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Letters to the Editor
of the Murdoch Childrens Research Institute with The Royal Children’s Hospital Centre for Community Child Health, and the Parenting Research Centre. Dr Julie Green1 Professor Frank Oberklaid2 1 Executive Director, Raising Children Network 2 Board Director, Raising Children Network and Director, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, Victoria, Australia
Reference 1 Kwok S. Website review: KidsHealth. J. Paediatr. Child Health 2013; 49: 1085–6.
Dear Editor, CEREBRAL VENOUS THROMBOSIS MASQUERADING PSEUDOTUMOUR CEREBRI IN A PAEDIATRIC PATIENT
AS
Cerebral venous thrombosis (CVT) is a serious multifactorial disease that has been reported to result from a combination of prothrombotic risk factors and/or underlying clinical conditions.1 The aetiology is related to thrombophilia, head and neck infections, and systemic illnesses.2 The incidence is estimated at .67 per 100 000 children and is still poorly understood.3 In addition, the clinical presentation can be easily confused with idiopathic intracranial hypertension. We report the case of a previously healthy 11-year-old male referred to an ophthalmologist with a 10-day history of headache and several days of blurry vision. After normal ocular exam, motility examination demonstrated no stereoacuity with a right esotropia at distance and near. Posterior pole examination exposed optic nerve swelling bilaterally, and subsequent lumbar puncture showed a markedly elevated opening pressure of 50 mmHg with normal cerebrospinal fluid composition. The patient was admitted to the hospital for further management where acetazolamide 250 mg three times a day was started. Since the initial magnetic resonance imaging was normal, management was based on a working diagnosis of pseudotumour cerebri. Further magnetic resonance arteriography/venography of the head revealed a left internal jugular thrombosis with decreased flow in the left transverse sinus shown in Figure 1. The patient was started on 70-mg enoxaparin subcutaneously every 12 h. On day eight of his hospitalisation, the results of the dilute rapid viper venom test and IgG cardiolipin antibody returned as positive, suggesting antiphospholipid antibody syndrome. On day 10, the patient’s symptoms were improving, and he was discharged with continued long-term oral anticoagulation.
Conflict of interest: We certify that there is no conflict of interest regarding the material discussed in the manuscript.
Fig. 1 Magnetic resonance venography of cerebral sinus thrombosis. Maximum intensity projection (MIP) showing flow in the right-sided venous system indicated by the arrows. The left side is notable for the absence of flow amidst background venous contamination.
Two weeks after discharge, the child’s ophthalmic examination was improving; there was only limited abduction deficit in the right eye. Upon his six-week follow-up, his headaches, swelling and sixth nerve palsy were completely resolved. In this case, there were a number of unusual factors that would have further delayed the correct diagnosis if not for doing a magnetic resonance venography. The atypical presentation for CVT and antiphospholipid antibody syndrome included his age, gender and lack of inciting infection. The diagnosis in children is susceptible to being misdiagnosed as pseudotumour which can delay proper treatment and lead to increased morbidity. The unusual presentation in this case highlights the importance of early MRV for children presenting signs of pseudotumour, whether they have other neurologic symptoms or not. Mr Faisal Ridha1 Associate Professor Sergul A Erzurum2 1 Northeast Ohio Medical University, Kent, Ohio, USA 2 Department of Surgery, Humility of Mary Health Partners, St. Elizabeth’s Hospital, Northeast Ohio Medical University, Youngstown, Ohio, USA
References 1 Heller C, Heinecke A, Junker R et al. Cerebral venous thrombosis in children: a multifactorial origin. Circulation 2003; 108: 1362–7. 2 Chan AK, Deveber G, Monagle P et al. Venous thrombosis in children. J. Thromb. Haemost. 2001; 1: 1443–55. 3 de Veber G, Andrew M, Adams C et al. Cerebral sinovenous thrombosis in children. N. Engl. J. Med. 2001; 345: 417–23.
Journal of Paediatrics and Child Health 50 (2014) 418–420 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
419
Letters to the Editor
of the Murdoch Childrens Research Institute with The Royal Children’s Hospital Centre for Community Child Health, and the Parenting Research Centre. Dr Julie Green1 Professor Frank Oberklaid2 1 Executive Director, Raising Children Network 2 Board Director, Raising Children Network and Director, Centre for Community Child Health, Royal Children’s Hospital, Melbourne, Victoria, Australia
Reference 1 Kwok S. Website review: KidsHealth. J. Paediatr. Child Health 2013; 49: 1085–6.
Dear Editor, CEREBRAL VENOUS THROMBOSIS MASQUERADING PSEUDOTUMOUR CEREBRI IN A PAEDIATRIC PATIENT
AS
Cerebral venous thrombosis (CVT) is a serious multifactorial disease that has been reported to result from a combination of prothrombotic risk factors and/or underlying clinical conditions.1 The aetiology is related to thrombophilia, head and neck infections, and systemic illnesses.2 The incidence is estimated at .67 per 100 000 children and is still poorly understood.3 In addition, the clinical presentation can be easily confused with idiopathic intracranial hypertension. We report the case of a previously healthy 11-year-old male referred to an ophthalmologist with a 10-day history of headache and several days of blurry vision. After normal ocular exam, motility examination demonstrated no stereoacuity with a right esotropia at distance and near. Posterior pole examination exposed optic nerve swelling bilaterally, and subsequent lumbar puncture showed a markedly elevated opening pressure of 50 mmHg with normal cerebrospinal fluid composition. The patient was admitted to the hospital for further management where acetazolamide 250 mg three times a day was started. Since the initial magnetic resonance imaging was normal, management was based on a working diagnosis of pseudotumour cerebri. Further magnetic resonance arteriography/venography of the head revealed a left internal jugular thrombosis with decreased flow in the left transverse sinus shown in Figure 1. The patient was started on 70-mg enoxaparin subcutaneously every 12 h. On day eight of his hospitalisation, the results of the dilute rapid viper venom test and IgG cardiolipin antibody returned as positive, suggesting antiphospholipid antibody syndrome. On day 10, the patient’s symptoms were improving, and he was discharged with continued long-term oral anticoagulation.
Conflict of interest: We certify that there is no conflict of interest regarding the material discussed in the manuscript.
Fig. 1 Magnetic resonance venography of cerebral sinus thrombosis. Maximum intensity projection (MIP) showing flow in the right-sided venous system indicated by the arrows. The left side is notable for the absence of flow amidst background venous contamination.
Two weeks after discharge, the child’s ophthalmic examination was improving; there was only limited abduction deficit in the right eye. Upon his six-week follow-up, his headaches, swelling and sixth nerve palsy were completely resolved. In this case, there were a number of unusual factors that would have further delayed the correct diagnosis if not for doing a magnetic resonance venography. The atypical presentation for CVT and antiphospholipid antibody syndrome included his age, gender and lack of inciting infection. The diagnosis in children is susceptible to being misdiagnosed as pseudotumour which can delay proper treatment and lead to increased morbidity. The unusual presentation in this case highlights the importance of early MRV for children presenting signs of pseudotumour, whether they have other neurologic symptoms or not. Mr Faisal Ridha1 Associate Professor Sergul A Erzurum2 1 Northeast Ohio Medical University, Kent, Ohio, USA 2 Department of Surgery, Humility of Mary Health Partners, St. Elizabeth’s Hospital, Northeast Ohio Medical University, Youngstown, Ohio, USA
References 1 Heller C, Heinecke A, Junker R et al. Cerebral venous thrombosis in children: a multifactorial origin. Circulation 2003; 108: 1362–7. 2 Chan AK, Deveber G, Monagle P et al. Venous thrombosis in children. J. Thromb. Haemost. 2001; 1: 1443–55. 3 de Veber G, Andrew M, Adams C et al. Cerebral sinovenous thrombosis in children. N. Engl. J. Med. 2001; 345: 417–23.
Journal of Paediatrics and Child Health 50 (2014) 418–420 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
419
