Neurotoxin-Induced Paralysis: A Case of Tick Paralysis in a 2-Year-Old Child

BackgroundTick paralysis is an arthropod-transmitted disease causing potentially lethal progressive ascending weakness. The presenting symptoms of tick paralysis overlap those of acute inflammatory diseases of the peripheral nervous system and spinal cord; thus, the condition is often misdiagnosed, leading to unnecessary treatments and prolonged hospitalization.PatientA 2-year-old girl residing in northern New York and having no history of travel to areas endemic to ticks presented with rapidly progressing ascending paralysis, hyporeflexia, and intact sensory examination. Investigation included blood and serum toxicology screens, cerebrospinal fluid analysis, and brain imaging. With all tests negative, the child's condition was initially mistaken for botulism; however, an engorged tick was later found attached to the head skin. Following tick removal, the patient's weakness promptly improved with no additional interventions.ConclusionOur patient illustrates the importance of thorough skin examination in all cases of acute progressive weakness and the necessity to include tick paralysis in the differential diagnosis of paralysis, even in nonendemic areas.     

Case Report: Homicide by a 10-Year-Old Girl with Autistic Disorder

This case study presents a 10-year-old girl with a diagnosis of Autistic Disorder, who killed her 6-month-old sister by throwing her out of a window. Her aggressive–impulsive behavior had a persistent pattern. She had a history of epilepsy, and was frequently exposed to physical abuse. She never attended a structured treatment program. Here, we discuss the possible risk factors including history of epilepsy, unsupervised—disorganized home environment, existence of physical abuse—neglect and lack of appropriate treatment program leading to violent behavior.     

Concurrent West Nile Virus Infection in Pneumococcal Meningitis: Clinical and MRI Features

We report the clinical and neuroimaging findings of an immunocompetent patient with concurrent pneumococcal and West Nile virus meningoencephalitis with relapsing clinical course despite a full course of antibiotic treatment. The patient developed acute oculomotor nerve palsy with pupillary involvement and bilateral hearing loss, and delayed right leg monoparesis. We speculate that coexisting bacterial and viral neuroinvasive infections contributed to the unusual clinical and imaging manifestations, and that overwhelming laboratory and clinical features of bacterial meningitis masked the typical features of CNS viral infection. Therefore, atypical presentations of bacterial meningitis should raise a high index of suspicion for coexisting infections, even in immunocompetent patients, and evolving neuroimaging findings may be helpful in substantiating clinical suspicion and guiding further management.     

Review of West Nile virus epidemiology in Italy and report of a case of West Nile virus encephalitis

West Nile virus (WNV) is a flavivirus that causes neurological disorders in less than 1 % of infected subjects. Human cases of WNV-associated fever and/or neurological disorders have been reported in Italy since 2008. The first outbreak occurred in the northeastern region of Italy surrounding the Po River and was caused by the Po River lineage 1 strain, and since then, WNV infections have been reported in several regions of central Italy. Although the virus is highly genetically conserved, stochastic mutations in its genome may lead to the emergence of new strains, as was observed in Italy in 2011 with the identification of two new lineage 1 strains, the WNV Piave and WNV Livenza strains. To help further define WNV epidemiology in Italy, we describe a case of an Italian man living in the Po River area who developed fatal encephalitis in 2009 due to infection with the WNV Piave strain. This finding supports the notion that the Piave strain has been circulating in this area of Italy for 2 years longer than was previously believed.     

Adult-onset opsoclonus-myoclonus syndrome due to West Nile Virus treated with intravenous immunoglobulin

A 63-year-old female with no significant past medical history was presented with a 5-day history of progressive opsoclonus-myoclonus, headaches, and fevers. Her workup was significant only for positive West-Nile Virus serum serologies. She received a 2-day course of intravenous immunoglobulin (IvIG). At an 8-week follow up, she had a complete neurological remission. Adult-onset opsoclonus-myoclonus syndrome is a rare condition for which paraneoplastic and infectious causes have been attributed. To our knowledge, this is the first case reported of opsoclonus-myoclonus secondary to West-Nile Virus treated with intravenous immunoglobulin monotherapy.     

Clinical and neuroradiologic features of 39 consecutive cases of West Nile Virus meningoencephalitis

Background: West Nile Virus (WNV) is a flavivirus WNV that has spread westwards across North America in recent years. It can cause a febrile illness and infection of the central nervous system, which is associated with poor outcome. Methods: We retrospectively studied the clinical and neuroradiologic features of 39 consecutive patients admitted during summer of 2002 that had IgM in the cerebrospinal fluid positive for WNV. Results: Fever, headache and altered mentation were predominant clinical features. Clinically significant involvement of lower motor neurons was seen in few cases. Magnetic resonance imaging (MRI) of the brain did not show changes attributable to meningitis or encephalitis except for one case of subcortical signal abnormalities. Unfavorable prognostic factors are old age, decreased level of alertness and elevated serum creatinine. Conclusions: Encephalopathic presentations, with or without additional neurological focality, dominated this series. Fever and meningitic signs are often absent. Involvement of lower motor neurons was uncommon. Given the paucity of positive findings, the value of MRI to support the diagnosis of WNV-meningoencephalitis is limited.     

An Unusual Cervical Spinal Meningioma in a Child

The incidence of spinal meningioma is very rare in children. A 14-year-old girl presented with right arm weakness, gait disturbance, and urinary incontinence. Cervical magnetic resonance imaging revealed an intradural extramedullary tumor dorsal to the spinal cord in the level of C1. The tumor was totally removed despite the severe cord compression. Meningotheliomatous meningioma was diagnosed after histological examination.     

Neuronal and glial cerebrospinal fluid protein biomarkers are elevated after West Nile Virus infection

Neurotrophic West Nile virus (WNV) disease is a severe arbovirus infection in which neuronal loss is the likely anatomical substrate for the high morbidity and mortality. We investigated whether cerebrospinal fluid (CSF) protein biomarkers were elevated in vivo and related to disease severity in patients with WNV infection. This exploratory study included 114 patients (24 acute WNV, 77 noninflammatory controls, six peripheral neuropathies, seven aseptic meningoencephalitis). CSF levels of neuronal (neurofilaments, NfH‐SMI35) and glial (glial fibrillary acidic protein, GFAP, S100B) biomarkers were measured by enzyme‐linked immunosorbent assay (ELISA). Immunocytochemistry was performed in two fatal WNV cases. A significant proportion of patients with WNV had pathological CSF levels for NfH‐SMI35 (58%, median concentration 1.01 ng/mL), GFAP (58%, 10 pg/mL), and S100B (90%, 1.29 ng/mL). The results were consistent with postmortem evidence for neuronal death and astrogliosis. Surprisingly, CSF protein biomarker levels were also found to be pathological in a considerable proportion of patients who presented with WNV fever only (100% for GFAP and S100B and 43% for NfH‐SMI35). Elevated CSF protein biomarker levels are suggestive of neuronal death and glial pathology in human WNV infection. The results indicate the presence of neuroinvasive disease across the spectrum of WNV disease, including WNV fever. Muscle Nerve, 2010     

Child-in-Family Therapy to Heal a Traumatically Bereaved 10-Year-Old Boy in Grandparental Kinship Care: A Case Study

This study explores the utility of an innovative therapeutic modality for the intra-familial treatment of children who have experienced traumatic loss. A case study is presented of the application of child-in-family therapy (CIFT) with a 10-year-old boy orphaned in political violence and experiencing severe externalizing and acting-out behaviors in grandparental kinship care. CIFT is conceptualized within the context of social and family support for those coping with trauma and loss. The study underscores the phenomenon of family caregiving, and of grandparents raising grandchildren. It highlights the complexities of kinship care when caregivers are experiencing a parallel process of recovery from traumatic loss. The possibility for posttraumatic growth among grandparental caregivers is raised. The limitations and contraindications of CIFT are considered, as well as the implications of study findings for clinical social work practice with children who have undergone traumatic loss, social policy, and ongoing research.     

Limb Paralysis as a Manifestation of Coxsackie B Virus Infection

Forty-four African children (25 girls, 19 boys) are described with single or multiple limb paralysis as a manifestation of infection with Coxsackie B virus. Single limb paralysis involved exclusively the lower extremity, with no nervous system involvement elsewhere and a relatively benign prognosis. Multiple limb paralysis occurred either alone or with other neurological deficits. Only two of 15 patients followed up for five months or longer regained premorbid motor status. Seven patients required assisted ventilation, of whom all but one died. Viral infection remains an important cause of acute limb paralysis in this population, and Coxsackie B is the agent often responsible.     

Rare ocular manifestation in a case of West Nile virus meningoencephalitis

West Nile Virus (WNV) is an arthropod-borne flavivirus, which causes flu-like illness and is sporadically associated with encephalitis. Transmission to humans occurs following a bite from an infected mosquito, which acquires the virus after feeding on dead birds. WNV meningoencephalitis is a rare infection with a neuroinvasive disease occurring in less than 1% of the cases, with varied presentations including aseptic meningitis, meningoencephalitis, and acute flaccid paralysis. Chorioretinitis is the most common eye finding in this infection, while other ocular manifestations have been rarely reported in the literature. We present the first case report of WNV meningoencephalitis, with rare ocular manifestations of acute hemorrhagic conjunctivitis, bilateral subconjunctival hemorrhages, and nystagmus. The rare ocular findings of acute hemorrhagic conjunctivitis, bilateral subconjunctival hemorrhages, and nystagmus diagnosed in our case can guide clinicians toward early diagnosis of WNV meningoencephalitis, while serologic testing is still pending.     

Unusual Development of Motor Skills in a Child with Trisomy-18

A child with trisomy-18 is reported who had by the age of four years developed motor skills considerably more advanced than any abilities previously noted in other children with this disorder. It is not possible to demonstrate how far this improvement was due to natural development, to physiotherapy, to the parent's handling or to other causes. However, if the degree of parental understanding, stimulation and participation in treatment has a significant effect on a child's progress, then further attempts to assess the value of physiotherapy for children should take this factor into consideration.     

Neuropathological findings in West Nile virus encephalitis: a case report

A 67-year-old woman had fever, myalgias, progressive weakness, and respiratory insufficiency. In 9 days, flaccid areflexic quadriparesis and bulbar palsy developed. She died 26 days after the onset of her illness. Serum and cerebrospinal fluid serology were positive for West Nile virus. Neuropathological study showed changes consistent with a viral encephalomyelitis, similar to poliomyelitis. The brainstem showed neuronal loss and multiple foci of necrosis. The spinal cord showed severe loss of anterior and posterior horn neurons. Immunohistochemistry identified West Nile virus antigens in the brainstem and spinal cord. Paralysis, in West Nile virus encephalitis, is caused by destruction of motor neurons.