Severe cyanide poisoning from an alternative medicine treatment with amygdalin and apricot kernels in a 4-year-old child.

BACKGROUND: The use of complementary and alternative medicine (CAM) is widespread in children with cancer and is poorly regulated. PATIENTS AND METHODS: Case report. RESULTS: We describe a case of severe cyanide poisoning arising from CAM use. A severely agitated, encephalopathic, unresponsive 4-year-old boy (initial Glasgow Coma Scale of 3) with a history of metastatic ependymoma was brought to our emergency department by ambulance services. Initial blood gas analysis demonstrated severe metabolic/lactic acidosis. On detailed questioning of the parents, the use of CAM including intravenous and oral "vitamin B 17" (amygdalin) and oral apricot kernel was reported. After administering sodium thiosulfate, rapid improvement in his medical condition with complete recovery without need for further intensive care treatment was seen. Serum cyanide level was markedly elevated. CONCLUSIONS: Cyanide poisoning can be the cause of severe encephalopathy in children receiving CAM treatment with substances containing cyanogenic glycosides.

Cerebral MRI and EEG studies in the initial management of pediatric headaches.

BACKGROUND AND STUDY PURPOSE: High resolution imaging modalities and electroencephalographic studies (EEG) are used in the assessment of children with headaches. We evaluated the role of cerebral MRI (cMRI) and EEG in the initial assessment of children with headache as the chief complaint of initial presentation. METHODS: A retrospective chart analysis was performed at a tertiary University Hospital. RESULTS: 209 patients were included in this study [mean age 11.3 years; male 91 (43.5%); female 118 (56.5%)]. The following types of headaches were seen: Unclassified headache: 23.4%; probable migraine 17.2%, migraine without aura 13.4%, complicated migraine 12.4%, migraine with aura 1.0%; tension-type 15.3%, and cluster headaches 0.5%, and secondary headaches 16.7%. In 93 children (44.5%) abnormal physical/neurological findings were noted (multiple entries possible). On cMRI studies the following findings were seen: Infection of sinuses (7.2%), pineal cysts (2.4%), arachnoidial cyst and Chiari malformation (1.9%), unspecified signal enhancement (1.0%), and pituitary enlargement, inflammatory lesion, angioma, cerebral ischaemia, and intra-cerebral cyst (each 0.5%). Electroencephalographic findings included both focal and generalised abnormal slowing (5.3%) and Spike-wave complexes (3.3%). CONCLUSIONS: Despite abnormal findings on neurological/physical examination in a substantial number of children with headaches, the yield of pathological cMRIs was low. The use of EEG recordings was not contributory to the diagnostic and therapeutic approach. More research is needed to better define those patients who are likely to have an intracranial pathology.

Diagnostic approach to children with minor traumatic brain injury.

STUDY PURPOSE: To analyse the management of minor traumatic brain injury (MTBI) in paediatric hospitals in Germany. METHODS: An electronic survey was sent to 72 children hospitals. RESULTS: All participating (45/72; 62.5 %) hospitals had facilities to perform an electroencephalogram (EEG), 98 % cranial ultrasonography, 94 % MRI studies, and 87 % a CT scan. The initial Glasgow Coma Scale, the clinical presentation/neurological deficits, the intensity of the trauma and external/visible injuries were most important for initial assessment. The main reason for in-patient monitoring was initial clinical neurologic presentation (44 %). X-ray scans were used routinely in only 2.2 %, cMRI scans in 6.7 % and cCT scans in 13.3 %; approximately one third employed ultrasonography. In 22.2 % was an EEG part of the routine diagnostic work-up. Inpatient monitoring for 24-48 h was done in 80 %. CONCLUSIONS: Children with MTBI are often monitored clinically without resorting to potentially harmful and expensive diagnostic procedures (cCT scans).

Electroencephalogram in children with minor traumatic brain injury.

BACKGROUND: Mild traumatic brain injury (MTBI) is one of the most frequent causes for hospitalisation in childhood. Because of different guidelines in the management the diagnostic approach varies substantially. Apart from neuroimaging studies (CT, MRI, sonography) an electroencephalogram (EEG) is often performed without any evidence-based data supporting its use. METHODS: Retrospective analysis of 150 children with MTBI (age 0-16 years), who were admitted to the Children's Hospital of the University of Saarland from January 2006 to December 2007. RESULTS: Mean age was 4.3 (SD 3.6) years: 55.3% were boys. The most common mechanisms of injury were: Minor fall <1 m of height (60%) and fall >1.5 m of height (10%). The most common symptoms were: one or more episodes of vomiting (60%), somnolence (26.7%) and headache (12.7%). On 118 patients an EEG was performed; 106 (89.8%) were normal, 11 (9.3%) pathological and 1 (0.9%) invalid because of artefacts. The pathological EEGs showed focal findings with localised slowing in nine cases, spike-wave complexes in one case and general slowing in one case. Of the 11 patients with pathological EEG, two had a CT scan, two a MRI and two had cranial sonography; all the neuro-imaging was normal. None of the children required neurosurgical intervention, had a negative outcome or showed persistent symptoms. CONCLUSION: The routine performance of an EEG after MTBI in children is not indicated because in most of the cases it is unrevealing, and may lead to unnecessary diagnostic procedures. Instead, children with MTBI should be closely monitored for possible clinical complications and neurological deterioration.