Tratamiento y evolución de la encefalitis inmunomediada en edad pediátrica, serie de casos / Treatment and outcome of immune-mediated encephalitis in children, a case series

Introducción: La encefalitis por anticuerpos contra el receptor N-metil.D.aspartato (NMDA-R) es un trastorno inflamatorio del sistema nervioso central (SNC) en el cual autoanticuerpos dirigidos hacia la subunidad NR1 del receptor N-metil-D aspartato (NMDA) desarrollan un conjunto de síntomas neuropsiquiátricos, convulsiones y movimientos anormales. El tratamiento recomendado incluye metilprednisolona (MP) y gamaglobulina (IVIg), y/o recambio plasmático terapéutico (RPT); y en caso de no respuesta: rituximab (RTX) y/o ciclofosfamida (CFM). Objetivos: Analizar características clínicas, bioquímicas, electroencefalograma (EEG), resonancia magnética (RM) cerebral, tratamientos recibidos y resultados observados en una serie de pacientes con encefalitis autoinmune (EA) probable o confirmada. Materiales y métodos: Analizamos las historias clínicas de pacientes menores a 17 años que cumplían criterios diagnósticos de Graus (2016) para EA probable, con seguimiento mayor a 6 meses, internados en el Hospital Garrahan entre 2008 y 2023. El diagnóstico se definió por la identificación de anticuerpos anti-NMDAR (N-metil D-aspartato) en líquido cefalorraquídeo (LCR) por ensayo basado en células - cell bassed assay (CBA). Resultados: Reunieron criterios de EA probable 94 pacientes con una edad media de 89.5 meses, 51% mujeres. Se dividieron en dos grupos: seropositivos y seronegativos de acuerdo al resultado del biomarcador. Seropositivos 45/94. El síntoma inicial más frecuente fue: convulsiones. El 28% requirió ingreso a Unidad de Cuidados Intensivos (UCI). 4 pacientes seropositivos y 1 seronegativo tuvieron encefalitis por el virus del herpes simple (Om) previamente. En una paciente seronegativa se diagnosticó teratoma ovárico. Hallazgos de estudios complementarios: LCR patológico en el 29%, RM cerebral en el 52%, EEG en el 74%. El tratamiento de primera línea más empleado fue MP + IVIg. El 46% de los pacientes presentó recuperación completa. Entre los pacientes que recibieron RTX, el 65% tuvo una recuperación completa. Ningún paciente que recibió RTX presentó recaída. Conclusión: Ante la sospecha de EA se debe considerar el inicio temprano de inmunoterapia para favorecer la rápida recuperación funcional. Se recomienda el uso temprano de RTX en los casos con presentación grave o respuesta subóptima al tratamiento de primera línea para beneficiar la respuesta clínica y reducir el riesgo de recaída (AU)

Introduction: Encephalitis due to antibodies against the N-methyl-D-aspartate receptor (NMDA-R) is an inflammatory disorder of the central nervous system (CNS) in which autoantibodies directed against the NR1 subunit of the N-methyl-D-aspartate (NMDA) receptor develop a set of neuropsychiatric symptoms, seizures, and abnormal movements. The recommended treatment includes methylprednisolone (MP) and intravenous immunoglobulin (IVIg), and/or therapeutic plasma exchange (TPE); and in case of non-response: rituximab (RTX) and/or cyclophosphamide (CFM). Objectives: To analyze clinical, biochemical, electroencephalogram (EEG), magnetic resonance imaging (MRI) of the brain, treatments received, and outcomes observed in a series of patients with probable or confirmed autoimmune encephalitis (AE). Materials and methods: We analyzed the medical records of patients under 17 years of age who met Graus' diagnostic criteria (2016) for probable AE, with follow-up of more than 6 months, hospitalized at Hospital Garrahan between 2008 and 2023. Diagnosis was defined by the identification of anti-NMDAR antibodies (N-methyl D-aspartate) in cerebrospinal fluid (CSF) by cell-based assay (CBA). Results: Ninety-four patients met criteria for probable AE with a mean age of 89.5 months, 51% female. They were divided into two groups: seropositive and seronegative according to the biomarker result. Seropositive 45/94. The most frequent initial symptom was seizures. Twenty-eight percent required admission to the Intensive Care Unit (ICU). Four seropositive patients and one seronegative patient had previously had herpes simplex encephalitis (Om). Ovarian teratoma was diagnosed in one seronegative patient. Findings of complementary studies: Pathological CSF in 29%, brain MRI in 52%, EEG in 74%. The most commonly used first-line treatment was MP + IVIg. Forty-six percent of patients experienced complete recovery. Among patients who received RTX, 65% had complete recovery. No patient who received RTX experienced relapse. Conclusion: In the suspicion of AE, early initiation of immunotherapy should be considered to promote rapid functional recovery. Early use of RTX is recommended in cases with severe presentation or suboptimal response to first-line treatment to benefit clinical response and reduce the risk of relapse (AU)

Diabetes tipo 1 y Miastenia Gravis / Type-1 Diabetes and Myasthenia Gravis

Introducción: El desarrollo de la tolerancia inmunológica frente a los autoantígenos se denomina autotolerancia. La Diabetes Mellitus tipo 1A (1ADM) es un trastorno metabólico secundario a la destrucción autoinmune de las células beta pancreáticas e insulitis. La miastenia grave (MG) es una enfermedad autoinmune causada por el bloqueo postsináptico de la placa mioneural por AAcs contra los receptores de acetilcolina (ACRA) o contra moléculas de la membrana postsináptica. La asociación entre DM1A y MG se puede observar en el síndrome poliglandular tipo III, caracterizado por enfermedad autoinmune de la glándula tiroides asociada con otras entidades autoinmunes. Método: Reporte de Casos, cuatro pacientes entre 7-19 años, con asociación de MG y DM1A atendidos en el Hospital Garrahan. Conclusión: La Tiroiditis de Hashimoto y la Enfermedad Celíaca son las enfermedades autoinmunes relacionadas más frecuentemente con DM1A en nuestra población. La bibliografía describe la asociación de MG y Tiroiditis de Hashimoto y su coexistencia con DM1A se describe en el Síndrome Poliglandular III. En este trabajo presentamos 4 casos de DM1A asociado con MG fuera de dicho síndrome (AU)

Introduction: The development of immune tolerance to autoantibodies (AAbs) is referred to as self-tolerance. Type 1A Diabetes Mellitus (1ADM) is a metabolic disorder secondary to autoimmune destruction of pancreatic beta cells and insulitis. Myasthenia gravis (MG) is an autoimmune disease caused by postsynaptic blockade of the myoneural plate by AAbs against acetylcholine receptors (Acra) or against postsynaptic membrane molecules. The association between 1ADM and MG may be observed in polyglandular syndrome type III, characterized by autoimmune disease of the thyroid associated with other autoimmune conditions. Methods: Case report; four patients between 7-19 years old, with an association of MG and 1ADM seen at the Garrahan Hospital. Conclusion: Hashimoto's thyroiditis and celiac disease are autoimmune diseases most frequently related to 1ADM in our population. In the literature, the association of MG and Hashimoto's thyroiditis has been described and its coexistence with 1ADM is reported in polyglandular syndrome III. In this study we present 4 cases of 1ADM associated with MG unrelated to this syndrome. (AU)

Natural History of Type 1 Spinal Muscular Atrophy in a Series of Argentinian Children.

BACKGROUND: SMA1 natural history is characterized by early development of chronic respiratory failure. Respiratory interventions in type 1 SMA infants are subject to great practice variability. Nusinersen, has been recently approved in Argentina. The advent of novel treatments has highlighted the need for natural history studies reporting disease progression in type 1 SMA. OBJECTIVE: To analyze the progression, respiratory interventions and survival based on the type of respiratory support in type 1SMA patients, in a third level pediatric hospital in Argentina. METHODS: Cohort of SMA1 patients followed at the Interdisciplinary Program for the Study and Care of Neuromuscular Patients (IPNM). Patient survival was analyzed by using the Kaplan-Meier method. Log-rank test was performed to compare the survival curve for three respiratory intervention groups. RESULTS: 59 patients. Mean age of symptom onset was 2.19 (±1.4) months, age at diagnosis was 3.9 (±2.1) months. Patients developed respiratory failure at 5.82 months (±2.32) and 13.8 months (±5.6) in Type 1B and Type 1C, respectively (p < 0.001) 53 p were SMA1B. Three copies were found in 1/6 SMA1C. Respiratory interventions: SRC 23 p (56.1%); SRC + NIV 8 p (19.5%); SRC + IV 10 p (24.4%). 8 patients were already on invasive ventilation when included in the IPNM. Patients with invasive ventilation showed longer survival. CONCLUSIONS: This series provides valuable information on respiratory intervention requirements and life expectancy in children with SMA1 before the implementation of novel treatments that increase the expression of the SMA protein.

Management of neuromuscular diseases and spinal muscular atrophy in Latin America.

Latin America (LA) has a population of ~645 million people distributed over 33 countries with marked political, cultural and economic differences. In LA, patients with inherited neuromuscular diseases (NMDs) often do not have access to specialized medical centers and many of them go undiagnosed. General management and care of spinal muscular dystrophy (SMA) patients in the region varies due to heterogeneous health care. An active generation of young clinical neurologists is being trained for the specialized care of SMA and other neuromuscular (NM) patients, both in the private and public sectors. The Euro-Latin-American Summer School of Myology (EVELAM) as well as efforts of professionals at large public centers in the major cities of LA have a leading role in this development. Different regional academic-scientific organizations as well as the expanding number of telethon centers and the creation of parent organizations, mostly concerning SMA, all together are contributing to the increased quality of the management of NMD patients. Over the past years, academic and clinical research, as well as the establishment of qualified centers for the molecular testing of NMD are pushing forward the creation of patient registries and the development of specific clinical trials, with Argentina and Brazil having a major role in this field. Nevertheless, increased awareness and further training of specialized health professionals are necessary to reach patients that are currently lacking care throughout the region.

Espectro clínico de pacientes con hallazgos histopatológicos y/o moleculares compatibles con enfermedad mitochondrial / Clinical spectrum of patients with histopathological and/or molecular findings compatible with mitochondrial disease

Objetivo: Describir el espectro clínico de pacientes con diagnóstico definitivo de Enfermedad Mitocondrial, y su correlación con hallazgos bioquímicos, neuroimagenológicos, neuropatológicos, y moleculares. Método: Se revisaron las historias clínicas de pacientes con Enfermedad Mitocondrial evaluados durante el período 1990-2011. Resultados: Se incluyeron 41 pacientes, con una edad media inicial de 3,7 años. Identificamos cuatro grupos:1) Síndromes clásicos (65%): a) MELAS del inglés “Mitochondrial encephalomyopathy, lacticacidosis, and stroke-like episodes”, (diez), b) Síndrome de Leigh (diez) c) Síndrome de Kearns –Sayre (cinco), d) PEO del inglés “Progressive External Ophthalmoplegia” plus (OEP plus) (dos), 2) Miopatía: nueve (21,5%) 3) Encefalomiopatías inespecíficas: cinco (12%). Se realizó biopsia muscular en 37 pacientes. Un 70% evidenció fibras rojo rasgadas, cuatro (10,5%) fibras citocromo oxidasa negativas y ocho (14,7%) incremento de la actividad oxidativa subsarcolemal y en la microscopia electrónica alteraciones del tamaño y número de mitocondrias. En 14 se completaron estudios moleculares: Siete presentaron una mutación puntual A3243G en el ADN mitocondrial (MELAS), un paciente una mutación en el ADN mitocondrial A1351G (Síndrome de Leigh) y un paciente una deleción del ADN mitocondrial (OEP plus). Conclusiones: Se pudo corroborar la existencia en nuestro medio de síndromes asociados a patología mitocondrial tradicionalmente reconocidos. Un grupo de pacientes con encefalomiopatías denominadas inespecíficas presentaron un cuadro clínico variable, hallazgos de laboratorio y de imágenes poco orientadores y fue la sospecha de una enfermedad mitocondrial lo que nos llevó a realizar la biopsia que finalmente fue diagnóstica. Es posible que este grupo sea más numeroso y las limitaciones que implica realizar una biopsia muscular se facilite con los estudios moleculares.

Espectro clínico de pacientes con hallazgos histopatológicos y/o moleculares compatibles con enfermedad mitochondrial / Clinical spectrum of patients with histopathological and/or molecular findings compatible with mitochondrial disease

Objetivo: Describir el espectro clínico de pacientes con diagnóstico definitivo de Enfermedad Mitocondrial, y su correlación con hallazgos bioquímicos, neuroimagenológicos, neuropatológicos, y moleculares. Método: Se revisaron las historias clínicas de pacientes con Enfermedad Mitocondrial evaluados durante el período 1990-2011. Resultados: Se incluyeron 41 pacientes, con una edad media inicial de 3,7 años. Identificamos cuatro grupos:1) Síndromes clásicos (65%): a) MELAS del inglés ôMitochondrial encephalomyopathy, lacticacidosis, and stroke-like episodesö, (diez), b) Síndrome de Leigh (diez) c) Síndrome de Kearns ûSayre (cinco), d) PEO del inglés ôProgressive External Ophthalmoplegiaö plus (OEP plus) (dos), 2) Miopatía: nueve (21,5%) 3) Encefalomiopatías inespecíficas: cinco (12%). Se realizó biopsia muscular en 37 pacientes. Un 70% evidenció fibras rojo rasgadas, cuatro (10,5%) fibras citocromo oxidasa negativas y ocho (14,7%) incremento de la actividad oxidativa subsarcolemal y en la microscopia electrónica alteraciones del tamaño y número de mitocondrias. En 14 se completaron estudios moleculares: Siete presentaron una mutación puntual A3243G en el ADN mitocondrial (MELAS), un paciente una mutación en el ADN mitocondrial A1351G (Síndrome de Leigh) y un paciente una deleción del ADN mitocondrial (OEP plus). Conclusiones: Se pudo corroborar la existencia en nuestro medio de síndromes asociados a patología mitocondrial tradicionalmente reconocidos. Un grupo de pacientes con encefalomiopatías denominadas inespecíficas presentaron un cuadro clínico variable, hallazgos de laboratorio y de imágenes poco orientadores y fue la sospecha de una enfermedad mitocondrial lo que nos llevó a realizar la biopsia que finalmente fue diagnóstica. Es posible que este grupo sea más numeroso y las limitaciones que implica realizar una biopsia muscular se facilite con los estudios moleculares

Recessive RYR1 mutations cause unusual congenital myopathy with prominent nuclear internalization and large areas of myofibrillar disorganization.

AIMS: To report the clinical, pathological and genetic findings in a group of patients with a previously not described phenotype of congenital myopathy due to recessive mutations in the gene encoding the type 1 muscle ryanodine receptor channel (RYR1). METHODS: Seven unrelated patients shared a predominant axial and proximal weakness of varying severity, with onset during the neonatal period, associated with bilateral ptosis and ophthalmoparesis, and unusual muscle biopsy features at light and electron microscopic levels. RESULTS: Muscle biopsy histochemistry revealed a peculiar morphological pattern characterized by numerous internalized myonuclei in up to 51% of fibres and large areas of myofibrillar disorganization with undefined borders. Ultrastructurally, such areas frequently occupied the whole myofibre cross section and extended to a moderate number of sarcomeres in length. Molecular genetic investigations identified recessive mutations in the ryanodine receptor (RYR1) gene in six compound heterozygous patients and one homozygous patient. Nine mutations are novel and four have already been reported either as pathogenic recessive mutations or as changes affecting a residue associated with dominant malignant hyperthermia susceptibility. Only two mutations were located in the C-terminal transmembrane domain whereas the others were distributed throughout the cytoplasmic region of RyR1. CONCLUSION: Our data enlarge the spectrum of RYR1 mutations and highlight their clinical and morphological heterogeneity. A congenital myopathy featuring ptosis and external ophthalmoplegia, concomitant with the novel histopathological phenotype showing fibres with large, poorly delimited areas of myofibrillar disorganization and internal nuclei, is highly suggestive of an RYR1-related congenital myopathy.

[Clinical and electroencephalographic aspects of late infantile neuronal ceroid lipofuscinosis]. / Lipofuscinosis neuronal ceroidea infantil tardía: aspectos clínicos y electroencefalográficos.

AIMS: In this paper we describe the clinical characteristics, and particularly the epileptic seizures and electroencephalographic findings, in 15 patients with a pathology diagnosis of late infantile neuronal ceroid lipofuscinosis (NCL). PATIENTS AND METHODS: Nine female and six male patients were studied and their clinical records covering the period February 1990 to June 2003 were analysed. Neuroimaging, neurometabolic studies, ERG, PE and repeated EEG were carried out in all cases. RESULTS: The mean age on onset of the disease was 3 years (range: 1-5 years). The initial symptom was epilepsy in all cases. Massive myoclonias and myoclonic-atonic seizures were the most frequent kinds of attacks. Focal myoclonias were observed in six patients. Other types of epileptic seizures observed included generalised tonic-clonic, absence, motor focal and complex focal. The epileptic seizures were resistant to therapy. Progressive neurological and visual impairment, pyramidal and cerebellar signs, as well as mental retardation were present in all cases. Intercritical EEG recordings showed diffuse paroxysms with spike and polyspike waves, multifocal spikes and, less often, focal spikes that were predominant in posterior regions. Photostimulation showed high amplitude (300-450) occipital spikes during the application of light stimulation between 1 and 8 Hz. ERG, VEP and SSEP results were pathological. Images showed signs of brain and cerebellar atrophy. Seven of the patients died between 8.5 and 11 years of age. CONCLUSIONS: Late infantile NCL must be considered in the case of a child aged between 1 and 5 years who presents seizures that are predominantly generalised myoclonias and myoclonic-atonic, in association with progressive neurological deterioration including pyramidal, cerebellar and visual signs and an EEG trace showing occipital paroxysms triggered by low frequency photostimulation.

Lipofuscinosis neuronal ceroidea infantil tardía: aspectos clínicos y electroencefalográficos / Clinical and electroencephalographic aspects of late infantile neuronal ceroid lipofuscinosis

Objetivo. Describimos las características clínicas, particularmente las crisis epilépticas y los hallazgos electroencefalográficos, en 15 pacientes con diagnóstico anatomopatológico de lipofuscinosis neuronal ceroidea (LNC) infantil tardía. Pacientes y métodos. Se estudiaron y se analizaron las historias clínicas de nueve pacientes del sexo femenino y seis del masculino durante el período comprendido entre febrero de 1990 y junio de 2003. En todos los casos se realizaron neuroimágenes, estudios neurometabólicos, ERG, PE y repetidos EEG . Resultados. La edad mediana de comienzo de la enfermedad fue de 3 años (intervalo: 1-5 años). La manifestación inicial fue la epilepsia en todos los casos. Las crisis más frecuentes fueron las mioclonías masivas y las crisis mioclonicoatónicas. Se observaron mioclonías focales en seis pacientes. Otros tipos de crisis epilépticas observados fueron tonicoclónicas generalizadas, ausencias, focales motoras y focales complejas. Las crisis epilépticas fueron refractarias al tratamiento. En todos los casos se presentaron deterioro neurológico y visual progresivo, signos piramidales y cerebelosos y retraso mental . Los EEG intercríticos mostraron paroxismos de punta y polipunta onda difusos, espigas multifocales y, menos frecuentemente, espigas focales predominantes en las regiones posteriores. La fotoestimulación mostró espigas occipitales de elevada amplitud (300-450) durante el estímulo lumínico entre 1 y 8 Hz. El ERG, los PE visuales y los PE somatosensoriales fueron patológicos. Las imágenes evidenciaron signos de atrofia cerebral y cerebelosa. Siete de los pacientes fallecieron entre los 8,5 y los 11 años. Conclusión. En un niño de 1-5 años que comienza con convulsiones, predominantemente mioclonías generalizadas y mioclonicoatónicas asociadas a deterioro neurológico progresivo que incluye signos piramidales, cerebelosos y visuales con un EEG con paroxismos occipitales desencadenados por la fotoestimulación a baja frecuencia, debemos pensar en una LNC infantil tardía

Aims. In this paper we describe the clinical characteristics, and particularly the epileptic seizures and electroencephalographic findings, in 15 patients with a pathology diagnosis of late infantile neuronal ceroid lipofuscinosis (NCL). Patients and methods. Nine female and six male patients were studied and their clinical records covering the period February 1990 to June 2003 were analysed. Neuroimaging, neurometabolic studies, ERG, PE and repeated EEG were carried out in all cases. Results. The mean age on onset of the disease was 3 years (range: 1-5 years). The initial symptom was epilepsy in all cases. Massive myoclonias and myoclonic-atonic seizures were the most frequent kinds of attacks. Focal myoclonias were observed in six patients. Other types of epileptic seizures observed included generalised tonic-clonic, absence, motor focal and complex focal. The epileptic seizures were resistant to therapy. Progressive neurological and visual impairment, pyramidal and cerebellar signs, as well as mental retardation were present in all cases. Intercritical EEG recordings showed diffuse paroxysms with spike and polyspike waves, multifocal spikes and, less often, focal spikes that were predominant in posterior regions. Photostimulation showed high amplitude (300-450) occipital spikes during the application of light stimulation between 1 and 8 Hz. ERG, VEP and SSEP results were pathological. Images showed signs of brain and cerebellar atrophy. Seven of the patients died between 8.5 and 11 years of age. Conclusions. Late infantile NCL must be considered in the case of a child aged between 1 and 5 years who presents seizures that are predominantly generalised myoclonias and myoclonic-atonic, in association with progressive neurological deterioration including pyramidal, cerebellar and visual signs and an EEG trace showing occipital paroxysms triggered by low frequency photostimulation

Clinical and histopathological aspects of central core disease associated and non-associated with RYR1 locus.

We analysed the clinical, histochemical, ultrastructural and genetic data of patients affected by central core disease (CCD) studied during the last 20 years. From a total series of 86 CCD-families, we have identified 46 CCD families with RYR1 mutations (16 autosomal dominant, 8 autosomal recessive, 17 sporadic cases and 5 de novo mutations). Out of the other 40 CCD families, the RyR1 gene was entirely excluded in 7 families, by cDNA sequencing or linkage analysis, indicating a genetic heterogeneity of CCD.

[Delayed-type subacute measles encephalitis]. / Encefalopatía sarampionosa subaguda retardada.

INTRODUCTION: We analyze the clinical, neurological, EEG, neuroradiological features and evolution of two patients with subacute measles encephalitis. CASE REPORTS: The patients, aged five years and eleven months respectively showed an acute, progressive neurological compromise and deterioration of consciousness, epilepsia partialis continua and progressive damage on neuroimaging, with a history of measles in the first case and exposure to the virus in the second. The first patient had Hodgkin's disease and the other had a familial C4 deficit disorder. Fundoscopic examination showed lesions on the retina. The EEG showed unilateral slow waves and spikes. Brain CT and MRI revealed progressive cerebral atrophy and a unilateral corticosubcortical lesion. Measles antibodies in CSF were found in the first child and oligoclonal bands in the second. Our first patient died after three months and the second has a severe neurological damage. CONCLUSION: In immunocompromised patients with the exposure to a history of measles, acute neurological compromised and deterioration of consciousness, epilepsia partialis continua and progressive damage on neuroimaging, subacute measles encephalitis should be considered.

Encefalopatía sarampionosa subaguda retardada / Subacute measles encephalitis

Introducción. Analizamos las características clínicas, neurológicas, electroencefalográficas y evolutivas en dos pacientes con encefalopatía sarampionosa subaguda retardada. Casos clínicos. Ambos pacientes, uno a los cinco años y el otro a los 11 meses, presentaron un deterioro agudo neurológico y de conciencia, epilepsia parcial continua y lesiones progresivas en los estudios de imágenes, con antecedentes de haber padecido sarampión en el primer caso y contacto con el virus en el segundo. El primer paciente tenía linfoma de Hodgkin y el segundo presentaba un déficit familiar de C4. El fondo de ojo evidenció lesiones retinianas, el EEG mostró ondas lentas unilaterales con ondas agudas o espigas intercaladas. La TAC y la RM de cerebro mostraron atrofia cerebral progresiva con lesiones extensas corticosubcorticales unilaterales. El análisis del LCR en el primer caso evidenció anticuerpos contra sarampión elevados, y en el segundo, bandas oligoclonales. El primer paciente falleció a los tres meses de haber iniciado el cuadro neurológico y el segundo paciente presenta un grave deterioro neurológico. Conclusión. En pacientes inmunosuprimidos con antecedentes de exposición al virus del sarampión, deterioro agudo neurológico y de conciencia, epilepsia parcial continua y lesiones progresivas en los estudios neurorradiológicos, debemos considerar el diagnóstico de encefalopatía sarampionosa subaguda retardada (AU)

Introduction. We analyze the clinical, neurological, EEG, neuroradiological features and evolution of two patients with subacute measles encephalitis. Case reports. The patients, aged five years and eleven months respectively showed an acute, progressive neurological compromise and deterioration of consciousness, epilepsia partialis continua and progressive damage on neuroimaging, with a history of measles in the first case and exposure to the virus in the second. The first patient had Hodgkin’s disease and the other had a familial C4 deficit disorder. Fundoscopic examination showed lesions on the retina. The EEG showed unilateral slow waves and spikes. Brain CT and MRI revealed progressive cerebral atrophy and a unilateral corticosubcortical lesion. Measles antibodies in CSF were found in the first child and oligoclonal bands in the second. Our first patient died after three months and the second has a severe neurological damage. Conclusion. In immunocrompromised patients with the exposure to a history of measles, acute neurological compromised and deterioration of consciousness, epilepsia partialis continua and progressive damage on neuroimaging, subacute measles encephalitis should be considered (AU)

[Reflex myoclonic epilepsy in infancy: a new reflex epilepsy syndrome or a variant of benign myoclonic epilepsy in infancy]. / Epilepsia mioclónica refleja del lactante: un nuevo síndrome epiléptico reflejo o una variante de la epilepsia mióclonica benigna del lactante.

CASE REPORTS: We report a clinical and EEG study of 8 children with reflex myoclonic epilepsy of infancy to further confirm the existence of this syndrome first described by Ricci et al in 1995. RESULTS: Between February 1990 to July 2002, we identified 64 epileptic patients with myoclonic seizures with an onset in the first six years of life. Eight (12.5%) of these patients had myoclonic seizure stimuli sensible. The seizures were characterized by generalized, myoclonic jerks triggered by tactile stimuli in six patients and acoustic stimuli in two, in one of them myoclonic jerks were triggered by both types of stimuli. The seizures appeared between 5 and 20 months of age. Two of the 8 patients had spontaneous myoclonic attacks during sleep. Interictal EEG was normal during wakefulness and occasional discharges were evident during sleep. In contrast, the ictal EEG during both wakefulness and sleep showed generalized spike wave and polyspike slow wave paroxysms. Neurologic examination, neuroimaging and neurometabolic studies were normal. Myoclonic jerks disappeared in 6 patients after valproic acid administration and in two after clobazan administration. Antiepileptic treatment was discontinued in 6 patients and no seizure recurrence was observed during a median follow up of 6 years. CONCLUSION: Our patients presented electro clinical criteria compatible with the syndrome of reflex myoclonic epilepsy of infancy. This syndrome could be considered to be a new reflex epileptic syndrome or a variant of benign myoclonic epilepsy in infancy.

Epilepsia mioclónica refleja del lactante: un nuevo síndrome epiléptico reflejo o una variante de la epilepsia mioclónica benigna del lactante / Reflex myoclonic epilepsy in infancy: a new reflex epilepsy syndrome or a variant of benign myoclonic epilepsy in infancy

Casos clínicos. Analizamos ocho pacientes con un cuadro electroclínico compatible con una epilepsia mioclónica refleja del lactante, a fin de ratificar la existencia de este síndrome, descrito inicialmente por Ricci et al en 1995. Resultados. Durante el período comprendido entre febrero de 1990 y julio de 2002, identificamos 64 pacientes epilépticos con crisis mioclónicas de comienzo en los seis primeros años de vida, de los que ocho (12,5 por ciento) tuvieron mioclonías de estímulo sensible. Los ocho pacientes presentaron un examen neurológico normal, con mioclonías generalizadas provocadas ante estímulos táctiles en seis pacientes y auditivos en dos. En uno de ellos las mioclonías se desencadenaron por ambos tipos de estímulos. Las crisis se iniciaron entre los 5 y los 20 meses de vida. Dos de ellos tuvieron sacudidas espontáneas durante el sueño. El electroencefalograma (EEG) intercrítico en vigilia fue normal, y durante el sueño se registraron ocasionales paroxismos de puntas y polipunta-onda lentas. El EEG crítico en sueño y vigilia mostró actividad de punta y polipunta-onda lenta generalizada. Los estudios de neuroimagen y neurometabólicos fueron normales. Las miclonías cedieron rápidamente con la administración de ácido valproico en seis pacientes y clobazam en dos. Tras un seguimiento promedio de seis años, seis niños están sin medicación y libres de crisis. Conclusión. Nuestros pacientes cumplen criterios clinicoelectroencefalográficos compatibles con la epilepsia mioclónica refleja del lactante, por lo cual pensamos que podría considerarse un nuevo síndrome epiléptico reflejo o una variante de la epilepsia mioclónica benigna del lactante (AU)

Case reports. We report a clinical and EEG study of 8 children with reflex myoclonic epilepsy of infancy to further confirm the existence of this syndrome first described by Ricci et al in 1995. Results. Between February 1990 to July 2002, we identified 64 epileptic patients with myoclonic seizures with an onset in the first six years of life. Eight (12.5%) of these patients had myoclonic seizure stimuli sensible. The seizures were characterized by generalized, myoclonic jerks triggered by tactile stimuli in six patients and acoustic stimuli in two, in one of them myoclonic jerks were triggered by both types of stimuli. The seizures appeared between 5 and 20 months of age. Two of the 8 patients had spontaneous myoclonic attacks during sleep. Interictal EEG was normal during wakefulness and occasional discharges were evident during sleep. In contrast, the ictal EEG during both wakefulness and sleep showed generalized spike-wave and polyspike slow-wave paroxysms. Neurologic examination, neuroimaging and neurometabolic studies were normal. Myoclonic jerks disappeared in 6 patients after valproic acid administration and in two after clobazan administration. Antiepileptic treatment was discontinued in 6 patients and no seizure recurrence was observed during a median follow up of 6 years. Conclusion. Our patients presented electro-clinical criteria compatible with the syndrome of reflex myoclonic epilepsy of infancy. This syndrome could be considered to be a new reflex epileptic syndrome or a variant of benign myoclonic epilepsy in infancy (AU)