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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute motor deficit or weakness is a fairly common presentation in the pediatric emergency room &#40;ER&#41;&#46; Across all age ranges&#44; 5&#37; of all patients visiting the ER have neurologic symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> In this setting&#44; the pediatrician must be comfortable in performing the initial workup&#44; as some etiologies may be life-threatening and demand urgent care&#46; Timely interventions are likely to restore patient&#39;s well-being and full health&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Weakness is categorized as a negative motor sign&#44; as well as ataxia and apraxia&#46; It is valuable to have a firm grasp on the definition of these three negative motor signs&#46; <span class="elsevierStyleItalic">Weakness</span> is defined as the inability to generate normal voluntary <span class="elsevierStyleItalic">force</span> in a muscle or normal voluntary <span class="elsevierStyleItalic">torque</span> in a joint&#44; while <span class="elsevierStyleItalic">ataxia</span> is the inability to generate a normal voluntary movement <span class="elsevierStyleItalic">trajectory</span> that cannot be attributed to weakness or involuntary muscle activity in the affected joints&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">2</span></a> Ataxic movements are uncoordinated and clumsy&#44; but there is no underlying weakness of the involved muscles&#46; <span class="elsevierStyleItalic">Apraxia</span> is the inability to perform <span class="elsevierStyleItalic">previously learned</span> complex movements&#44; which is not explained by weakness&#44; ataxia&#44; or involuntary motor activity&#44; <span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; the motor&#44; sensory&#44; basal ganglia&#44; and cerebellar functions are intact&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">2</span></a> It is noteworthy that sensory weakness does not exist&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">For the purpose of this study&#44; plegia will be used to denote complete or partial weakness&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> but the reader is informed that strictly speaking <span class="elsevierStyleItalic">plegia</span> means complete paralysis and <span class="elsevierStyleItalic">paresis</span> implies that muscle strength is only partially affected&#46; A common descriptor of acute weakness is <span class="elsevierStyleItalic">acute flaccid paralysis</span>&#44; meaning that in the ER setting&#44; paralysis is usually not accompanied by spasticity or other abnormal signs of central nervous system &#40;CNS&#41; motor tracts&#44; <span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; hyperreflexia&#44; clonus&#44; or Babinski reflex&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This study aimed to present a clinical diagnostic approach to children and adolescents who present with an acute motor deficit in the ER and to review the most frequent etiologies&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A systematic search was performed in PubMed database during April and May 2017&#44; using the following search terms in various combinations&#58; &#8220;acute&#44;&#8221; &#8220;weakness&#44;&#8221; &#8220;motor deficit&#44;&#8221; &#8220;flaccid paralysis&#44;&#8221; &#8220;child&#44;&#8221; &#8220;pediatric&#44;&#8221; and &#8220;emergency&#8221;&#46; The articles chosen for this review were published over the past ten years&#44; from 1997 through 2017&#46; This study assessed the pediatric age range&#44; from 0 to 18 years&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Clinical features and differential diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Acute weakness may present either as a localized or diffuse impairment&#46; A precise description of the motor deficit &#8212; its mode of onset&#44; duration&#44; and progression &#8212; is essential to allow a complete differential diagnosis&#46; In this sense&#44; a detailed history and a full physical examination&#44; including an objective neurologic examination&#44; provide the best opportunities to expedite etiology identification&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> outlines the essential information to be compiled during the initial approach of a patient presenting with acute weakness&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The pattern through which weakness extends to other body parts may offer clues to diagnosis&#46; For example&#44; a relatively symmetric&#44; ascending deficit suggests Guillain&#8211;Barr&#233; syndrome &#40;GBS&#41;&#44; while a descending paralysis raises suspicion of botulism&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Some patients will present to the ER with what appears to be acute weakness&#44; but a thorough assessment will reveal that in fact he&#47;she has <span class="elsevierStyleItalic">pseudoparalysis</span>&#44; <span class="elsevierStyleItalic">i&#46;e&#46;</span>&#44; muscle strength is preserved and the motor function is impaired by another mechanism&#44; most often severe pain&#46; Common pediatrics examples of this situation are inability to walk due to calf pain secondary to acute viral myositis&#44; pyogenic arthritis-related arthralgia &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; gonococcal arthritis in teenagers&#41;&#44; nursemaid&#39;s elbow&#44; or bone pain secondary to osteomyelitis&#44; bone fracture&#44; or dislocation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Since the eradication of poliomyelitis&#44; the two most common causes of acute flaccid paralysis in the ER are GBS and acute transverse myelitis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> Among other etiologies &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; the most relevant for the pediatric age group are acute disseminated encephalomyelitis &#40;ADEM&#41;&#44; infectious myelitis&#44; myasthenia gravis &#40;MG&#41;&#44; stroke&#44; alternating hemiplegia of childhood&#44; periodic paralyses&#44; brainstem encephalitis&#44; and functional muscle weakness&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Guillain&#8211;Barr&#233; syndrome</span><p id="par0050" class="elsevierStylePara elsevierViewall">GBS&#44; or acute inflammatory demyelinating polyradiculoneuropathy &#40;AIDP&#41;&#44; is an autoimmune disease that usually presents with acute onset of a rapidly progressive&#44; essentially symmetric weakness and areflexia in a previously well child&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a> The acute weakness in GBS tends to begin distally and to progress rostrally&#44; and in 50&#8211;70&#37; of cases it is preceded within four weeks by an acute respiratory or gastrointestinal infection&#46; The etiologic agents most frequently involved are <span class="elsevierStyleItalic">Campylobacter jejuni</span> and <span class="elsevierStyleItalic">Helicobacter pylori</span> in the gastrointestinal tract&#44; and <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> in the respiratory tract&#46; An annual incidence of 0&#46;5&#8211;2 cases per 100&#44;000 individuals has been reported in the age range &#60;18 years&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a> In less than 10&#37; of cases&#44; GBS is associated with vaccination in the preceding 30 days&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">AIDP is actually a descriptive term for the most common clinical presentation of GBS&#44; while in 10&#8211;15&#37; of cases&#44; the clinical features comprise variant GBS forms&#44; such as acute motor axonal neuropathy &#40;AMAN&#44; more rapidly evolving and more severe motor deficits&#44; no sensory deficits&#41;&#44; acute motor and sensory axonal neuropathy &#40;AMSAN&#44; reported nearly exclusively in adults&#41;&#44; Miller-Fisher syndrome &#40;ataxia&#44; ophthalmoplegia&#44; and areflexia without peripheral weakness&#41;&#44; pharyngeal-cervical-brachial motor variant &#40;ptosis&#44; facial&#44; pharyngeal&#44; neck flexor muscle weakness&#41;&#44; acute pandysautonomia&#44; and acute ophthalmoplegia&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">8&#44;10&#44;11</span></a> AMAN is due to axonal damage and is more frequently diagnosed in Asia and South America&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">11</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinical onset is characterized by limb pain&#44; limb weakness&#44; and in a few cases ataxia&#46; Physical examination usually shows a preserved mental status or irritability and decreased or abolished deep tendon reflexes in weak limbs&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">7&#44;8</span></a> Weakness progresses in a caudo-cranial direction&#44; but there are exceptions to this pattern&#46; Peak weakness is usually reached after seven to ten days&#44; but no later than four weeks&#46; The severity of arm weakness is the most reliable factor to predict respiratory insufficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The diagnosis is based on clinical findings&#44; and supported by albuminocytologic dissociation in cerebrospinal fluid &#40;CSF&#41;&#44; that is&#44; an increased protein level despite normal leukocyte count&#44; a spine magnetic resonance imaging &#40;MRI&#41; showing contrast-enhancement of nerve roots&#44; and&#47;or demyelination or axonal damage findings in electromyography with nerve conduction studies &#40;EMG&#41;&#46; Some patients have normal EMG studies in the first two weeks of illness&#44; but later on all patients show abnormal results&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Transverse myelitis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Acute transverse myelitis &#40;ATM&#41; accounts for one fifth of acquired demyelinating events in children&#59; it has an estimated annual incidence in children aged &#60;16 years of 2 per 1&#44;000&#44;000&#44; and its male&#58;female ratio is 1&#46;1&#8211;1&#46;6&#58;1&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">12</span></a> There are two peaks of pediatric incidence&#44; at the age ranges 0&#8211;2 years and 5&#8211;17 years&#44; with the highest incidence in the former&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">13</span></a> In two-thirds of cases&#44; there was a prodromal infection within the past 30 days&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Affected children develop an acute onset of symmetric paraplegia or tetraplegia&#44; decrease or loss of sensation&#44; and sphincter dysfunction&#44; and their clinical course extends over three phases&#58; acute &#40;usually two to seven days&#41;&#44; plateau &#40;1&#8211;26 days&#41;&#44; and recovery phases &#40;months to years&#41;&#46; In some patients&#44; pain is the presenting feature&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">ATM is a diagnosis of exclusion&#59; therefore&#44; it is important to carefully consider its differential diagnoses&#46; In this regard&#44; the diagnostic criteria established by the Transverse Myelitis Consortium Working Group may be valuable &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Children will benefit from a favorable motor outcome&#44; with up to 56&#37; having complete recovery&#59; one study found that the mean time to recover the ability to walk independently was 56 days&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Acute disseminated encephalomyelitis &#40;ADEM&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">ADEM is an inflammatory&#44; demyelinating disease that typically occurs within two days to four weeks following a viral infection or&#44; less commonly&#44; vaccination&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a> It presents with multifocal neurologic deficits accompanied by encephalopathy&#44; and its mean age of onset is 5&#46;7 years&#44; with a male&#58;female ratio of 2&#46;3&#58;1&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Clinical features may include fever&#44; headache&#44; vomiting&#44; meningeal signs&#44; visual loss&#44; seizures&#44; cranial nerve palsies&#44; and mental status changes&#44; ranging from lethargy to coma&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a> There is an ongoing controversy on whether ADEM and multiple sclerosis &#40;MS&#41; belong to the same disease spectrum or are completely distinct entities&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a> Although ADEM usually follows a monophasic course&#44; its recurring and multiphasic variants blurs the distinction from MS&#46; Brain MRI may be the most valuable tool to accomplish such distinction&#44; as ADEM cases exhibit large areas of increased signal intensity on T2 and FLAIR-weighted images&#44; with ill-defined borders&#44; distributed bilaterally in the cerebral white matter &#40;WM&#41; and often affecting the basal ganglia&#44; brainstem&#44; and cerebellar and cerebral cortex gray matter&#44; while MS cases usually show well-defined lesions that are confined to the periventricular WM&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a> Absence of encephalopathy&#44; age above 10 years&#44; presence of optic neuritis&#44; and intrathecal oligoclonal bands during an acute CNS demyelination event increase the risk of MS development&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">CSF may be normal or may display mild pleocytosis&#44; with or without elevated protein levels&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Early and aggressive treatment may attain good recovery with minimal or no deficit in over half the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Infectious myelitis</span><p id="par0110" class="elsevierStylePara elsevierViewall">Acute flaccid paralysis can result from spinal cord infection with a number of pathogens&#44; <span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; West Nile virus&#44; nonpolio enteroviruses&#44; dengue virus&#44; syphilis&#44; Lyme disease&#44; human immunodeficiency virus &#40;HIV&#41;&#44; cytomegalovirus&#44; Epstein-Barr virus&#44; HTLV-1&#44; and <span class="elsevierStyleItalic">Mycoplasma</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">14&#44;19</span></a> Its main distinctive feature from transverse myelitis is that the majority of children have focal&#44; poliomyelitis-like spinal cord paralysis with minimal or no sensory symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Acute viral myositis</span><p id="par0115" class="elsevierStylePara elsevierViewall">Acute viral myositis manifests as muscle pain and lower-limb weakness&#44; especially in the calves and thighs&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a> It is most commonly associated with influenza virus infection&#46; Accordingly&#44; its prodromal symptoms include fever&#44; headache&#44; cough&#44; and other respiratory signs&#46; Affected children may refrain from moving their legs secondary to pain&#44; or may indeed have weakness related with rhabdomyolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> Among 35 cases with median age of 7&#46;5 years&#44; muscle weakness lasted one to eight days&#44; and mean serum creatine-kinase was 5507<span class="elsevierStyleHsp" style=""></span>U&#47;l&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Myasthenia gravis</span><p id="par0120" class="elsevierStylePara elsevierViewall">MG is a relatively rare autoimmune neuromuscular disorder&#44; and its presentation in childhood is divided into transient neonatal MG and juvenile MG&#46; The former is due to transplacental transfer of acetylcholine receptor &#40;AChR&#41; antibodies and usually recovers within two months of life&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Clinical presentation is characterized by fatigability and fluctuating weakness of ocular&#44; facial&#44; limb&#44; bulbar&#44; and respiratory muscles&#46; Antibodies against AChR&#44; muscle-specific kinase &#40;MuSK&#41;&#44; and lipoprotein receptor-related protein 4 &#40;LRP4&#41; may participate in its pathogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">A study compared 114 Chinese juvenile MG patients with 207 young adults MG patients&#46; AChR antibodies were found in 77&#37;&#44; 80&#37;&#44; and 81&#37; of the 0&#8211;8 years&#44; 8&#8211;18 years&#44; and adult age ranges&#44; respectively&#46; Only one out of six patients that tested positive for MuSK and LRP4 antibodies was not an adult&#46; Repetitive nerve stimulation during electromyography &#40;EMG&#41; may be useful for diagnosis&#44; as well as the neostigmine test&#44; but this should be performed only in a controlled and monitored setting&#44; in the presence of staff who are skilled in cardiopulmonary resuscitation&#46; Atropine should be immediately available&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Stroke</span><p id="par0135" class="elsevierStylePara elsevierViewall">Stroke may occur in children older than one month as frequently as 13&#47;100&#44;000 per year&#46; Its incidence is higher in neonates &#40;25 to 40&#47;100&#44;000&#41; and is highest among premature infants &#40;up to 100&#47;100&#44;000&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a> The underlying mechanisms in pediatric patients include ischemic stroke&#44; sinovenous thrombosis&#44; and hemorrhagic stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> Affected patients usually present with an acute-onset focal neurological deficit&#44; <span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; hemiplegia&#44; hemianesthesia&#44; hemiataxia&#44; unilateral facial palsy&#44; and&#47;or aphasia&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a> Newborns may present with seizures&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Of the children with arterial ischemic stroke&#44; 20&#8211;30&#37; will have recurrent strokes&#59; therefore&#44; early diagnosis is paramount&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> Appropriate investigation with neuroimaging should not be delayed&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Alternating hemiplegia of childhood</span><p id="par0145" class="elsevierStylePara elsevierViewall">Alternating hemiplegia of childhood is a rare developmental disorder that is caused&#44; in 75&#37; of cases&#44; by a mutation in the <span class="elsevierStyleItalic">ATP1A3</span> gene of neuronal Na<span class="elsevierStyleSup">&#43;</span>&#47;K<span class="elsevierStyleSup">&#43;</span> ATPase&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> Its onset is before 1&#46;5 years of age and its clinical features consist of episodic unilateral hemiplegia&#44; dystonia&#44; quadriplegia&#44; and abnormal eye movements&#46; Each episode lasts for minutes&#44; hours&#44; or longer&#44; and frequently recurs&#46; Affected children may have developmental delay and epilepsy&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> The calcium channel blocker flunarizine can reduce frequency&#44; severity&#44; and duration of dystonic and hemiplegic spells&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Periodic paralyses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Periodic paralyses are associated with mutations in the sodium channel gene <span class="elsevierStyleItalic">SCN4A</span>&#44; the calcium channel gene <span class="elsevierStyleItalic">CACNA1S</span>&#44; or the potassium channel gene <span class="elsevierStyleItalic">KCNJ2</span>&#44; and should not be confused with secondary causes of episodic paralysis&#44; such as drug toxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> Patients present with episodic attacks of flaccid muscle weakness&#44; typically associated with hypo- or hyperkalemia&#46; Episodes can be triggered by carbohydrate- or potassium-rich foods&#44; or by rest after exercise&#46; Treatment with acetazolamide may decrease the frequency and severity of episodes&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Brainstem encephalitis</span><p id="par0155" class="elsevierStylePara elsevierViewall">Bickerstaff&#39;s brainstem encephalitis &#40;BBE&#41; and Miller-Fisher syndrome form a continuous spectrum&#44; both with ataxia and external ophthalmoplegia&#44; but only those patients with BBE develop impaired consciousness&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a> BBE is an uncommon disorder of unknown etiology&#59; however&#44; it is often associated with CNS cell surface antibodies&#44; particularly anti-GQ1b antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">31</span></a> The most common initial symptoms are diplopia and gait disturbance&#59; CSF albuminocytological dissociation is found in half the patients during the second week of illness&#44; and facial or limb weakness may be observed&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Spinal cord infarction</span><p id="par0160" class="elsevierStylePara elsevierViewall">It is rare in children&#44; and may mimic other commons entities&#44; such as ATM&#46; Absence of CSF pleocytosis and a normal protein level help to differentiate between these two entities&#46; It usually involves the anterior spinal artery&#46; Risk factors are minor spinal trauma&#44; parainfectious vasculopathies&#44; and surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">32</span></a> Children present with the typical spinal cord signs&#44; such as a sensory level&#44; bladder and&#47;or bowel dysfunction&#44; as well as paraplegia or tetraplegia&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Functional muscle weakness</span><p id="par0165" class="elsevierStylePara elsevierViewall">Acute weakness may be caused by functional neurological disorder &#40;FND&#41;&#44; a condition that was formerly called hysteria and conversion disorder&#44; and children as young as 5 years of age may be affected&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">33</span></a> In a British study of 204 children&#44; whose ages ranged from 7 to 15 years&#44; the most common presentation was weakness &#40;63&#37;&#41; and abnormal movements &#40;43&#37;&#41;&#44; and the most frequent antecedent stressor was bullying at school &#40;81&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">34</span></a> These authors estimated that the annual incidence of FND in the age range &#60;15 years was 1&#46;30&#47;100&#44;000&#46; A sharp observer will detect a few incongruous findings during physical examination of a patient presenting with weakness due to FND<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">6&#44;33&#44;35</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">monocular diplopia &#8211; the child complains of double vision which persists when one eye is closed&#46; Nevertheless&#44; monocular diplopia may also be caused by a refractive error&#44; particularly astigmatism</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">the child is unable to walk but can lift his&#47;her legs against gravity when lying on a bed&#46; The rest of the motor examination is normal&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">give-way weakness &#8211; sudden loss of tone after an initial good&#47;normal strength response when a muscle is tested against resistance</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">co-contraction &#8211; effortful contraction of one muscle and its agonist&#44; resulting in almost no movement at the joint</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">motor inconsistency &#8211; significant differences in motor performance under different testing conditions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Hoover sign &#8211; the examiner places a hand under the heel of the &#8220;good&#8221; leg and asks the patient to lift the weak leg against resistance&#46; A patient with FND will not exert downward pressure with the &#8220;good&#8221; leg&#46;</p></li></ul></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Diagnostic workup</span><p id="par0200" class="elsevierStylePara elsevierViewall">When a pediatric patient presents at the ER with a main complaint of acute motor deficit&#44; it is worthwhile to pay close attention to a few key aspects of history and physical examination &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a> suggest algorithms for investigating acute localized and diffuse weakness in the ER setting&#44; respectively&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">A localized deficit&#44; such as facial palsy &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a> or monoplegia &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> tends to have a smaller list of etiologies&#44; while a more diffuse deficit&#44; <span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; paraplegia&#44; hemiplegia&#44; or tetraplegia&#44; will require consideration of many etiologies &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; A word of caution is in order&#44; as a thorough physical examination of a patient who complains of monoplegia may reveal inconspicuous weakness of an additional limb&#44; so the patient is actually affected by hemiplegia or paraplegia&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">When a patient presents with acute-onset diffuse weakness&#44; the presence or absence of mental status changes&#44; <span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; encephalopathy&#44; will guide the diagnostic workup&#46; In encephalopathic patients&#44; CNS infection becomes a pressing hypothesis to be addressed by appropriate studies&#46; Other entities need to be considered as well&#44; such as seizures&#44; mass lesions&#44; dysfunction in other organ systems&#44; trauma&#44; and metabolic disturbances&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Great part of the neurologic examination deals with lesion localization&#44; and the authors believe that a general pediatrician working in the ER should master the basic examining skills to ascertain whether an acute motor deficit stems from the brain&#44; brainstem&#44; spinal cord&#44; neuromuscular junction&#44; skeletal muscle&#44; or peripheral nerves&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">A large number of tests and procedures are available to investigate an acutely weak patient&#46; As in similar situations&#44; initial priority should be given to rule out life-threatening and treatable conditions&#46; A stepwise&#44; cost-effective&#44; and timely workup is strongly recommended&#44; as outlined in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusions</span><p id="par0225" class="elsevierStylePara elsevierViewall">Most patients arriving in the ER with an acute motor deficit will benefit from a practical investigative approach and timely interventions based upon history&#44; physical examination&#44; and a few diagnostic tests&#44; and will be able to eventually recover their well-being and full health&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Guillain&#8211;Barr&#233; syndrome"
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              "titulo" => "Transverse myelitis"
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              "titulo" => "Acute disseminated encephalomyelitis &#40;ADEM&#41;"
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              "titulo" => "Alternating hemiplegia of childhood"
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              "identificador" => "sec0060"
              "titulo" => "Periodic paralyses"
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              "identificador" => "sec0065"
              "titulo" => "Brainstem encephalitis"
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              "identificador" => "sec0070"
              "titulo" => "Spinal cord infarction"
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              "titulo" => "Functional muscle weakness"
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    "fechaRecibido" => "2017-05-21"
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            0 => "Acute weakness"
            1 => "Motor deficit"
            2 => "Guillain&#8211;Barr&#233; syndrome"
            3 => "Transverse myelitis"
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            0 => "Fraqueza aguda"
            1 => "D&#233;ficit motor"
            2 => "S&#237;ndrome de Guillain&#8211;Barr&#233;"
            3 => "Mielite transversa"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This review article aimed to present a clinical approach&#44; emphasizing the diagnostic investigation&#44; to children and adolescents who present in the emergency room with acute-onset muscle weakness&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Sources</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A systematic search was performed in PubMed database during April and May 2017&#44; using the following search terms in various combinations&#58; &#8220;acute&#44;&#8221; &#8220;weakness&#44;&#8221; &#8220;motor deficit&#44;&#8221; &#8220;flaccid paralysis&#44;&#8221; &#8220;child&#44;&#8221; &#8220;pediatric&#44;&#8221; and &#8220;emergency&#8221;&#46; The articles chosen for this review were published over the past ten years&#44; from 1997 through 2017&#46; This study assessed the pediatric age range&#44; from 0 to 18 years&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Summary of the data</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Acute motor deficit is a fairly common presentation in the pediatric emergency room&#46; Patients may be categorized as having localized or diffuse motor impairment&#44; and a precise description of clinical features is essential in order to allow a complete differential diagnosis&#46; The two most common causes of acute flaccid paralysis in the pediatric emergency room are Guillain&#8211;Barr&#233; syndrome and transverse myelitis&#59; notwithstanding&#44; other etiologies should be considered&#44; such as acute disseminated encephalomyelitis&#44; infectious myelitis&#44; myasthenia gravis&#44; stroke&#44; alternating hemiplegia of childhood&#44; periodic paralyses&#44; brainstem encephalitis&#44; and functional muscle weakness&#46; Algorithms for acute localized or diffuse weakness investigation in the emergency setting are also presented&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The clinical skills to obtain a complete history and to perform a detailed physical examination are emphasized&#46; An organized&#44; logical&#44; and stepwise diagnostic and therapeutic management is essential to eventually restore patient&#39;s well-being and full health&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O objetivo deste artigo de revis&#227;o &#233; apresentar uma abordagem cl&#237;nica&#44; enfatizando a investiga&#231;&#227;o diagn&#243;stica&#44; voltada para crian&#231;as e adolescentes no pronto socorro com fraqueza muscular de surgimento agudo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Fontes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi realizada uma pesquisa sistem&#225;tica na base de dados PubMed entre abril e maio de 2017&#44; utilizando os seguintes termos de pesquisa em v&#225;rias combina&#231;&#245;es&#58; &#8220;agudo&#8221;&#44; &#8220;fraqueza&#8221;&#44; &#8220;d&#233;ficit motor&#8221;&#44; &#8220;paralisia fl&#225;cida&#8221;&#44; &#8220;crian&#231;a&#8221;&#44; &#8220;pedi&#225;trico&#8221; e &#8220;emerg&#234;ncia&#8221;&#46; Os trabalhos escolhidos para esta revis&#227;o foram publicados nos &#250;ltimos dez anos&#44; de 1997 a 2017&#46; Este trabalho aborda a faixa et&#225;ria pedi&#225;trica&#44; de 0 a 18 anos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resumo dos dados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">O d&#233;ficit motor agudo &#233; uma causa razoavelmente comum para crian&#231;as e adolescentes procurarem o pronto socorro&#46; Os pacientes podem ser classificados como apresentando defici&#234;ncia motora localizada ou difusa&#44; e uma descri&#231;&#227;o precisa das caracter&#237;sticas cl&#237;nicas &#233; essencial para possibilitar um diagn&#243;stico diferenciado completo&#46; As duas causas mais comuns de paralisia fl&#225;cida aguda no pronto socorro pedi&#225;trico s&#227;o s&#237;ndrome de Guillain-Barr&#233; e mielite transversa&#44; independentemente de outras etiologias serem consideradas&#44; como encefalomielite disseminada aguda&#44; mielite infecciosa&#44; miastenia grave&#44; derrame&#44; hemiplegia alternante da inf&#226;ncia&#44; paralisia peri&#243;dica&#44; encefalite do tronco encef&#225;lico e fraqueza muscular funcional&#46; Os algoritmos da investiga&#231;&#227;o de fraqueza aguda localizada ou difusa na configura&#231;&#227;o de emerg&#234;ncia tamb&#233;m s&#227;o apresentados&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">S&#227;o enfatizadas as habilidades cl&#237;nicas para obter um hist&#243;rico completo e realizar um exame f&#237;sico detalhado&#46; Um manejo diagn&#243;stico e terap&#234;utico organizado&#44; l&#243;gico e por etapas &#233; essencial para eventualmente restaurar o bem-estar e a sa&#250;de total do paciente&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Vasconcelos MM&#44; Vasconcelos LG&#44; Brito AR&#46; Assessment of acute motor deficit in the pediatric emergency room&#46; J Pediatr &#40;Rio J&#41;&#46; 2017&#59;93&#58;26&#8211;35&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algorithm for acute localized weakness investigation in the emergency setting&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AChR&#44; acetylcholine receptor&#59; CNS&#44; central nervous system&#59; EEG&#44; electroencephalography&#59; EMG&#44; electromyography&#59; GBS&#44; Guillain&#8211;Barr&#233; syndrome&#59; Hx&#44; history&#59; OPV&#44; oral polio vaccine&#59; PE&#44; physical examination&#59; RHS&#44; Ramsay-Hunt syndrome&#59; VAPP&#44; vaccine-associated paralytic poliomyelitis&#46; <span class="elsevierStyleSup">a</span>A cause of pseudoparalysis&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Algorithm for acute diffuse weakness investigation in the emergency setting&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AChR&#44; acetylcholine receptor&#59; CK&#44; serum creatine-kinase&#59; CNS&#44; central nervous system&#59; CSF&#44; cerebrospinal fluid&#59; EEG&#44; electroencephalography&#59; EMG&#44; electromyography&#59; GBS&#44; Guillain&#8211;Barr&#233; syndrome&#59; Hx&#44; history&#59; IgG&#44; immunoglobulin G&#59; K<span class="elsevierStyleSup">&#43;</span>&#44; serum potassium&#59; MS&#44; multiple sclerosis&#59; NMO&#44; neuromyelitis optica&#59; PE&#44; physical examination&#59; PRES&#44; posterior reversible encephalopathy syndrome&#59; RHS&#44; Ramsay-Hunt syndrome&#59; T<span class="elsevierStyleInf">4</span>&#44; thyroxine&#59; w&#47;o&#44; without&#46;</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span>A cause of pseudoparalysis&#46;</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">b</span>Myelopathy signs include a sensory level&#44; bladder and&#47;or bowel dysfunction&#44; and paraplegia or tetraplegia&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">History</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Is this the first time the child presents with weakness&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Onset &#8211; where was the child and what was he&#47;she doing when the deficit was detected&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rhythm &#8211; abrupt&#44; rapidly or slowly progressing&#44; fluctuating or remitting&#8211;recurring&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Is the weakness associated with any precipitating factors&#44; such as a place&#44; a person&#44; a food&#44; a medication&#44; or a time of the day&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Does the weakness improve with rest and worsen with activity &#40;fatigability&#41;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Has there been an increased frequency of falls in the recent past&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Has the weakness progressed in an ascending or descending mode&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Associated symptoms of infection &#40;fever&#44; headache&#44; vomiting&#44; diarrhea&#41; or of a concurrent disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Preceding or concomitant sensory symptoms&#44; such as pain&#47;tenderness&#44; dysesthesias&#44; numbness&#44; headache&#44; or visual disturbances&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Changes in urination and bowel habits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mental status changes &#8211; has there been any impairment in patient&#39;s mental status&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of recent infections and other illnesses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use of all medications&#44; including herbal medicine&#44; eye drops&#44; <span class="elsevierStyleItalic">etc&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Developmental history &#8211; ages of motor skills acquisition&#44; any regression&#44; other areas of development&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of trauma&#44; especially to the head and back&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of seizures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contact with other ill individuals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Psychosocial history &#8211; recent stress&#44; interactions with peers&#44; school performance&#44; behavioral issues&#44; death or departure of loved ones&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Contact with pets and other animals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Physical and neurologic examination</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vital signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Head circumference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Growth parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Body symmetry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nuchal rigidity and other meningeal signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory distress signs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mental status &#8211; alertness&#44; irritability&#44; orientation to time and place&#44; language skills&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cardiovascular and respiratory systems and abdomen examination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cranial nerve examination &#8211; pupils&#8217; size and reaction to light&#63; Visual acuity&#63; Funduscopy&#63; Facial weakness&#63; Extraocular muscle movements&#63; Palate and tongue movements&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Motor examination &#8211; muscle tonus and strength&#44; deep tendon reflexes&#44; ankle clonus&#44; pronator-drift test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Babinski sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sensory examination searching for a sensory level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Coordination &#8211; finger-to-nose test&#44; diadochokinesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Gait &#8211; is the child able to sit or to walk without&#47;with support&#63; Walking on tiptoes&#44; on ankles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Signs of a chronic muscle disease&#44; <span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; muscle atrophy&#44; fasciculations&#44; myotonia&#44; Gowers&#8217; sign&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">CNS&#44; central nervous system&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Most common etiologies</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Guillain&#8211;Barr&#233; syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Transverse myelitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Other etiologies</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acute disseminated encephalomyelitis &#40;ADEM&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Alternating hemiplegia of childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atlantoaxial dislocation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Botulism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Brain abscess&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CNS infections&#44; <span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; acute meningitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CNS mass lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic inflammatory demyelinating polyneuropathy &#40;CIDP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complicated migraine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Congenital myopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Epilepsy&#44; <span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; Todd&#39;s palsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Familial spastic paraplegia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Functional muscle weakness &#40;formerly called conversion disorder&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypoglycemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypophosphatemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hopkins syndrome &#40;associated with acute asthma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infectious myelitis &#40;<span class="elsevierStyleItalic">e&#46;g</span>&#46;&#44; by enterovirus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intracranial hemorrhage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Kawasaki disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metabolic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Myasthenia gravis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Periodic paralyses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spinal cord compression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vaccine-associated poliomyelitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vasculitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Transverse Myelitis Consortium Working Group&#46; Proposed diagnostic criteria and nosology of acute transverse myelitis&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Inclusion criteria</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilateral symptoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spinal cord inflammation demonstrated by cerebrospinal fluid pleocytosis&#44; elevated IgG&#44; or gadolinium enhancement&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Clinical findings consistent with anterior spinal artery occlusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Abnormal flow voids on the surface of the cord consistent with arteriovenous malformation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Serologic or clinical evidence of connective tissue disease &#40;sarcoidosis&#44; Beh&#231;et disease&#44; Sj&#246;gren syndrome&#44; systemic lupus erythematosus&#44; or mixed connective tissue disorder&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Central nervous system manifestations of syphilis&#44; Lyme disease&#44; HIV&#44; HTLV-1&#44; <span class="elsevierStyleItalic">Mycoplasma</span>&#44; or other viral infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Brain abnormalities suggestive of multiple sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>History of clinically apparent optic neuritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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