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.