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A case of borrelia spirochetosis with recurring episodes of progressively destructive chronic meningoencephalitis, untreated for 15 years, is presented. The patient, now 23 years old, represents an example of the natural course of the disease and may serve as a reminder of the diagnosis in retrospective cases as well as prospectively for acute and chronic states of serous meningitis/meningoencephalitis both in children and adults.

Full article: http://www.informaworld.com/smpp/content~content=a789160741&db=all

Cliniques Universitaires de Mont-Godinne, Universite Catholique
de Louvain, Departement de Pediatrie, Yvoir, Belgium.
david.tuerlinckx@uclouvain.be

Lyme neuroborreliosis (LNB) represents the second most frequent
manifestation of Lyme disease (LD) in Europe after cutaneous
involvement. In the USA, LNB represents the third most frequent
manifestation of LD after cutaneous involvement and arthritis.
The scope of this article is, in the light of recent
publications, to review the specific manifestations of LNB in
children including predictive models, and to discuss diagnosis
criteria, new diagnostic tools and new therapeutic options.
Differences in disease patterns between the USA and Europe are
also highlighted.

Full article: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=20377339&retmode=ref&cmd=prlinks

November 13, 2009 (Washington, DC) — The odds that a child living in a Lyme-endemic area of the United States who presents with a joint effusion will be diagnosed as having Lyme arthritis is 29%. The odds are even higher (44%) if the affected joint is the knee. The leukocyte count is useful in distinguishing between septic and Lyme arthritis, researchers announced here.

“There was an increase in the number of cases in the United States by 101% over the past 15 years, possibly due to increased recognition of Lyme disease,” said Aristides I. Cruz Jr., MD, resident in the Department of Orthopedics and Rehabilitation at Yale University in New Haven, Connecticut. During his presentation, he noted that 93% of all Lyme disease cases arise from 10 states, most in the Northeast United States.

December 9, 2009 — Young adults with higher blood lead levels are more likely to have major depressive disorder (MDD) or panic disorder, even if they have exposure to lead levels generally considered safe, new research suggests.

Maryse F. Bouchard, PhD, Universite de Montreal, Quebec, Canada, and Harvard School of Public Health, Boston, Massachusetts, and colleagues found individuals with lead levels of 2.11 μg/dL or more had 2.3 times the odds of having MDD and nearly 5 times the odds of panic disorder compared with those with lead levels of 0.7 μg/dL or less.

“What is most surprising is the finding that lead can be associated with adverse mental health status at such low levels of exposure,” Dr. Bouchard told Medscape Psychiatry. The mean blood level in study subjects was 1.61 μg/dL.

The study is published in the December issue of Archives of General Psychiatry.

The investigators analyzed data from 1987 adults aged 20 to 39 years who were participants in the National Health and Nutrition Examination Survey between 1999 and 2004. Participants underwent medical examinations that included collection of a blood sample and also completed a diagnostic interview to identify MDD, panic disorder, and generalized anxiety disorder.

The number of individuals who met diagnostic criteria for MDD was 134 (6.7%), 44 (2.2%) had panic disorder, and 47 (2.4%) had generalized anxiety disorder.

Because smoking is related to blood lead levels, the researchers conducted additional analyses excluding the 628 smokers. Among nonsmokers, the elevation in risk between the highest and lowest blood lead levels was increased to 2.5-fold for MDD and 8.2-fold for panic disorder.

Need to Reduce Environmental Exposure

Previous studies conducted in highly exposed employees from foundries, smelters, and battery plants show that these workers (who had blood lead levels averaging 40 μg/dL) have reported elevated symptoms of depression, hostility, and anxiety, said Dr. Bouchard.

A study conducted in nonoccupationally exposed older men showed that those with higher blood lead levels (averaging 6.3 μg/dL) also had a higher prevalence of self-reported anxiety, phobic anxiety, and depression. “In my study group, the mean blood lead level was only 1.6 μg/dL, which is representative of the exposure level in the general population,” Dr. Bouchard said.

Eliminating lead from gasoline has decreased average blood lead levels in the general population, but remaining sources of exposure include paint, industrial processes, pottery, and contaminated water.

However, Dr. Bouchard pointed out that blood lead levels reflect not only current exposure but also past exposures because lead is sequestered in bones and is slowly released into the blood.

“These findings suggest that lead neurotoxicity may contribute to adverse mental health outcomes, even at levels generally considered to pose low, or no, risk,” the researchers conclude. “These findings, combined with recent reports of adverse behavioral outcomes in children with similarly low blood lead levels, should underscore the need for considering ways to further reduce environmental lead exposures,” they write.

Dose-Response Relationship Questioned

Edwin van Wijngaarden, PhD, interim chief of the Division of Epidemiology, Community & Preventive Medicine at the University of Rochester in New York, reviewed the study for Medscape.

“Although the data reported by Bouchard et al are certainly suggestive of an association between blood lead levels and major depressive disorder, the nature of the dose-response relationship is somewhat uncertain, with no clear pattern until the upper quintile.

“The authors emphasize the statistically significant trend statistics, which are appropriate if there is a true linear trend — not sure if that is the case here. The results for panic disorder and generalized anxiety disorder suffer from limited statistical power and consequently statistically imprecise risk estimates, and I would be cautious interpreting the dose-response patterns reported for these outcomes,” he said.

Dr. van Wijngaarden also noted that the mental health outcomes studied were only available for adults aged 20 to 39 years and might differ for older adults with higher levels of cumulative lead exposure.

Dr. van Wijngaarden and colleagues recently examined population-based data on blood lead levels in relation to depression in the United States in a study that will be published in the near future.

This study was supported by the Canadian Institutes for Health Research and the National Institute of Environmental Health Sciences. Dr. Bouchard and Dr. van Wijngaarden have disclosed no relevant financial relationships.

Arch Gen Psychiatry. 2009;66:1313-1319.

Traditional balsamic vinegars have always been procured using time-tested methods of barrel fermentation that instill the rich balsamic flavor loved by many. However research is beginning to show that many of these vinegars, particularly those that are aged for the longest periods of time, contain dangerously high levels of lead that could be contributing to childhood behavior disabilities like Attention Deficit Hyperactivity Disorder (ADHD).

In 1991, the Centers for Disease Control and Prevention (CDC) set the maximum threshold of lead exposure in children to 10 micrograms (mcg) per deciliter, a level that more recent research suggests is too high. The CDC itself recognizes that the toxicity of lead is so severe that there is no specific minimum threshold for which adverse effects do not occur.

In 2002, a California lawsuit concerning lead-tainted vinegar led to state mandates that established the maximum allowable daily level of lead at .5 mcgs per day, which translates to 34 parts per billion (ppb). Shelves in the state stocked with untested or threshold-exceeding balsamic vinegar must contain a warning sign indicating that the products contain lead and may be harmful to health.

Since not all balsamic vinegars contain lead, and some more than others, producers are expressing concern that balsamic vinegar is receiving a bad rap despite the fact that many other grape products also contain lead. They also allege that independent experts have verified that grapevines tend to absorb lead from the ground and that the occurrences are completely normal and to be expected.

Some toxicologists and others, however, oppose the idea that lead contamination is occurring due to soil conditions and rather suggest that production and storage methods are the culprits. Testing has revealed that vinegars aged the longest in wood barrels had the highest levels of lead contamination.

Many producers are now independently testing and verifying their vinegar products in order to meet guidelines and to assure customers that their products are safe. Many brands meet or exceed the California threshold requirements and some even print a stamp of approval on their labels.

Since trace amounts of lead can be found in all kinds of foods, it seems unfair to simply target balsamic vinegar. However it is best to practice caution and seek out those products that have verifiably minimal levels of toxic carcinogens like lead.

There are also a variety of heavy metal detoxification regimens that can be utilized in order to keep the body in tip-top shape, including supplementation with chlorella, spirulina, sulfur-rich foods like cabbage and garlic, and fresh juicing. While it is best to keep heavy metal ingestion at a minimum, nutrient-rich diets play an important role in continually purifying the blood and detoxifying the body.

Sources:

Special Report: Some vinegars – often expensive, aged balsamics – contain a big dose of lead – Environmental Health News

Clinically Proven Oral Chelation: Baseline’s Alternative Health Newsletter

OEHHA Proposition 65 – Safe Drinking Water and Toxic Enforcement Act of 1986

“There was an increase in the number of cases in the United States by 101% over the past 15 years, possibly due to increased recognition of Lyme disease,” said Aristides I. Cruz Jr., MD, resident in the Department of Orthopedics and Rehabilitation at Yale University in New Haven, Connecticut. During his presentation, he noted that 93% of all Lyme disease cases arise from 10 states, most in the Northeast United States.

“Children are more likely to present with arthritis as initial manifestation of Lyme disease,” Dr. Cruz told the audience.

“Children with Lyme arthritis presenting with a limp and a swollen joint will typically have a lower peripheral white blood cell count,” Dr. Cruz added. “They are less likely to have complete non-weight-bearing on the affected limb, less likely to have a fever, and [arthritis symptoms are] more likely to involve the knee joint compared with children with septic arthritis.”

The findings were reported here at the American Academy of Pediatrics 2009 National Conference & Exhibition.

Basic Diagnostic Tools Help Distinguish Lyme From Septic Arthritis

“In the Northeast, we see a lot of Lyme disease,” said Yi-Meng Yen, MD, PhD, instructor in orthopaedic surgery, Harvard Medical School, Children’s Hospital Boston in Massachusetts. “It is hard to distinguish whether [it] is Lyme disease or whether [it] is septic arthritis,” Dr. Yen agreed.

“Septic arthritis mandates that we take the patient to the operating room and do a surgery, whereas Lyme arthritis theoretically can be treated with antibiotics,” he told Medscape Pediatrics in an interview. For instance, he said, “Our institution has been looking at MRIs [magnetic resonance images] as a way to reliably distinguish between the two, because it takes several days sometimes for the lab tests to come back to definitely tell you whether you have Lyme disease or not. So, in those few days, if you have septic arthritis, that’s a bad thing.”

“To reliably, quickly diagnose what the patient has can help us determine the treatment quickly,” added Dr. Yen, who was not involved in this study.

“If you are clinically susceptible for septic arthritis, it pays to go to the operating room,” Dr. Cruz said in answer to a question from the audience. “In the past, almost all these patients automatically went to the operating room.”

However, if the clinical presentation is consistent with Lyme arthritis, treatment with antibiotics should suffice, he added. “The point of this study was to come up with some clinically useful criteria to arm ourselves with more tools to diagnose the disease.”

Dr. Cruz and his team sought to evaluate clinical parameters that could eventually be used to differentiate Lyme arthritis from septic arthritis in children and help with diagnosis and subsequent treatment.

In this retrospective analysis, the investigators reviewed data from children who underwent lower-extremity joint aspiration at Yale University Medical Center, a tertiary care children’s hospital in a Lyme disease endemic area.

Between August 2002 and August 2008, more than 200 children underwent a total of 212 aspirations for a joint effusion. Cell count, culture, hematologic inflammatory markers, and subsequent surgical intervention were available for 170 of the 212 aspirates.

Dr. Cruz’s team compared findings from 50 children with serologically confirmed Lyme disease with data from 21 patients with culture-positive septic arthritis.

They found statistically significant differences between the 2 cohorts. For instance, the peripheral white blood cell count was 9.5 x 1000/μL (range, 3.0 – 14.9 x 1000/μL) in the aspirates from children with Lyme disease vs 12.5 (range, 5.5 – 30.1) in children with septic arthritis (P = .002).

Other parameters, such as joint fluid cell count, erythrocyte sedimentation rate, and C-reactive protein levels, were not significantly different between the 2 groups and could not be used to differentiate between septic and Lyme arthritis.

Interestingly, said Dr. Cruz, of all the children presenting with a joint effusion at their hospital, 29% were likely to be diagnosed as having Lyme arthritis overall compared with 44% if the aspirate was a knee aspirate.

“Is it worthwhile to develop something that’s very reliable? Absolutely!” said Dr. Yen. “Especially in the Northeast centers. It is a growing healthcare problem and a lot more study should be put into it.”

Dr. Cruz and Dr. Yen have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2009 National Conference & Exhibition (NCE): Abstract 5806. Presented October 17, 2009.

Journalist

Crina Frincu-Mallos, PhD

Crina Frincu-Mallos is a freelance writer for Medscape Medical News.

• American Academy of Pediatrics (AAP) 2009 National Conference and Exhibition

This coverage is not sanctioned by, nor a part of, the American Academy of Pediatrics.

From Medscape Medical New

Regards,

Linda

November 3, 2009 (Honolulu, Hawaii) – Overall nutritional status in children with attention deficit hyperactivity disorder (ADHD) shows that this patient population is at risk for low trace mineral status, including deficiencies in zinc and copper – minerals that may play a crucial role in the production of dopamine, norepinephrine, and melatonin, which regulates sleep.

Presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting, a study conducted by investigators at the University of British Columbia and the Children’s and Women’s Health Centre in Vancouver, Canada, showed among 44 children aged 6 to 12 years with ADHD, rates of zinc and copper deficiency were 45% and 35%, respectively.

Dr. Margaret Weiss

“There are a lot of studies in ADHD children looking at sugar intake, etcetera, but no one has ever actually looked at the dietary intake and subsequent nutrients of children with ADHD, ” principal investigator Margaret Weiss, MD, PhD, told Medscape Psychiatry.

With first author Joy Kiddie, RD, the study included 44 drug-naive and drug-treated ADHD children aged 6 to 12 years. Of these children, 17 were medication-naive, 18 were taking stimulant medications, and 9 were taking atomoxetine.

The children’s dietary intake was assessed using a 3-day food record and 24-hour recall. The food record assessed macronutrient/micronutrient intake relative to the recommended dietary allowances and food group recommendations.

The 24-hour recall was used to assess the percentage of low-nutrient density foods, or so-called “junk food” intake.

The study revealed that serum zinc below laboratory norms was present in 77% of children aged 6 to 9 years and 67% of children aged 10 to 12 years, and 25% of the children were below the cutoffs for zinc deficiency. Serum copper below laboratory norms was present in 23% of children.

No Difference in Junk Food Consumption

The investigators found that the study sample consumed comparable levels of protein, carbohydrate, and fat compared with recommendations and population norms, and ADHD children were no different than population norms in intake of low-nutrient density foods. However, 40% of the children consumed less than the recommended levels of meat and meat alternatives and had low levels of related micronutrients that are essential cofactors for the body’s manufacture of dopamine, norepinephrine, and melatonin.

Measurement of blood levels of micronutrients replicated previous findings of zinc deficiency and demonstrated copper deficiency for the first time. In addition, a majority of children had serum ferritin levels lower than 50 μg/mL, a level considered necessary for entry into the central nervous system.

“There is a commonly held belief that children with ADHD eat more junk food than other children, but the study did not confirm this view,” said Dr. Weiss. “However, our data suggest children with ADHD are nutritionally different from the rest of the population in that they eat less meat, fish, and poultry and have low levels of related micronutrients that are essential cofactors for the body’s manufacture of dopamine norephinephrine, and melatonin.”

Need to Focus on Nutrition

In a separate study of zinc supplementation also presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting, Eugene Arnold, MD, and colleagues from The Ohio State University, Columbus, found that supplementation with 15 or 30 mg of elemental zinc made no difference to symptoms compared with placebo in a group of children diagnosed with ADHD after 13 weeks of treatment.

This study, said Dr. Weiss, raises many questions because previous research has suggested that zinc supplementation does make a difference. “It may not just be a question of what children eat but also whether they can absorb or metabolize zinc, or whether they are excreting it. In other words, is there some kind of phenomenon of zinc wasting?” she said.

Dr. Weiss said that, based on this study, it is too early to make any clinical recommendations beyond ensuring that children with ADHD have an adequate diet that includes appropriate levels of fish, meat, and poultry. However, she acknowledged, this can be a challenge in children on stimulant medications because of the drugs’ appetite-suppressing effect.

She added that it is important that clinicians with expertise in the assessment of nutritional status provide parents with information about good nutrition. “Traditionally, the emphasis on ADHD has been on treating the core symptoms of the disorder, but it is also important to assess and manage basic issues of health such as sleep, nutrition, and growth. Good health makes a difference,” said Dr. Weiss.

Dr. Weiss has disclosed that she is on the advisory board of and/or has received research or grant support from Eli Lilly and Company, Janssen, Purdue University, Shire Pharmaceuticals Inc, and Takeda Pharmaceuticals North America, Inc.

American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract 17.3. Presented October 31, 2009.