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5ヽVerller ER,Blau N,Tllbnv B TcStrahydrobiopter‐
she could complain o!mlld senso呼 distur‐ respectively, indicating the persistelltly ele―in blochemも1 叩and pathophyddo観BltlChem】 bance on the lei sidc of her body Howelreri vated blood pressure
20111458t597‑414
all oF these symptoms subsided rapidly(theAs the cause of TIA, brain computed
6 Muehimann AM!Kies SD,Tumer CA,ヽ Volfrllan
duraton of the symploms was within
tomography,magneuc resOnance(MR)imag‐
S,Lewis MH,Dcville DP Self‐iniuHOus behav、
1 0 m i n ) , w h e n S h e w a s b r o u g h t t oingt h eandc mhrTRc r ‐ aFlg10graphy revcaled nonnal
1(〕
uH limbic dysregulation alld strcss efftcts lll an3ency
visit
rroln
thehospitalparenchynlal
and vascular imagin3i 130 flnd,animal model)Intellect Dis Res 20121 56:490‑
Upon her arrival at the hospital, herings
con,of arteriopadlies,includin3 moyamoya
500
DOL10 11]1/116512227201202800x

sciousnessvas、 clear, and the systolic blood
disease,vasculitis or dissection,、vere evident

Laborato呼examinations of plasma reninpressure was 150/95mm Hgt Her height was

162 cm(+1 8 SD abovc the average〕
apaneSe activity,plas司
na concentrations of electrolytes、V Lcuz』@un+Omal化
lVincenzoJeuzガ)ちACTH,cortisol,thylold
horlnoncs and cate―giris
hci3htrorage),andbOdy
wei3ht,75kg
M Mastrangelol A Celato,C CarduccP,
C Carducci2(+38 SD)Her BMI(bOdy mass index)was

cholamines wcre all within the normal ran3e285(>97th percentile).Her glowlh chart isThust elldocrine diseases responsible for sec―l Department of Pediatrcs, ch d Neurology andshown in the Figure l By lurther detatledondatt hypertellsion were ruled out
P s y c h b″
t5呼
8 P i e n ZU 3n ′V e r J t y o f R o r n e
2 Depertment of Experimental
泌edicine,
卜Sapienza, questionin3,it｀
Vas connrmed that she had notin the evaluatio■oi the patient's obesity,
Universta di ROmalost any memo呼ofthe endre course of events
increased waist circumttrence(82 6 cm),訊D, Chid NeurOlo8′
Correspondencei V LeuzzⅢ卜exccpt for thc loss of scveral seconds,Noassodated with detrated scrum tttglyceride
Div sion,DepBrtment oI Paed atttcs,Ch‖d Neurology
abnormal lleur01ogical signs inctuding
theconcentradon(140mノdL)and deVatcd
and Psychiatrv,via dei Sabe lo8, 00185 Rom3,
Opuc ttndus were obsetted ttcept 'or
blood pressure,met the criteria of metabolic
lta ydecreased leFt grip strength of 12 kg(righigrip
TeL十+5906447122821
syndromein)apaneSe children(2)Semm
Fax+596447122291
was nol lneasured)In the family hislo呼total cholesterol andhiBh―lipOprotein―densihrほma‖:vincenzo leuzzi(2UnirOmal it
taken by her parents, alltihypertensive
chdesterdはmedi‐ 56 and 50 mg/dL,resped市
dvl
7ere indicatcd for esselltial levels
hypertell‐cations■
were normal.The abdominai CT scansion Ambulato呼blood pressure monloHngshowed renlarkable fatlr challBes Of dle liverof the patient during her daily life andrevealed
increased visceral fat accumulation[thethat the average systollc and diastolicblood or visceral fat to subcutaneous Fat
proportionina
was notably increased to 25 140opressures
were 145 and 85 mmH3,

鶴頓Transient ischaettBic attack
case of a gB80rbldly obese giri
associated with Hletabolic●8Ble
Synd『悟的Sir,It is well k■
own that transiellt ischaemic
attack(TIA)assoCiated witl hypertenslon
occurs in the elderly,but there is scant infor―
Ination available on the incidence oi such a
cond山on m chHren lll mre recendy encoun‐
tercd a morbidly obese girl who developed
suddcn onset of hcmiparesis,transient symp―
toms with no neurological sequelae,and wasdiagnosed with TIA Trallsiendy worsenedhype■
ension with a baclKBround OF metabdic
syndrome associated vith、 increased insulin
resistance was considered to contribute to the 1的
underlying patho3enesis that caused ille TIA
in the present patient
7hO had been sufreHng
A 12‑year―
old girl,■
Froln silmple obesity since enteing ele,nentarv
school,fell down outside at her home in themorming hours of)unc,when she was intcnd―
ing to go to sch001. On that occaslon,she Felt
sudden weaklless in her left upper and lower
ieg,的uowed by a temporal blackout(Severalseconds)Her b100d pressure was immedi―
ately measured by automated sphygmoma‐
粕い(年)■ometer by her lllother, who worked asvas unexpect―FigBBre l standard th
occupational health nurse,and、
grol町
curve for healthy Japanese female children in 2000 Red line indicates the curve
e d l y e l e v a t e d t o 1 6 0 / 1 0 2 m m H 3 . T h e pbr
a t ioure n t pttent(upper bwe,wttghゅhttghwas unable to colllmunicate smoothly, but02012 The Autho「ttJlgttcg 02012'ot〕
nd3もon Ad3 P置
前atttc3 201 2 1 01,pp e482‑e485(s)″αθβ′
Reo後石 I「orunReaders'Forum

Ceorge lmataka(geo@dOkkyOmed acip)′(60 50 cm2/200 52 cm2)l Thc Calculated ho‐moeostasis model of assessment― insuhn Go ichikawa,Naoto Shimura,Osamu Attsaka
resistancc bascd on the concentrations of Dep3古memt of Pedbtttcs, Dok,o MediCa

TIA in the presenl obese giri was because of F3X:+81282‑8629471
temporally worsencd hypertens10n,which was ErlR3 i geOCdOkkyomed Bcipa manifestatio■
ofthe compomcnt of metabolic
syndrome ln llletabolic syndlome,hyperten‐

565°C Physical cxaminajon revealed pale"
grey skill vith
、 acrocyanosis CardloloBical,
respirato甲and neulological examinadonswcre ali normali oxygen saturaton ratc was870/1}The paticnt remained cyanotic despltc
oxygen administration Blood tcsts revcaled
severe methaemo810binaenlla(407硫 )i theboy's condijon rapidly improved aler theadlllinistration oF intravenous methylene blue,
and methaemo310bin ievel returned to normal(060o)4 h lateL Hc was dischar3Cd 24 h laterin g00d cOnditions Further investigation
induded complete haenlo810bin proile,prov―
ing negative His parents,who ate the same
hamburgers alld rererred dizziness and cepha―lalBia,had a methaemo310bin level of 5 9‰
and 4 50o,respecuvelyi they werc treated sup―襴鉢辮路襴ン品開y部
品al&ettr獄:‖laざ
描胡ntta認
it mRa町

portively with oxygcn, Inonitored closely anddischarged the day alter Also,the boy's uncles
M e t a b o l l c s y n d r o l n e m a y i n c r e a s e t h e Methaemo310binacttia is a potenllally life‐
cipatcd in the meal and referred dizziness
parはrisk of cerebrovascular disease. even ill chil―and cephalalgia, bllt did not preseni to thethreatenin3 COndition caused by the exposured r e n 傾 ) T 0 0 u r k n O w i e d g e l o u r c a s e おt h e o f h a e m o g l o b i n t o o x i d i z i n 3 a g e n t s (Elllergency1)
Department IIisll―old sisteryear―carliest manifestaton of TIA because ofLess than one percenl of haemoglobin's did llot eat hanlburger,、vas asymptomatic andhyperlcllslom associated with metabolic syn‐ iron is nolma‖
y oxidized Haemoglobi■低oxl‐ had normal methaemoglobin leveldrome. As similar cascs in childhood will
Five days later, nve siblings、 con―
dized form (methaemoglobin)CannOi bindvere
increase in the ttture along with the emerginBoxygen and produces cyanosis,hypoxia,dizzi―
ductcd t0 0ur departinent because of abdomi‐
epidemic or obesity in developing countdes, ness, nausea, malaise and, at higher levels,
nal pain, nausca, cephalalBia, dizzilless andmalaisc aRer eating meat one of them,age‐
stupor,coma,metabolic acidosis and cardio‐
paediatricians should consider the appropriate
m a n a g e m e n t o f h y p e r t e n s l o n6 () 1a 、
s a m O d i ‐ vascular魅ing S and the most unwell,showed also cyaⅢ
i lure.Tlle accunlulauol1 0f methae‐
品a b l e r i s k f a c t o r l o r c e r e b r o w a s c u l a r dmoglobin
iseasein the ettthrocytes occurs for■osisthree
His methaemoBlobin level was 54 80/o,
main reasonsi nrst, a dolninantly illherited
so intravenous methylene blue was adminis―
abno■■ality in haemoglobin's structure teredpre―alter histo呼was excluded
Rererences
Of lavisl■
i Zhan3ヽVM′,Cadilhac DA,Domllan GA.0'Calla‐ vcntillg the reductio■of mcthaemog10bin lo One llour later, the boy's conditlon returned
to baseMne(lnethacmoBlobinl 1 90ro)Out Of
8han C,Dewey HM Hypertension and TIA Int〕 haemoglobini second, a rccessively inherited
Stroke 20091 4:206‑14
deSciency in the methaemoBlobin reductase the other siblings, three giris of ll, 15 and2 01lzeki T,Nakagawa Y,Oclliai F Epidemlolo8y
enzyme,last,theは posure to haemoglobin― 15 years presellted elevated methaemoglobin
and diagnOsic crlteHa rOr metaboHc syndlome
levels(125硫
oxid12ing chemicals or drugs such as nitntes/̲
,144怖 and 66%i respectively)
a n d O b e S t y ianp】
anese chlldren Nihon ttnsl10
nitrates in contaminated wel卜
water and mcati and were treated with intravenous methylene
2011169(Suppl l)1745‑51
lcvels、
which are thc most common causcs of met― bluc Five hours iatcr,their verc
0 6,6ウ5 Gellovesi S,Brambilla P,Giussalll M,Caibiati S,
haemoglobinaenlla(2)Children
from
lower
070o
and
O.5怖i
respectivety,andcompletc
ヽ
4astrialll S,Pien122i F,et al lnsulin resistance,
reBresslon of the symptoms was obsetted A
social class or ethnic groups with spccinc die"prellypertellsion, hypertensiom and blood pres‐
由化h Bir1 0f 14 ycars、vith nausea and cepha‐s u r e v a l u e s i n p a c d i a t r i c a g e l H y p e rtattt e n shabls
2 0 1 2 iare at highcr risk(3‑5)G6PD
deFlciency should be cxcluded alnlost on
lalgia had a methaeinoglobin level oF 2.60/0,
50i527‑35
4 Harrdl〕W,MOrRml B,,SChrage WC Impホ red familiar and personal histo呼lstered oxygen andltoredi
mo■beFore mcthy―was adml■
5 hhypoxic cerebral vasodilatiO:l ill youllger
adullslene
blueⅢ
lateri her level was and0 6眺
she was dis‐the antidote fOr nitrite/11itrates‐
w i t h m c t a b o h c sd yr Io ェm e D i a b t t s c D A R e s induced methaenlogloblllael11la, is adnlillis―cllargcd.
2 0 1 2 1 D 0 1 1 0 1 1 7 7 / 1 4 7 9 1 6 4 1 1 2 4 4 8 8 7 5 1 u ltered Veヽ report nwO separate clusters of Furlher invcstigatiolls o1l tllcse two sepal ate
2 1EbuP ahead of printlRomanian children living lll the same urban clusters revealed they had all eaten nleat
5 ヽV e g h u b e r D , Zlaukl】
l D , N a s e l C , W i lEl1f1o‐
rtll‐bought at the samc butcher shop ln the samesetting in orth―■、vcstcrn ltaly prcscnting
H n t t e r MA也1― l e r T , Bsos高R‐
icdl M,et ral Eattyw‖hintewdays
withdizziness,cephalalgia
pelod,two other different clusters of adults
cerebrovascular discase in a 2‐
old 、vithyear―with methaemogiobinaenlla artcr cating ineat
t、cases, cyanosis aRer comsulllinge x t r c m e o b e s i t y a n d c o l n p l e t e m e t a b o hand,c s y nin
― vobought at the same butcher shop wcremeat with high nitrate colltellt
dlolllc due lo feeding oF excessively highold boy 、v as rcported in olher hospitals of our area A
amounts of energy Eur)Pediatr 2007t 1661 ln
57‑the 8rst cluster, a 7‑year、
41
corlducted to our iniergency Deparinlent police investigatlon
vas conducted,and the、
6 S h a m l a M , H a k i n l A M T h e m a l l a g e n l e n t obecause
fof vomiting, abdominal pain, cepha‐butcher was foulld to adulterate the meat withh y p c r l c n s i o n f o r p r i m a t t s t r O k e p r e v ela18ia,
n t i o n i dizzincss,
amalaisc and cyanosis fewhiBh,dose nitrate in order to presewe it overp r o p o s e d a p p r o a c h h t ) s t O k e 2 0 1 1 1 6 ! 1 4hours
4 ‑ 9 atter eating a hamburge■
No histo呼of the lega‖y permitted time
胸v i s m w a s r e p o r t e d O n ,a hd ei n wi as s i no ■Ours are怖′o typical clustcrs of methacmo―
D O i 1 0 1 1 1 l 1ヵ6 5 卜2 2 2 7 2 0 1 2 0 2 8 ] 6 x
medlocre conditio■
3ody temperature as
Hア globinaemia nfter the ingestion of a highsyndrome(4)sir,02012 The Author(5)″て力βttJlalrtθ
o2012 FoundB3on Ar13 P控』高Ⅲに32012101,pp e482‑e485