Taking the bait: Strychnine poisoning.

A 48-year-old male intentionally ingested "gopher killer" containing strychnine as a, suicide attempt. He rapidly developed generalized muscle spasms with opisthotonos followed by cardiovascular collapse. He was resuscitated, treated with 24 h of, neuromuscular paralysis, and was discharged on hospital day 10 without sequelae. A blood strychnine concentration obtained five hours post ingestion was 2.2 mg/L. Strychnine poisoning is exceedingly rare in the modern United States and this report contains a video recording of the classic exam findings.

Mice Harboring a Non-Functional CILK1/ICK Allele Fail to Model the Epileptic Phenotype in Patients Carrying Variant CILK1/ICK.

CILK1 (ciliogenesis associated kinase 1)/ICK (intestinal cell kinase) is a highly conserved protein kinase that regulates primary cilia structure and function. CILK1 mutations cause a wide spectrum of human diseases collectively called ciliopathies. While several CILK1 heterozygous variants have been recently linked to juvenile myoclonic epilepsy (JME), it remains unclear whether these mutations cause seizures. Herein, we investigated whether mice harboring either a heterozygous null Cilk1 (Cilk1+/-) mutation or a heterozygous loss-of-function Cilk1 mutation (Cilk1R272Q/+) have epilepsy. We first evaluated the spontaneous seizure phenotype of Cilk1+/- and Cilk1R272Q/+ mice relative to wildtype littermates. We observed no electrographic differences among the three mouse genotypes during prolonged recordings. We also evaluated electrographic and behavioral responses of mice recovering from isoflurane anesthesia, an approach recently used to measure seizure-like activity. Again, we observed no electrographic or behavioral differences in control versus Cilk1+/- and Cilk1R272Q/+ mice upon isoflurane recovery. These results indicate that mice bearing a non-functional copy of Cilk1 fail to produce electrographic patterns resembling those of JME patients with a variant CILK1 copy. Our findings argue against CILK1 haploinsufficiency being the mechanism that links CILK1 variants to JME.

Botulinum Neurotoxin Injections in Childhood Opisthotonus.

Opisthotonus refers to abnormal axial extension and arching of the trunk produced by excessive contractions of the paraspinal muscles. In childhood, the abnormal posture is most often related to dystonia in the setting of hypoxic injury or a number of other acquired and genetic etiologies. The condition is often painful, interferes with ambulation and quality of life, and is challenging to treat. Therapeutic options include oral benzodiazepines, oral and intrathecal baclofen, botulinum neurotoxin injections, and deep brain stimulation. Management of opisthotonus within the pediatric population has not been systematically reviewed. Here, we describe a series of seven children who presented to our institution with opisthotonus in whom symptom relief was achieved following administration of botulinum neurotoxin injections.

Art and psychogenic nonepileptic seizures.

Psychogenic nonepileptic seizures (PNES) are episodes of seizure-like symptoms that are not associated with epileptiform discharges on electroencephalogram (EEG). They can be remarkably difficult to distinguish from epileptic seizures: both may involve alterations in mental status and behavior, sensory or perceptual disturbances, as well as simple or complex motor patterns. Pictorial expressions of PNES have always attracted attention from the lay public and medical practitioners alike, by showing the rich variety of semiologies seen in the condition and its differences with epileptic seizures. In this article, we present two new contemporary artistic descriptions by the Canadian artist Iris Hauser about PNES. The depictions highlight key signs seen in PNES such as "eyes closed during events", "the hyperextension of the back and limbs", and the "claw-like finger posturing". We believe that the drawings can provide a valuable educational component in the initial assessment of patients suspected of having PNES as a training tool to identify and refer patients for more advanced testing.

Tétanos, una enfermedad que se creyó superada: revisión de caso / Tetanus, a disease that was believed to be overcomed: a case review

El tétanos generalizado es una enfermedad infecciosa altamente mortal sin intervenciones médicas y en nuestro tiempo, prevenible mediante inmunización activa. Se presenta el caso de un preescolar de 4 años quien sufre herida cortante en la palma de la mano izquierda y quien se presenta 4 días más tarde con datos clínicos de tétanos generalizado. Fue intubado y admitido a la terapia intensiva del Hospital del Niño Dr. José Renán Esquivel. Su hospitalización se vio caracterizada por neumonía nosocomial, una lesión anfractuosa lingual e inestabilidad autonómica. Además de la antibioticoterapia con metronidazol y la aplicación de inmunoglobulina antitetánica, precisó apoyo hemodinámico con dobutamina y norepinefrina. Para lograr un completo control de las crisis de hipertonía, se ofreció manejo con infusión de midazolam, levetiracetam, clobazam, baclofeno y toxina botulínica.

Generalized tetanus is a highly fatal infectious disease without medical interventions and in our time, preventable by active immunization. The case of a 4-year-old preschooler is presented who suffers a sharp wound in the palm of the left hand and who presents 4 days later with generalized tetanus. He was intubated and admitted to intensive care unit at Dr. José Renán Esquivel Children's Hospital. His hospitalization was characterized by nosocomial pneumonia, an anfractuous lingual lesion and autonomic instability. In addition to antibiotic therapy with metronidazole and the application of tetanus immunoglobulin, hemodynamic support with dobutamine and norepinephrine was required. To achieve complete control of hypertonic crisis, management with infusion of midazolam, levetiracetam, clobazam, baclofen and botulinum toxin was offered.

Complication of otitis media leads to opisthotonos in a toddler.

Opisthotonos, extreme involuntary neck and back extension, is rarely seen in modern emergency departments. Vaccines have prevented the most common causes of this clinical presentation. Alternatively, otitis media is one of the most common pediatric infections and is characteristically non-invasive and harmless. In exceedingly rare cases, otitis media can develop complications and progress to invasive pneumococcal diseases including mastoiditis and meningitis. Streptococcus pneumoniae accounts for the majority of otitis media infections, however, since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) and 13-valent pneumococcal conjugate vaccine (PCV13) otitis media and its complications have decreased significantly. The present case reports of a previously healthy and immunized child presenting to a pediatric emergency department (PED) with opisthotonos, and was found to have pneumococcal meningitis, bacteremia and mastoiditis arising from otitis media.

Tétanos, una enfermedad vigente en población pediátrica: Reporte de un caso / Tetanus, a current disease in pediatric population: Case report

Introducción: El tétanos es una enfermedad aguda causada por una toxina producida por Clostridium tetanii. La enfermedad puede afectar a personas de cualquier edad, y la tasa de letalidad es alta. Gracias a la inmunización se ha logrado reducir el número de casos de la enfermedad, aunque se siguen presentando casos sobre todo en países con rezago social y económico. Objetivo: Describir caso clínico de un paciente pediátrico con tétanos generalizado, para reforzar la importancia de la profilaxis y diagnóstico precoz. Caso clínico: Escolar femenina de 6 años de edad con antecedente de esquema de inmunizaciones incompleto (una dosis de pentavalente), quien 10 días después de hacerse una herida cortopunzante por astilla de madera en brazo derecho, evolucionó con fiebre, dolor muscular y contracciones generalizadas, diagnosticándose tétanos generalizado en base a los antecedentes y el cuadro clínico. El tratamiento se estableció en base a las últimas recomendaciones de la Organización Mundial de la salud (OMS): esquema antibiótico Penicilina-Metronidazol, toxoide tetánico y gammaglobulina antitetánica a dosis altas. Se da de alta con secuelas motoras leves, las que se remitieron luego de 2 años de seguimiento y terapia de rehabilitación. Conclusión: El tétanos se sigue presentando en la población pediátrica principalmente asociado a falta de vacunación, es necesario conocer la enfermedad para hacer diagnóstico temprano y ofrecer manejo acorde a recomendaciones internacionales.

Introduction: Tetanus is an acute disease caused by a toxin produced by Clostridium tetanii. The disease can affect people of any age, and the fatality rate is high. Thanks to immunization the number of cases of the disease has decreased, although they are still present in isolation in countries with social and economic backwardness. Objective: To describe a case of a pediatric patient with generalized tetanus to reinforce the relevance of prophylaxis and early detection. Case Report: 6 years old female patient, with only one dose of pentavalent vaccine, 10 days after sharps injury by wood chips, starts with fever, muscle pain and generalized contractions, Tetanus was diagnosed by clinical symptoms and history. The management was based on the latest recommendations of the World Health Organization (WHO): Penicillin-Metronidazole antibiotic regimen, tetanus toxoid and tetanus high-dose gammaglobulin. After 2 years of follow-up under physiotherapy support, slight motor sequelae were observed. Conclusion: Tetanus is still presented in the pediatric population, associated with lack of vaccination. It is necessary to know the disease to provide proper diagnosis and management according to international lineaments.

Impact of Mild Asphyxia in Delivery on Motor Development / 中国康复理论与实践

@#Objective To explore the impact of intrapartum mild asphyxia on motor development in infants. Methods 30 infants with any of the following were as asphyxia group: heart rate more than 160 beats/min in the process of childbirth, and then down to 70-80 beats/ min, no cyanose; Apgar score 1 min more than 8. Other 30 normal infants were as control group. They were assessed with Neuropsychological Development Scale for 0-6 Years Old 3, 6 and 9 months after birth. Results Opisthotonos was more frequent in the asphyxia group than in the control group (P<0.01) 3 months after birth, but there was no significant difference in total score (P>0.05). Sitting forward was more frequent in the asphyxia group 6 months after birth, and the score of motor was less in the asphyxia group than in the control group (P< 0.05). More of the asphyxia group couldn't stand with help, and with poor motor score 9 months after birth (P<0.05). Conclusion Intrapartum mild asphyxia may infulence the motor development of infant in long-term.

Impact of Mild Asphyxia in Delivery on Motor Development / 中国康复理论与实践

Objective To explore the impact of intrapartum mild asphyxia on motor development in infants. Methods 30 infants with any of the following were as asphyxia group:heart rate more than 160 beats/min in the process of childbirth, and then down to 70-80 beats/min, no cyanose;Apgar score 1 min more than 8. Other 30 normal infants were as control group. They were assessed with Neuropsychologi-cal Development Scale for 0-6 Years Old 3, 6 and 9 months after birth. Results Opisthotonos was more frequent in the asphyxia group than in the control group (P0.05). Sitting forward was more frequent in the asphyxia group 6 months after birth, and the score of motor was less in the asphyxia group than in the control group (P<0.05). More of the asphyxia group couldn't stand with help, and with poor motor score 9 months after birth (P<0.05). Conclusion Intrapar-tum mild asphyxia may infulence the motor development of infant in long-term.

Intoxicação por metronidazol em um cão / Intoxication metronidazole in a dog

Relata-se o caso de intoxicação de uma cadela da raça dálmata tratada cronicamente com o metronidazol, onde o diagnóstico foi baseado no histórico de administração, que pode ser de doses normais a aumentadas, e na resolução dos sinais clínicos após a suspensão da droga e instituição do tratamento de suporte, conforme cita a literatura (KIM et al, 2011; HECKLER et al, 2012). Nesses casos o prognóstico geralmente é favorável, mas alguns cães podem morrer ou desenvolver lesões hepáticas (HECKLER et al, 2012).