included the elderly subjects, receiving influenza vaccine, having underlying disease, or a very short time interval between vaccination and symptoms. CONCLUSION: We have maintained vaccine safety management system through both rapid response to serious AEFI and vaccine injury compensation in order to sustain public trust in the National Immunization Program.

Analysis of Influenza Related Neurologic Complications for Recent 3 Years

OBJECTIVE: Influenza infection can stimulate secretion of proinflammatory cytokine and induce neurological symptoms due to post-infection immunity reaction. This study attempts to study clinical aspects of patients with neurologic complication and their difference to other patients with no neurological complication. METHODS: From January of 2012 to May of 2014, 535 patients diagnosed to have influenza in Soonchunhyang University Bucheon Hospital were included as subjects. They were classified into two groups based on existence of neurologic complication and retrospectively analyzed of clinical features and lab results. RESULTS: Thirty (5.6%) out of 535 patients showed neurologic complication and there were no significant difference in annual incidence of neurologic complication. Despite that the patient group with neurologic complication had history of neurological disorders and high admission rate, they did not show difference in age, gender, fever duration, and influenza A infection rate as compared with no neurologic complication group. In blood test, erythrocyte sedimentation rate and C-reactive protein was significantly low in patients with neurologic complication, but white blood cell count was not significantly different between two groups. Neurological complication was mostly seizure with 25 patients. Four patients showed encephalopathy and 1 patient was diagnosed with meningitis. CONCLUSION: Five point six percent among infants infected with influenza A were accompanied with neurologic complication, but none showed long-term sequelae. There was no difference in the annual incidence and incidence of neurological complication was higher in patients with history of neurologic disorder, but there were no other risk factors.

New daily persistent headache with isolated sphenoiditis in children / 소아과

Isolated sphenoid sinusitis is a rare disease in children, and its symptoms are often nonspecific and confusing. Rarely, severe headache can be the first or only symptom of isolated sphenoid sinusitis. New daily persistent headache (NDPH) is a form of chronic daily headache that may have features of both migraines and tension-type headaches. NDPH is difficult to diagnose and requires a multifaceted approach. Here, we report on a 10-year-old boy and an 11-year-old girl who both presented with typical NDPH symptoms. These patients had no nasal symptoms or signs of infection. Neither nonsteroidal anti-inflammatory drugs nor topiramate had any effect on the headaches. Their neurological and ophthalmological examinations were normal. The results of routine blood work, including thyroid function tests, inflammatory markers, complete blood count, tests for viral infection, and a metabolic panel, were normal. A brain magnetic resonance imaging scan showed isolated sphenoid sinusitis. Both patients' symptoms resolved completely after approximately 1 month of oral antibiotics for sinusitis.

The Association between Cerebrospinal Fluid Pleocytosis and Clinical Manifestations of Enteroviral Meningitis in Children

OBJECTIVE: Enteroviruses are major causes of aseptic meningitis in children. This study aimed to describe the clinical manifestations of enteroviral meningitis according to the presence of cerebrospinal fluid (CSF) pleocytosis, and to investigate the factors influencing the CSF pleocytosis in children with this condition. METHODS: Eighty children with enteroviral meningitis treated at Soonchunhyang University Hospitals in Seoul and Bucheon between July 2012 and August 2013 were enrolled. The patients were diagnosed by reverse transcription-polymerase chain reaction (RT-PCR), and the clinical variables were compared according to the presence of CSF pleocytosis. RESULTS: Of the 80 patients, 54 (67.5%) and 26 (32.5%) patients had and did not have CSF pleocytosis, respectively. Forty-eight (60%) patients were male, and the median age was 63 months (range, 2 to 192 months). Seventy-six (95%), 67 (83.7%), 51 (63.7), and 2 (2.5%) patients presented with fever, headache, vomiting, and seizure, respectively. Increased CSF protein and pressure were associated with CSF pleocytosis. However, age, peripheral white blood cell count, C-reactive protein, CSF glucose, CSF/serum glucose ratio, and onset-puncture time interval were not associated with the presence of CSF pleocytosis. CONCLUSION: This study demonstrated a high proportion of non-pleocytic enteroviral meningitis in children, and identified several clinical manifestations that were associated with CSF pleocytosis. The findings of this study may help us better understand the characteristics of the disease and facilitate early diagnosis and treatment of enteroviral meningitis. During the outbreak seasons of enteroviral meningitis, the importance of continuous surveillance of enteroviruses and rapid RT-PCR testing should be emphasized.

A Case of Moyamoya Disease without Transient Ischemic Attacks

Moyamoya disease is a cerebrovascular disorder characterized by internal carotid arteries' occlusion or stenosis. Its etiology remains unknown, and it occurs more frequently in Asian countries than western countries. It can occur at any age, and approximately 50% of patients are children. Initial manifestations of moyamoya disease are very different according to age. In general, cerebral ischemic symptoms like transient ischemic attacks (TIA) are the most common manifestation of children. It is a chronic progressive disease and cause recurrent stroke, so early diagnosis and management is very important. We report a case of moyamoya disease without TIA, in a 7 years old female child presenting as unusual symptoms, such as walking difficulty and dysarthria.

Sepsis from Neonatal Mastitis and Breast Abscess

Although some full-term neonates suffer from mastitis or a breast abscess, mastitis is not common in neonates and concurrent bacteremia is a rarely seen. We report the case of a 30-day old boy of African ethnicity, who was a full-term infant and appropriate for gestational age. At birth, he had bilateral palpable breast masses. He had high fever as well as swelling and nipple discharge in both breasts 30 days after birth. An ultrasonography of the breast showed masses with septa in both breasts. The breast masses were red in color, swollen, and felt hot to the touch. We incised the mass and performed a culture of the discharge. Staphylococcus epidermidis was detected in both blood and the breast discharge. In conclusion, the infant experienced neonatal bacteremia that originated from a breast abscess.

Toxic epidermal necrolysis induced by lamotrigine treatment in a child / 소아과

Toxic epidermal necrolysis is an unpredictable and severe adverse drug reaction. In toxic epidermal necrolysis, epidermal damage appears to result from keratinocyte apoptosis. This condition is triggered by many factors, principally drugs such as antiepileptic medications, antibiotics (particularly sulfonamide), nonsteroidal anti-inflammatory drugs, allopurinol, and nevirapine. Lamotrigine has been reported potentially cause serious cutaneous reactions, and concomitant use of valproic acid with lamotrigine significantly increases this risk. We describe a case of an 11-year-old girl with tic and major depressive disorders who developed toxic epidermal necrolysis after treatment with lamotrigine, and who was diagnosed both clinically and pathologically. Children are more susceptible to lamotrigine-induced rash than adults, and risk of serious rash can be lessened by strict adherence to dosing guidelines. Unfortunately, in our case, the patient was administered a higher dose than the required regimen. Therefore, clinicians should strictly adhere to the dose regimen when using lamotrigine, especially in children.

Clinical Characteristics of Headache in Children

PURPOSE: Headache is a common neurological condition for children to seek for medical care. The underlying causes of headache include migraine, tension type headache, intracranial masses, and sinusitis and so on. The study was aimed to analyze the clinical findings and the results of neuroimaging studies in children with headache. METHODS: A total of 120 children with headache were involved in the study who replied to the questionnaires at the department of pediatrics of Soonchunhyang University Hospital from March 2006 to October 2012. We evaluated the causes of headache by MRI scans and classified them based on the International Classification of Headache Disorders (2nd Edition, ICHD-II), 2004. RESULTS: Thirty one out of 120 children (25.8%) were classified as secondary headache with abnormal MRI findings such as sinusitis, pineal cyst, venous angioma, demyelinating disease and 89 (74.2%) patients were classified into primary headaches. Migraines without aura were diagnosed in 43 (48.3%) patients, migraine with aura in 18 (20.2%) patients, and tension type headache in 21 (23.6%) patients respectively. There was no significant difference on the median age between the patients with primary (10.5 years) and secondary (9.13 years) headache. When compared by gender ratio, primary and secondary headaches were 1.34:1 and 2.1:1 respectively. CONCLUSION: The correct diagnosis of headache may not be simple due to a variety of presentations of headache in children. We therefore have to pay a close attention to their complaints and get the neuroimaging study done if necessary.

An Arg528His Mutation of the CACNL1A3 Gene in a Korean Family with Hypokalemic Periodic Paralysis

Familial hypokalemic periodic paralysis (HOPP) is an autosomal dominant disorder characterized by episodic attacks of muscle weakness with concomitant hypokalemia (<3.5 mEq/L). The onset of HOPP usually occurs within the first and second decade of life. Mutations in the skeletal muscle calcium (CACNL1A3) and sodium channel (SCN4A) genes have been reported to be responsible for familial HOPP. Voltage-sensitive ion channels mediate action potentials in electrically excitable cells and play important roles in signal transduction in other cell types. Therefore, abnormalities in a channel's function lead to disarray of signal transduction and thus various neurological symptoms. Those are called channel diseases, which include familial HOPP. We report a 14-year-old boy with HOPP from a family in which two members of two generations are affected. Genetic examination identified a mutation causing a codon change from arginine to histidine at the amino acid portion #528 (R528H) in the calcium channel gene CACNL1A3.

Headache with Dural Thickening on MRI as an Initial Presentation of Leukemia: A Case Report

Headache can be divided into two categories: primary and secondary. Secondary headaches are associated with central nervous system or other pathology, and the underlying cause of a secondary headache can lead to death. For that reason, a thorough history and examination is key to determining the cause of headache. Other investigations including neuroimaging studies should be strongly considered in children with a history worrisome for intracranial pathology or an abnormal neurologic examination. We present a case of headache with diffuse hypertrophy of the dura mater due to lymphomatous dural infiltration. MRI revealed diffusely enhancing dural thickening. Biopsy of the dura mater found precursor B-cell lymphoblastic lymphoma. The patient was diagnosed with acute lymphoblastic leukemia and the headache was the initial presentation of acute leukemia. In this case, the rapid expansion of the dura mater resulted in elevation of intracranial pressure and caused an acute onset, progressive headache.

Clinical characteristics of 2009 pandemic influenza A (H1N1) infection in children and the performance of rapid antigen test / 소아과

PURPOSE: In autumn 2009, the swine-origin influenza A (H1N1) virus spread throughout South Korea. The aims of this study were to determine the clinical characteristics of children infected by the 2009 H1N1 influenza A virus, and to compare the rapid antigen and real-time polymerase chain reaction (PCR) tests. METHODS: We conducted a retrospective review of patients > or =18 years of age who presented to Soonchunhyang University Hospital in Seoul with respiratory symptoms, including fever, between September 2009 and January 2010. A real-time PCR test was used to definitively diagnose 2009 H1N1 influenza A infection. Medical records of confirmed cases were reviewed for sex, age, and the time of infection. The decision to perform rapid antigen testing was not influenced by clinical conditions, but by individual factors such as economic conditions. Its sensitivity and specificity were evaluated compared to real-time PCR test results. RESULTS: In total, 934 patients tested positive for H1N1 by real-time PCR. The highest number of patients (48.9%) was diagnosed in November. Most patients (48.2%) were aged between 6 and 10 years. Compared with the H1N1 real-time PCR test results, the rapid antigen test showed 22% sensitivity and 83% specificity. Seventy-eight patients were hospitalized for H1N1 influenza A virus infection, and fever was the most common symptom (97.4%). CONCLUSION: For diagnosis of 2009 H1N1 influenza A virus infection, the rapid antigen test was inferior to the real-time PCR test in both sensitivity and specificity. This outcome suggests that the rapid antigen test is inappropriate for screening.

Guillain-Barre Syndrome Caused by Swine Influenza(H1N1) Vaccination: A Case Report

Guillain-Barre syndrome(GBS), characterized by Landry's ascending paralysis, has been known to be caused by some viruses and some vaccinations. We report a case of GBS caused by swine influenza vaccination. The patient presented with rapidly progressive ascending paralysis after vaccination. After intravenous immunoglobulin therapy and other conservative treatments, he recovered without any complications. Whilst the patient did not exhibit typical GBS features, we still suspect that this case represents a variant of GBS. GBS secondary to vaccination is rare and the association has yet to be proven. We therefore recommend that swine influenza vaccination continue despite this apparent case of secondary GBS.

Clinical Characteristics with Risk Factors for Term Neonatal Seizures

PURPOSE: Neonatal seizures reflect neurologic disorders, affecting neonatal morbidity and mortality. Nevertheless, risk factors for seizures in term infants have been less well defined. We studied risk factors and clinical manifestations associated with term neonatal seizures. METHODS: We used retrospective case-control frequency matching study. We not only identified risk factors for term neonatal seizures, but also analyzed day of seizure onset, seizure types, findings of EEG and neuroimagings, and response to treatment. RESULTS: Our data showed that asphyxia is the most important risk factor for neonatal seizures in term infants. We could not find the relationship between the maternal risk factors and the risk of term neonatal seizures. Days of seizure onset were diverse. The seizures caused by asphyxia occurred earlier, of which 90% did within the first 48 hours. Various types of seizures were observed of which subtle seizures were the most common type in neonatal asphyxia. EEG was diagnostically available. However, it did not provide critical evidence to predict prognosis of their seizures. Neuroimaging studies were not helpful for the clinical diagnosis. Term infants with seizures who used antiepileptic drugs showed effective responses in managing seizures. There were no sustained seizures in 48 % of all cases who used phenobarbital only. CONCLUSION: We confirmed neonatal asphyxia is the most important risk factor for term neonatal seizures. Other risk factors are required to be further evaluated. We should identify and establish etiologic risk factors for term neonatal seizures particularly following neonatal asphyxia, and challenge to predict seizure onset and manage presumed seizures in advance.

A Case of Infantile Spasms in Tuberous Sclerosis with Fetal Cardiac Tumors

Tuberous sclerosis(TS), a type of neurocutaneous syndrome, is inherited in an autosomal dominant manner. Approximately 60% of children with TS have rhabdomyomas of the heart, and 40% of fetuses in whom rhabdomyomas are detected by a prenatal ultrasonography eventually end up with TS. Therefore, when multiple cardiac rhabdomyomas are detected by a fetal ultrasonography, TS should be suspected and further examination should be considered after birth. Infantile spasms is a common type of seizure among young children with TS. We describe a patient with TS who showed cardiac tumors on a fetal ultrasound. Also, hypomelanotic macules, retinal tumors, brain cortical tubers, nodules in subependymal regions, and infantile spasms was detected after birth.

Neonatal seizures in Korea, 1983-2009 / 소아과

Neonatal seizures are the most common and distinctive clinical sign of prenatal and/or neonatal brain disorders. Newborn infants with seizures are at risk of mortality and survivors at risk for neurologic impairment, developmental delay, and subsequent epilepsy. Fifteen reports on neonatal seizures in Korea from 1983 to 2009 were analyzed. A total of 731 neonatal seizure cases were reported. Day of seizure onset, etiology, type of seizures, electroencephalogram findings, and outcomes were analyzed. It is necessary to establish a basic report for a future nationwide study of neonatal seizures.

A case of acute transverse myelitis following chickenpox / 소아과

Acute transverse myelitis (ATM) in most patients is characterized by an abrupt onset of progressive weakness and sensory disturbance in the lower extremities with a preceding viral infection such as Epstein-Barr, herpes simplex, influenza, mumps and Varicella-zoster viruses (VZV). Although less frequent, some residual deficits including bladder dysfunction or weakness in the lower extremities may follow ATM, from which recovery usually begins within the first week of the onset of symptoms. In this report, we describe the case of a 9-year-old girl who experienced ATM following chickenpox and had bladder dysfunction as a sequela.

A case of antiepileptic drug hypersensitivity syndrome by lamotrigine mimicking infectious mononucleosis and atypical Kawasaki disease / 소아과

Antiepileptic drug hypersensitivity syndrome (AHS), a delayed immunological reaction, is a relatively rare side effect of antiepileptic drugs and is usually overlooked. An array of symptoms can occur one to eight weeks after treatment with an antiepileptic drug. Symptoms may be as simple as a fever, skin rash, or lymphadenopathy, but may eventually involve internal organs and cause fatal outcomes. Additionally, because the symptoms resemble the features of various arrays of diseases and the reported mortality rate is approximately 10%, the importance of early diagnosis and ability to differentiate AHS from other diseases cannot be overemphasized. We report a case of a 14-year-old girl with AHS caused by lamotrigine, which mimicked atypical Kawasaki disease and infectious mononucleosis.