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POSTERS Infectious Disease.

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HM-8. Referral and treatment patterns in chronic
daily headache
Sivaswamy L, Pawlik K (Detroit, MI)
Objective: Chronic daily headache (CDH) is most commonly encountered and treated by primary care providers.
The objective of this study was to evaluate treatment and
referral patterns of CDH by primary care physicians in a
large metropolitan area.
Methods: Patient records with a final diagnosis of chronic
daily headache, who were referred to the Pediatric Headache
Clinic at a tertiary care hospital, were retrospectively analyzed
(n�, 40 females, mean age 13.1yrs). ICHD-II criteria were
applied to stratify them into chronic tension type (32%) and
chronic migraine subgroups. Use of prophylactic agents,
advice regarding over the counter analgesics, time lag prior to
referral, work up, counseling regarding lifestyle changes and
referral to specialties other than neurology were evaluated.
Results: 8/56(8.4%) of children were advised prophylaxis,
with natural remedies suggested in half the cases. The average time lapse to being seen by a neurologist was 18.3
months (range�months -62 months). 16/56 had brain
imaging, however none required intervention. 30/56 families
recalled being counseled regarding lifestyle issues and weight
whereas only 10/56(17.8%) were cautioned regarding overuse of analgesics. 8.9% were either referred or chose to see
other pediatric subspecialists prior to seeing a neurologist.
Conclusions: Preliminary data seems to suggest that children with CDH experience significant delay in seeing a neurologist. There appears to be a low rate of use of prophylactic agents and insufficient information being given to
families regarding overuse of analgesics while discussion of
lifestyle changes occurs in over half the study population.
HM-9. Intravenous magnesium as abortive treatment
for headaches in children
Gertsch EA (Aurora, CO), Loharuka S (Berkley, CA), WolterWarmerdam KG, Tong S, Kedia S (Aurora, CO)
Objective: To examine effectiveness and tolerability of intravenous (IV) magnesium for abortive headache treatment in
children.
Methods: An IRB approved retrospective chart review at
The Children?s Hospital of Aurora, Colorado of individuals
ages 5?18 years old who received IV magnesium in the
emergency room (ER) or hospital for migraine, tension-type
headache (TTH), or status migrainosis. Responders were
those with moderate to significant improvement in qualitative or numeric pain scores. Patients with complex medical
conditions, secondary etiology for headache, or multiple
encounters were excluded.
Results: Twenty children with an average age of 15.7
years (SD 1.7), predominately female (80%), received IV
magnesium, 13 (65%) receiving magnesium in the ER and
seven (35%) as an inpatient. Five (25%) had migraine, four
(20%) had TTH, and 11 (55%) had status migrainosis.
Seven (35%) responded to IV magnesium, one with migraine, one with TTH, and five with status migrainosis
(p�57). Ten of thirteen (77%) children receiving IV magnesium in the ER were admitted for further treatment and
three were discharged home. Side effects of IV magnesium
included pain (1/20), redness (1/20), burning (1/20),
and decreased respiratory rate without change in oxygenation (1/20).
Conclusions: In our pediatric cohort, IV magnesium was
tolerated in children but not effective in reducing headache.
Magnesium deficiency may have a role in the pathophysiology of both TTH and migraines. However, use of magne-
sium as abortive therapy remains unclear. Prospective
randomized controlled studies will help to further establish
the effectiveness, tolerability, and role of magnesium for
abortive treatment of pediatric headaches.
HM-10. Combined occipital nerve/supraorbital nerve
stimulation for treatment of refractory headaches: initial
adolescent experience (12?17)
Linder SL (Dallas, TX)
Objectives: Assessment of the efficacy and safety of dual
occipital ? supraorbital nerve stimulation in adolescent
headache patients with severe incapaciting headaches.
Subjects & Methods: Seventeen adolescents, ages 12?17,
including 12 females and 5 males, were screened for implantation of occipital ? supraorbital nerve stimulators.
Each subject had failed standard headache management
therapies including dyhydroergotamine 45.
Trial impulse pulse generators (IPG) were placed across
the occipital and supraorbital nerves. Criterion for a positive
response was 75% improvement after a 3?5 day trial. Responders had an (IPG), which responded to an external programming computer, placed in the gluteal region.
Results: Fifteen of seventeen subjects had implantation.
Twelve of fifteen have continued to have good response.
Three subjects initially had good response but later failed.
Seventy-five percent remain headache free. Twenty-five
percent are still having some headaches but have had 50%
improvement. All were able to decrease their need for medication or stop medications entirely. All returned to school.
Before implantation all were on a modified school program.
Conclusion: Combination occipital ?supraorbital nerve
neurostimulation provides an effective alternative treatment
for adolescent patients with chronic severe headaches.
POSTERS: Infectious Disease
I-1. Unusual presentation of Rocky Mountain Spotted
Fever (RMSF).
Mudigoudar B, Arya K, Jalandoni K, McSween T
(Brooklyn, NY)
Objective: RMSF is a life threatening infection caused by
Rickettsia rickettsii. Its early recognition is crucial but difficult. Severe rhabdomyolysis in patients with RMSF is rare
and there are no such cases reported in those without rash.
We report an unusual case of RMSF without rash causing
severe rhabdomyolysis.
Methods: A case report.
Results: A 16 year old boy, native of Brooklyn, NY
was hospitalized with 4 days of high fever and 2 days of
gastrointestinal symptoms. Later he developed severe pain
in both lower extremities and difficulty walking. There
was no history of tick bite, recent travel or sick contact.
On examination he had severe tenderness in both thighs
but no rash. Motor examination in lower extremities was
limited due to pain but rest of his neurological examination was normal. Laboratory investigations revealed
thrombocytopenia, hyponatremia, elevated liver enzymes
and C Reactive Protein. Serum levels of muscle enzymes
were extremely elevated (CPK up to 19,195) and urinalysis showed myoglobinuria. Initial work up was negative
for several infections (Influenza A & B, RSV, CMV,
EBV, Hepatitis Panel, HIV Elisa, Ehrilichiosis, Babesiosis,
Comprehensive Viral, Blood, Stool and Urine Cultures).
Titers for RMSF were positive (IgG > 1:1024 and IgM
Program and Abstracts, Child Neurology Society S167
>1:64), confirming the diagnosis. He was treated with
Doxycycline for 10 days. He became afebrile 3 days later
and walked after a week.
Conclusions: RMSF should be kept in mind as a rare
cause of severe rhabdomyolysis after ruling out the common
etiologies even in patients who doesn?t exhibit rash.
I-2. Basal ganglia inflammation in children with
post-infectious neuropsychiatric manifestations: a positron
emission tomography study using [11C]-PK-11195
Chugani HT, Kumar A, Chakraborty P, Muzik O
(Detroit, MI)
Objective: Swedo and colleagues (1998) described 50 children with obsessive-compulsive disorder and motor tics
associated with group-A b-hemolytic streptococcal infections
and coined the acronym ?PANDAS? (pediatric autoimmune
neuropsychiatric disorders associated with streptococcal
infections). However, this disorder remains controversial.
We applied PET scanning with [11C]-PK-11195 (PK) to
detect potential neuroinflammation in children with clinically-diagnosed PANDAS-like conditions.
Methods: Twelve children (mean age: 1162.2 years; 10
males) with PANDAS-like disorders, and 11 normal adults
(mean age: 2767.7 years; 5 males) underwent dynamic PKPET imaging and binding potential (BP) was calculated in different brain regions. Tourette syndrome patients were excluded.
Results: BP was increased in the caudate nuclei (N�,
lentiform nuclei (N� and thalami (N� of PANDASlike subjects, compared to normals (TABLE). Two children
underwent repeat PK-PET following IVIG treatment. One
showed normalization of PK binding in right caudate and
left thalamus, accompanied by clinical improvement; the
other showed normalization of PK binding in right lentiform nucleus, but interval increase in right caudate, with
some clinical improvement.
Table: BP values in children with PANDAS-like conditions
and increased PK binding
n
Caudate
nucleus
Lentiform
nucleus
Thalamus
Left
2
Binding
Potential
(range)
0.169?0.178
Normal
range
(95%CI)
0.09?0.16
Right
Left
3
2
0.168?0.228
0.262?0.291
0.09?0.16
0.20?0.26
Right
Left
Right
3
2
2
0.224?0.228
0.41?0.42
0.41?0.42
0.15?0.21
0.33?0.40
0.32?0.40
Conclusions: Our findings suggest increased activated
microglial cells in basal ganglia and thalamus of some children with PANDAS-like conditions, suggesting underlying
neuroinflammation. Further evaluation in a larger drug-na??ve sample is required to gain more insight into this
condition.
I-3. Anti N-methyl-D-aspartate (NMDA) Receptor
Limbic Encephalitis presenting as refractory seizure
followed by Hashimoto?s thyroiditis and systemic lupus
erythematosus: case report and review
Binalsheikh IM, Wang SG (Boston, MA)
S168
Annals of Neurology
Vol 70 (suppl 15) 2011
Objective: To report a case of anti NMDA limbic encephalitis that evolved into Hashimoto?s thyroiditis and systemic
lupus erythematosus (SLE) to emphasize the importance of
autoimmune mechanism in pediatric limbic encephalitis.
Methods: chart review.
Results: A healthy 14 year old girl was admitted with
confusion and seizure. She had a 5 days history of viral prodrome followed by headache and photophobia. On day of
admission, she had confusion and developed seizure. Upon
arrival to the hospital, she was confused, febrile with nuchal
rigidity. Lumbar puncture showed pleocytosis with subsequent negative culture. EEG showed bilateral temporal seizure. MRI brain showed a symmetrical hippocampal T2
hyper intense signal. During her stay, she required both Levetiracetam and Phenytoin to achieve seizure control. Over
the following months, she started to complain of weight
gain, hair loss, depression, impaired memory and De?ja? vu
feeling. Serial thyroid function testing eventually revealed
hypothyroidism with positive anti-thyroid peroxidase and
anti-thyroglobulin antibodies. Repeated MRI showed persistent hippocampal T2 hyper intense signal with volume loss.
She had persistent neutropenia and high ESR, with positive
ANA and dsANA, along with proteinuria. Anti- NMDA
antibody was positive in both serum and CSF. She experienced subjective improvement with thyroxin therapy. Despite fulfilling the criteria for SLE, family declined steroids
or other immune modulating therapy.
Conclusions: Limbic encephalitis is a potential treatable
condition. Anti NMDA antibodies most likely contribute to
the pathophysiology of SLE psychosis. The identification of
anti NMDA antibodies in cases of pediatric limbic encephalitis may represent autoimmune diseases especially SLE.
I-4. Benign Acute Childhood Myositis: a comparative
study between young and old children in Korea
Youngmi K, Hyeyojng K, Taehyeong K (Busan, Korea), Yoonjin
L, Sueun P, Sangook N (Yangsan, Korea)
Objective: The aim of this study was to describe the difference of the clinical and laboratory findings of benign acute
childhood myositis (BACM) between young-aged children
(group 1; 1age<6)and old-aged children (group 2;
age6).
Methods: We conducted a retrospective review of 57
BACM cases diagnosed in Pusan National University Hospital between July 2009 and June 2010. We compared clinical
and diagnostic characteristics between two groups.
Results: 42 (73.7%) were boys with 2.8:1 male predominance. Mean age was 2.6 years in group 1 and 10.1 years in
group 2. Preceding symptoms were fever, cough, headache,
rhinorrhea, and sore throat. The mean interval between
onset of viral illness and onset of BACM was 3.8 days in
group 1 and 3.1 in group 2. The mean duration of BACM
was 4.1 days in group 1 and 9.0 in group 2. Cheif complaints were a refusal to walk in group 1 and myalgia in
group 2. The calf muscles were involved in 71.4%. Serum
creatinine kinase was increased in all cases (219-23012 U/
L). Viral studies were positive in 34 patients (60%) with
positive for parainfluenza (14.0%), influenza A (H1N1)
(12.3%), influenza B (12.3%), rhinovirus (7.0%), metapneumovirus (7.0%), enterovirus (5.3%), adenovirus
(3.5%), mumps virus (1.8%) and RSV (1.8%). All the
patients had a good outcome and fully recovered.
Conclusions: BACM has excellent prognosis and mainly
due to a viral etiology. Pediatric neurologists must be
aware the characteristics of BACM to prevent unnecessary
investigations and to differentiate BACM from serious
neuromuscular conditions.
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