Background COVID toes or chilblain-like skin lesions have been widely reported during COVID-19 pandemic. Most cases were described in patients with negative microbiological tests for SARS-CoV-2, therefore the possible relationship with SARS-CoV-2 infection, as well as with the nowadays broadly available mRNA-based vaccination, has not been fully elucidated. Case presentation We here describe the case of a 14-year-old male who developed chilblain-like skin eruptions during SARS-CoV-2 infection despite two mRNA-based vaccine doses and review the clinical and epidemiological characteristics of chilblain-like lesions as a cutaneous presentation of COVID-19 in children. Conclusions Most children and adolescent with COVID toes have a mild or asymptomatic SARS-CoV-2 infection. Our report aims to highlight the possible onset of these skin lesions in vaccinated children, if infection has occurred, and the potential use of systemic corticosteroids as a first line treatment. Additional evidence is required to better understand SARS-CoV-2 infection and cutaneous manifestations in children and determine the relationship between chilblain-like lesions and COVID-19 vaccination.

The association between migraine and stroke is still a dilemma for neurologists. Migraine is associated with an increased stroke risk and it is considered an independent risk factor for ischaemic stroke in a particular subgroup of patients. The pathogenesis is still unknown even if several studies report some common biochemical mechanisms between these two diseases. A classification of migraine-related stroke that encompasses the full spectrum of the possible relationship between migraine and stroke includes three main entities: coexisting stroke and migraine, stroke with clinical features of migraine, and migraine-induced stroke. The concept of migraine-induced stroke is well represented by migrainous infarction and it is described in the revised classification of the International Headache Society (IHS), representing the strongest demonstration of the relationship between ischaemic stroke and migraine. A very interesting common condition in stroke and migraine is patent foramen ovale (PFO) which could play a pathogenetic role in both disorders. The neuroradiological evidence of subclinical lesions most typical in the white matter and in the posterior artery territories in patients with migraine, opens a new field of research. In conclusion the association between migraine and stroke remains an open question. Solving the above mentioned issues is fundamental to understand the epidemiologic, pathogenetic and clinical aspects of migraine-related stroke.

### Learning point for clinicians This case report highlights: (i) the difficulty of infant botulism (IB) diagnosis as it is a rare disease, (ii) the efficacy and safety of trivalent equine antitoxin in IB treatment, (iii) honey is not the only cause of IB and (iv) the need for physician training to recognize and diagnose IB. A 4-month-old baby (7 kg) was admitted to the Pediatric Department for constipation, feeding difficulties, weak cry, lethargy and weak muscular body control. Symptoms of infant botulism (IB) appeared 1 month before the admission, after hexavalent vaccine administration, with a slow and progressive evolution. The baby has become lethargic, with blunted facial expression and weak cry. Seven days before admission he started refusing breast milk. Clinical history revealed no perinatal or delivery complications and the baby was normal for development and growth (50th percentile). On admission the baby was fully conscious and the initial …

We scrutinize an updated version of the non-linear (quadratic) k-ε-ζ-f aiming at sensitizing the model to the effect of rotation. This objective was obtained by imposing that Cμ coefficient depends on the strain and vorticity tensors, the latter explicitly including solid body rotation. The model was tested on plane channel and square-sectioned duct flows. Results are assessed against DNS literature data and properly developed LES computations. We demonstrate that, when considering the channel flows, the developed formulation is able to accurately reproduce flow and turbulent variables at various angular velocity regimes. Good predictions are also obtained for the duct flow, where the flow is subjected to the mutual influence of rotation and near-wall turbulence anisotropy. In particular, the non-linear rotation-sensitized model is able to reproduce the near-wall turbulent kinetic energy distribution close to the suction side, returning a zero value in the mid-span and a small peak close to the vertex on the suction side. Budgets analysis of turbulent kinetic energy demonstrates that the proposed model is able to properly reproduce any of the terms in the k-equation.

Hypoxic-ischemic encephalopathy (HIE) is an important cause of acute neurological damage in newborns at (or near) term. Several trials in recent years have shown that moderate hypothermia by total body cooling or selective head is an effective intervention to reduce mortality and major disability in infants survived a perinatal hypoxic-ischemic attack. Follow-up in these patients is very important to establish neurodevelopmental outcome, and specific markers can lead us to detect predicting sign for good or poor outcome. We reported a few cases of newborn with HIE treated with hypothermia, in whom the comparison between electroencephalogram (EEG) and magnetic resonance imaging (MRI) represents the first marker for neurodevelopment outcome prediction. The continuous EEG monitoring showed a depressed EEG activity with diffuse burst depression in 7 patients. No epileptic abnormalities were registered. In 10 out of 20 patients no abnormalities of the background activity and no epileptic abnormalities were observed. We found that a depressed EEG activity during the first 72 h of life and a diffused alteration of basal ganglia at MRI were correlated with a poor neurodevelopmental outcome at 18 months of follow-up.

Idiopathic scoliosis is the most common form of spinal deformity in children. However, secondary causes of scoliosis, such as ganglioneuroma, should be always considered to avoid wrong diagnosis, and further investigations are required when there are atypical signs. We report a case of ganglioneuroma misdiagnosed as idiopathic scoliosis and review the literature to identify the red flags useful for physicians during the evaluation of a child with scoliosis. On the basis of both clinical and radiographic criteria that emerged from this study, we propose an algorithm that could help in the differential diagnosis, suggesting when to perform an MRI.

Alterations of the brain microstructure and metabolism have been identified in patients with neurofibromatosis type 1 (NF1). In this study, we analyzed the basal ganglia of NF1 subjects without cognitive delay throughout a combined approach with magnetic resonance spectroscopy (MRS) and diffusion tensor imaging (DTI) in order to better define the metabolic and microstructural characteristics of these regions and, furthermore, to verify if metabolic and microstructural abnormalities may be present in normally developed NF1 patients.

Childhood-onset cluster headache is an excruciatingly painful and distressing condition. A retrospective study was conducted on charts of patients referring to our Headache Center. Those diagnosed as cluster headache were selected. We identified 11 children (6 males and 5 females). The mean age of cluster headache onset was 10 years (range: 5-16). All children had episodic cluster headache. All children had unilateral orbital pain; 7 patients had throbbing pain, whereas 4 children complained stabbing pain. The mean duration of the attack was 86 minutes (ranging from 30 to 180 minutes). The frequency of episodes was between 1 and 4 per day. All children had the typical cluster headache autonomic features, such as lacrimation, conjunctival injection, ptosis, and nostril rhinorrhea. Steroids showed a good clinical efficacy in interrupting cluster headache recurrence. As symptomatic drugs, acetaminophen as well as ibuprofen were ineffective; indomethacin was effective in 1 case.

Background: Creatine kinase (Ck) catalyzes the reversible transfer of high-energy phosphate groups between adenosine triphosphate and phosphocreatine. The brain isoform (Ck bb ) is greatly induced in mature osteoclasts, playing an important role in bone-resorbing function during osteoclastogenesis. High Ck bb serum level has been found in patients with osteopetrosis and in patients with bisphosphonate (BP)-induced osteopetrosis. BPs are considered the treatment of choice for children with osteogenesis imperfecta (OI), acting as potent inhibitors of bone resorption by suppressing the activity of osteoclasts. Methods: We determined total serum Ck and isoform activity in 18 prepubertal children with type I OI, before and during treatment with the BP neridronate infusions. Results: Basal serum Ck bb levels were slightly elevated with respect to controls (mean ± SD = 3.0 ± 2.7 vs. 2.0 ± 2.2) and progressively increased after neridronate treatment ( t 0 vs. t 4 : mean ± SD = 3.0 ± 2.7 to 10.8 ± 8.1), with significant increment after first, second, and fourth infusions ( P < 0.01). An inverse correlation was found between serum Ck bb and serum CTx at basal level. Conclusion: Our results support previous observations that increased serum Ck bb reflects failure of osteoclasts or, at least, suppression of osteoclasts. Upon considering that BPs are long acting, this information could be useful to prevent the risk of overtreatment after long-term BP exposure in pediatric patients with OI.

A 47-year-old woman, with no personal or familial history of Neurofibromatosis type 1 (NF1) or 2, was referred for evaluation of left unilateral Lisch nodules (LN) discovered through a routine eye care performed one month before (Figure 1a and b). Fundus oculi evaluation was normal in both eyes. The patient had occasionally attended routine eye examinations since her childhood, without discovering anomalies. Her past medical history was remarkable for migraine with aura, essential hypertension, and mild hypercholesterolemia. No other NF1 stigmata were noticed with the exception of one very pale 1.0 1.0cm cafe`au-lait spot below the left leg. Magnetic resonance imaging of brain and spine, cardiac and abdominal ultrasound findings were unremarkable. The term segmental NF1 is used when the NF1 stigmata are confined to one or more body segments because of somatic mosaicism for the NF1 gene. Segmental NF1 is estimated to be rarer than the fullblown phenotype, with a prevalence of 1 in 36–40,000 subjects. 1 In patients with segmental form, the involved parts of the body may develop all the manifestations with the same chronological order as they appear in the generalized phenotype. 2

Childhood-onset cluster headache is an excruciatingly painful and distressing condition. A retrospective study was conducted on charts of patients referring to our Headache Center. Those diagnosed as cluster headache were selected. We identified 11 children (6 males and 5 females). The mean age of cluster headache onset was 10 years (range: 5-16). All children had episodic cluster headache. All children had unilateral orbital pain; 7 patients had throbbing pain, whereas 4 children complained stabbing pain. The mean duration of the attack was 86 minutes (ranging from 30 to 180 minutes). The frequency of episodes was between 1 and 4 per day. All children had the typical cluster headache autonomic features, such as lacrimation, conjunctival injection, ptosis, and nostril rhinorrhea. Steroids showed a good clinical efficacy in interrupting cluster headache recurrence. As symptomatic drugs, acetaminophen as well as ibuprofen were ineffective; indomethacin was effective in 1 case.

Pediatrics InternationalVolume 54, Issue 2 p. 309-310 Hypochloremic metabolic alkalosis in a child with Henoch–Schönlein purpura Patrizia D'Eufemia, Corresponding Author Patrizia D'Eufemia Department of PediatricsPatrizia D'Eufemia, MD, Department of Pediatrics, Sapienza University of Rome, Via Regina Elena, 324 00161 Rome, Italy. Email: [email protected]Search for more papers by this authorIvana Raccio, Ivana Raccio Department of PediatricsSearch for more papers by this authorStefano Papasso, Stefano Papasso Department of PediatricsSearch for more papers by this authorAlessandro Ambrosini, Alessandro Ambrosini Department of PediatricsSearch for more papers by this authorAnna Zambrano, Anna Zambrano Department of PediatricsSearch for more papers by this authorMiriam D'Avanzo, Miriam D'Avanzo Pediatrics Radiology Unit, Sapienza University of Rome, Rome, ItalySearch for more papers by this authorEnrico Properzi, Enrico Properzi Department of PediatricsSearch for more papers by this author Patrizia D'Eufemia, Corresponding Author Patrizia D'Eufemia Department of PediatricsPatrizia D'Eufemia, MD, Department of Pediatrics, Sapienza University of Rome, Via Regina Elena, 324 00161 Rome, Italy. Email: [email protected]Search for more papers by this authorIvana Raccio, Ivana Raccio Department of PediatricsSearch for more papers by this authorStefano Papasso, Stefano Papasso Department of PediatricsSearch for more papers by this authorAlessandro Ambrosini, Alessandro Ambrosini Department of PediatricsSearch for more papers by this authorAnna Zambrano, Anna Zambrano Department of PediatricsSearch for more papers by this authorMiriam D'Avanzo, Miriam D'Avanzo Pediatrics Radiology Unit, Sapienza University of Rome, Rome, ItalySearch for more papers by this authorEnrico Properzi, Enrico Properzi Department of PediatricsSearch for more papers by this author First published: 16 April 2012 https://doi.org/10.1111/j.1442-200X.2012.03585.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 McCarthy HJ, Tizard EJ. Clinical practice: diagnosis and management of Henoch-Schönlein purpura. Eur. J. Pediatr. 2010; 169: 643–50. 2 Greenbaum LA. Electrolyte and acid-base disorder. In: RM Kliegman, RE Behrman, HB Jenson, BF Stanton (eds). Nelson Textbook of Pediatrics, 18th edn. Saunders Elsevier, Philadelphia, 2007; 267–308. 3 Harada T, Kaneko T, Ito S et al. SMA syndrome – a risk factor for duodenal involvement in Henoch-Schönlein purpura. Pediatr. Int. 2011; 53: 630–3. 4 Kawasaki M, Suekane H, Imagawa E et al. Duodenal obstruction due to Henoch-Schönlein purpura. AJR Am. J. Roentgenol. 1997; 168: 969–70. 5 Wyllie R. The digestive system. In: RM Kliegman, RE Behrman, HB Jenson, BF Stanton (eds). Nelson Textbook of Pediatrics, 18th edn. Saunders Elsevier, Philadelphia, 2007; 1558–65. Volume54, Issue2April 2012Pages 309-310 ReferencesRelatedInformation

Since the outbreak of novel influenza A (H1N1) in 2009, various neurologic complications have been cited.1 A 2-month-old girl died of a rapidly progressive encephalopathy after influenza infection. MRI, performed after 12 hours from the onset of symptoms, showed bilateral and symmetric lesions including the thalamus, the cortical–subcortical regions of the occipital and parietal lobes, and brainstem tegmentum …

Rasmussen encephalitis (RE) is a chronic inflammatory disease leading to unilateral hemispheric atrophy, associated with progressive neurological dysfunction and intractable seizures. The best approach to RE is hemispherectomy. However long-term immunotherapy seems to prevent or slow down hemispheric tissue loss and the associated functional decline.

Antibodies to 2-glycoprotein I (anti-2GPI) have been associated with recurrent thrombosis and pregnancy morbidity. However, the prevalence of anti-2GPI in children suffering from cerebral and cerebellar infarction is unknown. We report on a 10-month-old boy who had an ischemic cerebellar stroke, secondary to antiphospholipid syndrome with high titers of immunoglobulin G anti-2GPI (first titer: 132U) anticardiolipin antibodies and lupus anticoagulant tests were negative. All other causes of infarction were excluded. To our knowledge, this is the first reported case of childhood cerebellar ischemic stroke with only anti-2GPI but no antibodies detectable in standard antiphospholipid assays.

Epileptic nystagmus (EN) describes repetitive eye movements that result from seizure activity. We describe a patient with EN and vertigo first noted at the age of 4 yr and 10 mo. Brain MRI did not show anomalies. Ictal EEG recordings revealed epileptic activity during three episodes of horizontal, left-beating nystagmus not crossing the midline. Ictal 99mTc-ECD SPECT demonstrated the presence of active foci in multiple cerebral regions including bilateral prefrontal, bilateral parieto-temporo-occipital and the left parieto-insular-vestibular areas. A wide area of hypoperfusion was also evident in the right hemisphere, prevailing in the parieto-occipital regions and the medial prefrontal gyrus. Topiramate was started at a dose of 2 mg/kg/d with complete seizure control after 14 d. EEG and SPECT were repeated after a seizure-free period of 1 mo; disappearance of epileptic activity and modification of cerebral perfusion were evident. This case reaffirms the cortical origin and involvement of temporo-occipital and frontal cortex in the genesis of saccadic epileptic nystagmus. Rapid complete control of clinical events coincided with the normalization of EEG and improvement of the SPECT pattern.