Case Reports in Pediatrics The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. A Case of Infective Endocarditis and Pulmonary Septic Emboli Caused by Lactococcus lactis Tue, 27 Sep 2016 13:54:07 +0000 Infective endocarditis is a rare condition in children with normal hearts. We present here a case of previously healthy eleven-year-old girl with infective endocarditis and pulmonary septic emboli caused by a very rare bacterial etiology (Lactococcus lactis). Identification of this pathogen was only made by polymerase chain reaction. Bshara Mansour, Adib Habib, Nazih Asli, Yuval Geffen, Dan Miron, and Nael Elias Copyright © 2016 Bshara Mansour et al. All rights reserved. Bronchial Leech Infestation in a 15-Year-Old Female Mon, 26 Sep 2016 16:37:40 +0000 Foreign body aspiration (FBA) is a common incidence in young children. Leeches are rarely reported as FBA at any age. This study describes a 15-year-old female who presented with hemoptysis, hematemesis, coughs, melena, and anemia seven months prior to admission. Chest X-ray showed a round hyperdensity in the right lower lobe. A chest computed tomography (CT) demonstrated an area of consolidation and surrounding ground glass opacities in the right lower lobe. Hematological investigations revealed anemia. Finally, bronchoscopy was performed and a 5 cm leech was found within the right bronchus and removed by forceps and a Dormia basket. Mohammad Ashkan Moslehi, Mohammad Hadi Imanieh, and Ali Adib Copyright © 2016 Mohammad Ashkan Moslehi et al. All rights reserved. Airway Management in a Patient with Wolf-Hirschhorn Syndrome Mon, 26 Sep 2016 13:49:50 +0000 We present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general anesthesia for laparoscopic gastrostomy tube placement with a focus on airway management. WHS is a rare 4p microdeletion syndrome resulting in multiple congenital abnormalities, including craniofacial deformities. Microcephaly, micrognathia, and glossoptosis are common features in WHS patients and risk factors for a pediatric airway that is potentially difficult to intubate. We discuss anesthesia strategies for airway preparation and management in a WHS patient requiring general anesthesia with endotracheal intubation. John F. Gamble, Dinesh J. Kurian, Andrea G. Udani, and Nathaniel H. Greene Copyright © 2016 John F. Gamble et al. All rights reserved. Mitochondrial Disease as a Cause of Neonatal Hemophagocytic Lymphohistiocytosis Mon, 26 Sep 2016 13:48:07 +0000 Diagnosis of mitochondrial respiratory chain disorder (MRCD) is often difficult. Its pathogenesis is still unclear. We diagnosed MRCD by measuring the activity of the mitochondrial respiratory chain enzyme, and the patient also had hemophagocytic lymphohistiocytosis (HLH). A preterm female infant was born at 34 weeks of gestation. On day 6, HLH was revealed by bone marrow aspiration. She died on day 10 due to uncontrollable HLH. An autopsy was performed, and we measured the activity of the mitochondrial respiratory chain enzyme in the liver, muscle, and heart. The activity of complex I was decreased in all tissues. As we could not prove another origin of the HLH, she was diagnosed as having HLH caused by MRCD. It is useful to measure the activity of the mitochondrial respiratory chain enzyme for diagnosing MRCD. MRCD, which has a severe clinical course, may be related to HLH. Kazumasa Fuwa, Mitsuru Kubota, Masami Kanno, Hiroshi Miyabayashi, Ken Kawabata, Keiichi Kanno, and Masaki Shimizu Copyright © 2016 Kazumasa Fuwa et al. All rights reserved. Galactocele in a Male Infant with Transient Hyperprolactinaemia: An Extremely Rare Cause of Breast Enlargement in Children Mon, 26 Sep 2016 06:49:26 +0000 Galactocele is a rare breast condition in infants. Here, we report a 16-month-old boy who developed progressive left breast enlargement. Ultrasonography and magnetic resonance imaging revealed a 4 cm cystic lesion at left breast. Hormonal assay showed transient hyperprolactinaemia with no known cause identified. Subsequently, galactocele was confirmed on histopathological examination after complete surgical excision. No recurrence was observed on regular follow-up. C. T. Lau, K. K. Y. Wong, and P. Tam Copyright © 2016 C. T. Lau et al. All rights reserved. Use of Zoledronic Acid in Paediatric Craniofacial Fibrous Dysplasia Thu, 22 Sep 2016 16:33:54 +0000 We describe a case of a paediatric patient affected by mandibular fibrous dysplasia (FD) with severe and chronic pain who was successfully treated with zoledronic acid (ZOL): a third-generation bisphosphonate. Further research is needed to assess its safety and efficacy as a treatment option for FD in the paediatric population. Chiara Di Pede, Sabrina Congedi, Sara Rossin, Antuan Divisic, Alesandra De Gregorio, Caterina Agosto, Igor Catalano, Alessandro Mazza, Leonardo Sartori, Stefano Masiero, and Franca Benini Copyright © 2016 Chiara Di Pede et al. All rights reserved. Pyoderma Gangrenosum: A Rare Cause of Cutaneous Ulceration and One Easily Misdiagnosed Wed, 21 Sep 2016 12:19:16 +0000 Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis often misdiagnosed. It is uncommon in infants and children accounting for 4% of cases. A one-year-old male in paediatric ICU ventilated for bronchopneumonia was referred with ulcerated areas on his neck and axilla corresponding to sites of recent removal of central and arterial lines. Examination revealed areas of deep ulceration with violaceous undermined borders in keeping with PG. This was supported by a skin biopsy showing a neutrophilic infiltrate in the deeper dermis. Topical clobetasol propionate was commenced and a dramatic improvement within 24 hours noted. Blood results showed a leucocytosis of 29.7; a differential WCC showed toxic granulation in neutrophils with myeloid left shift; immunoglobulins showed elevated IgG 23 and IgA 4.86. The elevated WCC made us consider a leukaemic trigger; however, they settled with treatment of the underlying infection. PG in children is more likely to have an atypical distribution involving the head and neck (26.6%) or buttocks (15%). An interesting feature in this case is the presence of pathergy, a term used to describe the induction or exacerbation of PG at sites of iatrogenic or incidental trauma. It is seen in 31% of patients with PG. Wedad Abdelrahman, Maureen Y. Walsh, Susannah E. Hoey, and Donal O’Kane Copyright © 2016 Wedad Abdelrahman et al. All rights reserved. Melanocortin-4 Receptor Deficiency Phenotype with an Interstitial 18q Deletion: A Case Report of Severe Childhood Obesity and Tall Stature Wed, 21 Sep 2016 11:15:39 +0000 Childhood obesity is a growing health concern, associated with significant physical and psychological morbidity. Childhood obesity is known to have a strong genetic component, with mutations in the melanocortin-4 receptor (MC4R) gene being the most common monogenetic cause of obesity. Over 166 different MC4R mutations have been identified in persons with hyperphagia, severe childhood obesity, and increased linear growth. However, it is unclear whether the MC4-R deficiency phenotype is due to haploinsufficiency or dominant-negative effects by the mutant receptor. We report the case of a four-and-a-half-year-old boy with an interstitial deletion involving the long arm of chromosome 18 (46,XY,del(18)(q21.32q22.1)) encompassing the MC4R gene. This patient presented with tall stature and hyperphagia within his first 18 months of life leading to significant obesity. This case supports haploinsufficiency of MC4-R as it describes a MC4-R deficiency phenotype in a patient heterozygous for a full MC4R gene deletion. The intact functional allele with MC4-R haploinsufficiency has the potential to favor a therapeutic response to gastric surgery. Currently, small molecule MC4-R agonists are under development for pharmacologic therapy. Sarah Abdullah, William Reginold, Courtney Kiss, Karen J. Harrison, and Jennifer J. MacKenzie Copyright © 2016 Sarah Abdullah et al. All rights reserved. ALTE and Feeding Intolerance as a Presentation of Double Aortic Arch Sun, 18 Sep 2016 10:54:21 +0000 Many children who are admitted to pediatric hospitals with the chief complaint of apparent life-threatening event (ALTE) are, in fact, well appearing by the time the inpatient medical team evaluates the patient. This presents a diagnostic and therapeutic challenge. We describe a case of a six-month-old full-term female presenting with an ALTE and found to have a double aortic arch, a congenital anomaly that usually presents with a more progressive onset of symptoms such as chronic cough, positional stridor, and feeding difficulties. This case highlights the importance of maintaining a broad differential in a patient presenting with findings of tracheoesophageal pathology on clinical exam. Rekha Krishnasarma, Liza Green Golan Mackintosh, and Francine Bynum Copyright © 2016 Rekha Krishnasarma et al. All rights reserved. Right Atrial Appendage Aneurysm in a Newborn Diagnosed with Fetal Echocardiography Thu, 15 Sep 2016 13:31:41 +0000 Right atrial appendage aneurysm is a very rare condition which can be asymptomatic or can cause arrhythmia or life-threatening thromboembolism. We report a case of newborn with right atrial appendage aneurysm who was diagnosed with fetal echocardiography. Anticoagulant therapy was applied to prevent thromboembolism and he is still going on follow-up without any complaint. Helen Bornaun, Elif Yartaşı Tik, Gonca Keskindemirci, Ali Ekiz, Kazım Öztarhan, Reyhan Dedeoğlu, and Merih Çetinkaya Copyright © 2016 Helen Bornaun et al. All rights reserved. Down-Turner Syndrome: A Case with Double Monoclonal Chromosomal Abnormality Thu, 08 Sep 2016 13:14:15 +0000 Introduction. The coexistence of Down and Turner syndromes due to double chromosome aneuploidy is very rare; it is even more rare to find the presence of a double monoclonal chromosomal abnormality. Objective. To report a unique case of double monoclonal chromosomal abnormality with trisomy of chromosome 21 and an X ring chromosome in all cells studied; no previous report has been found. Case Report. Female, 28 months old, with pathological short stature from birth, with the following dysmorphic features: tilted upward palpebral fissures, short neck, brachycephaly, and low-set ears. During the neonatal period, the infant presented generalized hypotonia and lymphedema of hands and feet. Karyotype showed 47,X,r(X),+21 [30]. Conclusion. Clinical features of both Down and Turner syndromes were found, highlighting short stature that has remained below 3 score from birth to the present, associated with delayed psychomotor development. G-banded karyotype analysis in peripheral blood is essential for a definitive diagnosis. Gioconda Manassero-Morales, Denisse Alvarez-Manassero, and Alfredo Merino-Luna Copyright © 2016 Gioconda Manassero-Morales et al. All rights reserved. Management of Ankyloglossia and Breastfeeding Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and Frenotomy Tue, 30 Aug 2016 15:51:48 +0000 The problems of suction in newborns give rise to multiple consequences for both the mother and the newborn. The objective of this paper is to present a case of ankyloglossia (“tongue-tie”) and the suction problems that were treated by a multidisciplinary team. The subject is a 17-day-old male patient, with ankyloglossia and suction problems during breastfeeding (pain in the breastfeeding mother, poor weight gain, and long breastfeeds). The patient followed the circuit established in our centre between the services of Oral and Maxillofacial Surgery and Breastfeeding and Speech Therapy and Orofacial Rehabilitation (CELERE). The evolution following the breastfeeding sessions, the myofunctional stimulation, and the lingual frenotomy was very favourable, thereby solving the suction problems that the newborn presented. All our patients receive breastfeeding sessions and myofunctional therapy as treatment. We know that a frenotomy is not always necessary and we believe that the stimulation of sucking before and after the surgical intervention is important in order to improve the final result. Elvira Ferrés-Amat, Tomasa Pastor-Vera, Paula Rodríguez-Alessi, Eduard Ferrés-Amat, Javier Mareque-Bueno, and Eduard Ferrés-Padró Copyright © 2016 Elvira Ferrés-Amat et al. All rights reserved. Congenital Malaria due to Plasmodium Vivax Infection in a Neonate Mon, 29 Aug 2016 09:58:18 +0000 Although malaria is endemic in India, congenital malaria is not very common. Congenital malaria is a very rare condition in both endemic and nonendemic areas. We report a case of congenital malaria in a six-day-old neonate with fever and splenomegaly. The diagnosis was picked up accidentally on a peripheral smear examination. Congenital malaria should be kept as differential diagnosis of neonatal sepsis. Timely detection of this condition could lead to early diagnosis and treatment, thereby preventing neonatal mortality. Ravi Bhatia, Dinesh Rajwaniya, and Priti Agrawal Copyright © 2016 Ravi Bhatia et al. All rights reserved. High Flow Priapism in a Pediatric Patient after Circumcision with Dorsal Penile Nerve Block Sun, 28 Aug 2016 08:36:15 +0000 We report the first documented case of high flow priapism after circumcision with dorsal penile nerve block. A 7-year-old male who had undergone circumcision three years before presented to our institution with a 3-year history of persistent nonpainful erections. Workup revealed a high flow priapism and, after discussion of the management options, the patient’s family elected continued observation. Michael A. Granieri, Joseph J. Fantony, and Jonathan C. Routh Copyright © 2016 Michael A. Granieri et al. All rights reserved. Empedobacter brevis Meningitis in a Neonate: A Very Rare Case of Neonatal Meningitis and Literature Review Thu, 25 Aug 2016 17:03:40 +0000 Empedobacter brevis is gram-negative bacilli that belongs to Flavobacteriaceae family. It was previously known with name of Flavobacterium breve. The reservoir of these bacteria is soil, plants, water, food, hospital water sources, including incubators, sinks, faucets, tap water, hemodialysis systems, saline solutions, and other pharmaceutical solutions. We report a case of term female newborn, admitted with complaint of respiratory distress developing soon after birth and developed clinical features of sepsis at age of 92 hours of postnatal life. The sepsis screen was positive and blood culture and cerebrospinal fluid showed growth of Empedobacter brevis that was resistant to multiple antibiotics. The neonate was treated with appropriate antibiotics and was discharged successfully. The novelty of the case report is that this is the first case report of neonatal sepsis caused by Empedobacter brevis. Deepak Sharma, Ankur Patel, Priyanka Soni, Pradeep Sharma, and Basudev Gupta Copyright © 2016 Deepak Sharma et al. All rights reserved. Reversible Severe Pulmonary Hypertension after Adenotonsillectomy: A Case Report of a Child Treated at Bugando Medical Centre, Northwestern Tanzania Mon, 22 Aug 2016 14:04:03 +0000 Upper airway obstruction (UAO) due to adenotonsillar hypertrophy represents one of the rare causes of pulmonary hypertension in children. We report a case of adenotonsillar hypertrophy, managed at pediatric and otorhinolaryngology departments in Bugando Medical Centre (BMC), northwestern Tanzania, with complete remission of symptoms of pulmonary hypertension following adenotonsillectomy. A 17-month-old boy presented with difficulty breathing, dry cough, and noisy breathing since 1 year. He had facial and lower limb oedema with a pan systolic murmur at the tricuspid area, fine crepitations, and tender hepatomegaly. A grade II tonsillar hypertrophy and hypertrophied adenoids were seen on nasal and throat evaluation. A 2D-echocardiography showed grossly distended right atrium and ventricle, dilated pulmonary artery, and grade III tricuspid regurgitation. His final diagnosis was severe pulmonary hypertension with right-sided heart failure due to adenotonsillar hypertrophy. He had complete remission of cardiopulmonary symptoms after adenotonsillectomy and had normal control echocardiography six and twelve months after surgery. Children with symptoms of upper airway obstruction and cardiopulmonary involvement could benefit from routine screening for pulmonary hypertension. Adenotonsillectomy should be considered for possible complete remission of both UAO and cardiopulmonary symptoms. Rogatus Kabyemera, Neema Chami, Neema Kayange, Respicius Bakalemwa, Antke Zuechner, Tumaini Mhada, Gustave Buname, Adolfine Hokororo, and Johannes Kataraihya Copyright © 2016 Rogatus Kabyemera et al. All rights reserved. Congenital Chloride Diarrhea: Diagnosis by Easy-Accessible Chloride Measurement in Feces Mon, 22 Aug 2016 06:17:22 +0000 Background. Congenital chloride diarrhea (CCD) is an autosomal recessive disorder caused by mutations in the genes encoding the intestinal Cl−/ exchanger and is clinically characterized by watery, profound diarrhea, electrolyte disturbances, and metabolic alkalosis. The CCD diagnosis is based on the clinical symptoms and measurement of high chloride concentration in feces (>90 mmol/L) and is confirmed by DNA testing. Untreated CCD is lethal, while long-term clinical outcome improves when treated correctly. Case Presentation. A 27-year-old woman had an emergency caesarian due to pain and discomfort in gestational week 36 + 4. The newborn boy had abdominal distension and yellow fluid per rectum. Therapy with intravenous glucose and sodium chloride decreased his stool frequency and improved his clinical condition. A suspicion of congenital chloride diarrhea was strongly supported using blood gas analyzer to measure an increased chloride concentration in the feces; the diagnosis was confirmed by DNA testing. Discussion. Measurement of chloride in feces using an ordinary blood gas analyzer can serve as a preliminary analysis when congenital chloride diarrhea is suspected. This measurement can be easily performed with a watery feces composition. An easy-accessible chloride measurement available will facilitate the diagnostics and support the initial treatment if CCD is suspected. C. Gils, M.-C. Eckhardt, P. E. Nielsen, and M. Nybo Copyright © 2016 C. Gils et al. All rights reserved. A Case of Congenital Malignant Spinal Cord Glioma as a Cause of Congenital Ascites in a Neonate Sun, 14 Aug 2016 07:27:40 +0000 Congenital ascites is rare, but when it occurs, urinary ascites secondary to posterior urethral valve obstruction is the most common, and tumors are the least. Among the tumors in the pediatric population, the central nervous system tumors are common, but spinal cord tumors are rare. We describe a very rare case of congenital malignant spinal cord glioma presenting as isolated congenital ascites secondary to neurogenic bladder. A female infant was diagnosed sonographically with isolated congenital ascites at 40 weeks’ gestational age, with uneventful development prior to 40 weeks’ gestational age. Magnetic resonance imaging of the spine done within the first week of life identified a lobulated spinal mass with heterogeneous enhancement within the conus medullaris. Spinal fluid analysis showed evidence of small round blue cells and the pathology from the excision biopsy of the mass confirmed a WHO grade III or IV malignant glioma. The postoperative course was uneventful with resolution of the ascites and spontaneous micturition. The patient was discharged home without an indwelling urinary catheter. We report the first documented case of a newborn infant with isolated congenital ascites from neurogenic bladder secondary to a spinal cord glioma. Bianca Karber, Lenore Omesi, Sunny Chang, Andrew Handel, Monica Hegedus, and Echezona Maduekwe Copyright © 2016 Bianca Karber et al. All rights reserved. Corrigendum to “Multiple Congenital Colonic Stenosis: A Rare Gastrointestinal Malformation” Mon, 25 Jul 2016 12:38:17 +0000 Elisa Zambaiti, Cinzia Chiaramonte, Sergio Salerno, Giuseppe Li Voti, and Fortunato Siracusa Copyright © 2016 Elisa Zambaiti et al. All rights reserved. An Uncommon Case of Adolescent Ovarian Teratoma Incarcerated in Inguinal Hernia Wed, 20 Jul 2016 09:51:19 +0000 Mature cystic teratoma is the most frequent benign ovarian neoplastic lesion in adolescents and is generally composed of fully differentiated tissue arising from multipotential three germinal layers. It accounts for approximately 50% of benign ovarian tumors in childhood. Rarely, a bilateral, synchronous, or metachronous presentation can be observed, supporting a conservative approach as the first surgical approach. We report a case of an ovarian mature cystic incarcerated in indirect inguinal hernia in a 15-year-old girl undergoing ovary-sparing surgery. To our knowledge this is the first case of such lesion incarcerated in an inguinal hernia reported in literature. Marco Pensabene, Vincenza Girgenti, Marcello Cimador, Giuseppe Li Voti, Vito Rodolico, and Fortunato Siracusa Copyright © 2016 Marco Pensabene et al. All rights reserved. Persistence of Retinopathy of Prematurity in an Infant with Tetralogy of Fallot Wed, 20 Jul 2016 05:59:31 +0000 We report an infant with tetralogy of fallot (TOF) who was born at 35 weeks of gestation and of 1700 g birth weight and presented with persistent retinopathy of prematurity (ROP) at 6 months of age. Follow-up ophthalmic examinations were done at 2, 3, and 4 weeks of age. A demarcation line in Zone II was noticed on the first ocular examination done at 4 weeks of postnatal age. At 6 months of postnatal age, the infant still had an avascular peripheral retina with the demarcation line in Zone II. Even though this index subject did not have any typical risk factors for ROP, TOF seems to be the probable reason for developing as well as persistence of avascular retina. Murat Gunay, Taner Yavuz, Gokhan Celik, and Gunay Uludag Copyright © 2016 Murat Gunay et al. All rights reserved. Vitamin D and Risk for Vitamin A Intoxication in an 18-Month-Old Boy Sun, 10 Jul 2016 12:39:15 +0000 An 18-month-old boy presented with abdominal pain, vomiting, diarrhea, and poor appetite for 6 days. He had been given a multivitamin preparation once daily, containing 50.000 IU of vitamin D and 10.000 IU of vitamin A for a wide anterior fontanelle for about three months. He presented with hypercalcemia, low levels of parathyroid hormone (PTH), and very high serum 25-hydroxyvitamin D (25-OHD) levels. Renal ultrasound showed nephrocalcinosis. He did not have sign or symptom of vitamin A intoxication. Patient was successfully treated with intravenous hydration, furosemide, and prednisolone. With treatment, serum calcium returned rapidly to the normal range and serum 25-OHD levels were reduced progressively. In conclusion the diagnosis of vitamin D deficiency rickets without checking 25-OHD levels may cause redundant treatment that leads to vitamin D intoxication (VDI). Valentina Talarico, Massimo Barreca, Rossella Galiano, Maria Concetta Galati, and Giuseppe Raiola Copyright © 2016 Valentina Talarico et al. All rights reserved. A Physician’s Nightmare: Fever of Unknown Origin Tue, 28 Jun 2016 10:31:28 +0000 Fever of unknown origin (FUO) remains to be a challenge despite advancement in diagnostic technologies and procedures. FUO is considered when fever presents intermittently without an explanation. It has been linked to various etiologies, which makes it difficult to diagnose. We present the case of 18-month-old female with recurrent fever, splenomegaly, abdominal pain, and constipation. The workup for her symptoms revealed wandering spleen. Wandering spleen is a result from excessive laxity or absence of splenic ligaments. The patient underwent splenectomy and was advised to continue on Senna, Miralax, and high fiber diet. Her mother reported that the fever is no longer present and there is marked improvement in her constipation and abdominal pain after splenectomy. Sana Din, Farrukh Anwer, and Mirza Beg Copyright © 2016 Sana Din et al. All rights reserved. Regression of Cardiac Rhabdomyomas in a Neonate after Everolimus Treatment Mon, 27 Jun 2016 06:49:35 +0000 Cardiac rhabdomyoma often shows spontaneous regression and usually requires only close follow-up. However, patients with symptomatic inoperable rhabdomyomas may be candidates for everolimus treatment. Our patient had multiple inoperable cardiac rhabdomyomas causing serious left ventricle outflow-tract obstruction that showed a dramatic reduction in the size after everolimus therapy, a mammalian target of rapamycin (mTOR) inhibitor. After discontinuation of therapy, an increase in the diameter of masses occurred and everolimus was restarted. After 6 months of treatment, rhabdomyomas decreased in size and therapy was stopped. In conclusion, everolimus could be a possible novel therapy for neonates with clinically significant rhabdomyomas. Helen Bornaun, Kazım Öztarhan, Tugba Erener-Ercan, Reyhan Dedeoğlu, Deniz Tugcu, Çiğdem Aydoğmuş, Merih Cetinkaya, and Sultan Kavuncuoglu Copyright © 2016 Helen Bornaun et al. All rights reserved. Unusual Ventilatory Response to Exercise in Patient with Arnold-Chiari Type 1 Malformation after Posterior Fossa Decompression Tue, 21 Jun 2016 13:46:03 +0000 We present a case of a 17-year-old Hispanic male with Arnold-Chiari Type 1 [AC-Type 1] with syringomyelia, status post decompression, who complains of exercise intolerance, headaches, and fatigue with exertion. The patient was found to have diurnal hypercapnia and nocturnal alveolar hypoventilation. Cardiopulmonary testing revealed blunting of the ventilatory response to the rise in carbon dioxide (CO2) resulting in failure of the parallel correlation between increased CO2 levels and ventilation; the expected vertical relationship between PETCO2 and minute ventilation during exercise was replaced with an almost horizontal relationship. No new pathology of the brainstem was discovered by MRI or neurological evaluation to explain this phenomenon. The patient was placed on continuous noninvasive open ventilation (NIOV) during the day and CPAP at night for a period of 6 months. His pCO2 level decreased to normal limits and his symptoms improved; specifically, he experienced less headaches and fatigue during exercise. In this report, we describe the abnormal response to exercise that patients with AC-Type 1 could potentially experience, even after decompression, characterized by the impairment of ventilator response to hypercapnia during exertion, reflecting a complete loss of chemical influence on breathing with no evidence of abnormality in the corticospinal pathway. Keely Smith, Ana M. Gomez-Rubio, Tomika S. Harris, Lauren E. Brooks, and Ricardo A. Mosquera Copyright © 2016 Keely Smith et al. All rights reserved. Cooccurrence of Postural Orthostatic Tachycardia Syndrome with Two Different Clinical Entities Sun, 19 Jun 2016 12:17:27 +0000 Postural orthostatic tachycardia syndrome (POTS) is an abnormal heart rate response to a positional change. Several potential mechanisms for pathophysiology of POTS are defined. This syndrome can coexist with different clinical situations. In our report, the first case was a 13-year-old female who has been followed up for diagnosis of homocystinuria. She was admitted to our outpatient clinic with complaints of dizziness after suddenly moving from supine to upright position and chest pain after exercise. Tilt table test was performed to evaluate dizziness. According to the tilt table test the patient was diagnosed with POTS. The second case was a 17-year-old female who had been evaluated in different centers with the complaints of fainting, bruising, redness, and swelling on the hands and feet after moving from supine position to upright position during the last 4 years. Postural orthostatic tachycardia syndrome was diagnosed by tilt table test and ivabradine was started. Herein, we aimed to point out the cooccurrence of different clinical entities and POTS. Funda Oztunc, Sezen Ugan Atik, Reyhan Dedeoglu, Firuze Erbek Alp, and Selman Gokalp Copyright © 2016 Funda Oztunc et al. All rights reserved. Ibuprofen for Ductus Arteriosus Months after Birth Tue, 14 Jun 2016 09:10:45 +0000 Ibuprofen is a well-known agent used to treat patent ductus arteriosus in preterm neonates in the first days of life. In the current case report we illustrate the potential use of ibuprofen in two preterm neonates 60 and 88 days after birth, respectively. To our knowledge, this is the first report on the effects of ibuprofen on patent ductus arteriosus in preterm newborns after months of life. These cases suggest that the ductus arteriosus does not become refractory for ibuprofen after the first days of life. Late closure of the duct with ibuprofen might still improve the cardiorespiratory condition and prevent infants from surgical closure. Controlled trials are necessary to further study these findings. Odile Frauenfelder, Ingrid M. van Beynum, Irwin K. M. Reiss, and Sinno H. P. Simons Copyright © 2016 Odile Frauenfelder et al. All rights reserved. Diplopia, Convergent Strabismus, and Eye Abduction Palsy in a 12-Year-Old Boy with Autoimmune Thyroiditis Thu, 09 Jun 2016 12:01:35 +0000 Pseudotumor cerebri (PTC) is defined by clinical criteria of increased intracranial pressure, elevated intracranial pressure with normal cerebrospinal fluid (CSF) composition, and exclusion of other causes such tumors, vascular abnormalities, or infections. The association of PTC with levothyroxine (LT4) has been reported. A 12-year-old boy has been followed up for autoimmune thyroiditis under LT4. Family history was irrelevant for endocrine or autoimmune diseases. A TSH level of 4.43 μUI/mL (0.39–3.10) motivated a LT4 adjustment from 75 to 88 μg/day. Five weeks later, he developed horizontal diplopia, convergent strabismus with left eye abduction palsy, and papilledema. Laboratorial evaluation revealed elevated free thyroxine level (1.05 ng/dL [0.65–1.01]) and low TSH, without other alterations. Lumbar puncture was performed and CSF opening pressure was 24 cm H2O with normal composition. Blood and CSF cultures were sterile. Brain MRI was normal. LT4 was temporarily discontinued and progressive improvement was observed, with a normal fundoscopy at day 10 and reversion of diplopia one month later. LT4 was restarted at lower dose and gradually titrated. The boy is currently asymptomatic. This case discloses the potential role of LT4 in inducing PTC. Despite its rarity and unclear association, PTC must be seen as a potential complication of LT4, after excluding all other intracranial hypertension causes. Pedro Marques, Sandra Jacinto, Maria do Carmo Pinto, Catarina Limbert, and Lurdes Lopes Copyright © 2016 Pedro Marques et al. All rights reserved. Acute Hepatitis and Pancytopenia in Healthy Infant with Adenovirus Wed, 01 Jun 2016 13:16:48 +0000 Adenoviruses are a common cause of respiratory infection, pharyngitis, and conjunctivitis in infants and young children. They are known to cause hepatitis and liver failure in immunocompromised patients; they are a rare cause of hepatitis in immunocompetent patients and have been known to cause fulminant hepatic failure. We present a 23-month-old immunocompetent infant who presented with acute noncholestatic hepatitis, hypoalbuminemia, generalized anasarca, and pancytopenia secondary to adenovirus infection. Amr Matoq and Asma Salahuddin Copyright © 2016 Amr Matoq and Asma Salahuddin. All rights reserved. Ischemic Stroke in Confederation with Trivial Head Trauma Sun, 29 May 2016 14:15:03 +0000 Minor head injuries in children are common, resulting in brain concussion, and these injuries mostly end up without complications. Usually head trauma results in hemorrhagic stroke. Here we present a case of ischemic stroke following a trivial head trauma. A 10-month-old girl presented with posttraumatic right sided hemiparesis with right sided facial palsy. MRI brain revealed an area of acute infarct in the left capsuloganglionic region. The child was initially managed conservatively, as the hematological parameters were normal, and was started on anticoagulant therapy. An improvement in the clinical condition was achieved in 12 hrs of treatment with gain in power and resolution of weakness in 10 days. The specific cause for hemiparesis in the child is not elicited; possibility of genetic and environmental factors can be attributable. Archana Balachandran, Siddarameshwar Kalyanshettar, Shankargouda Patil, and Vijaykumar Shegji Copyright © 2016 Archana Balachandran et al. All rights reserved.