An unusual cause of recurrent vomiting in a young girl
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The etiology of recurrent vomiting in children is diverse and includes gastrointestinal, neurological and metabolic causes. The present case has been reported in The Indian Journal of Pediatrics.

A 4-y-old girl presented with vomiting for 3 mo and weight loss (4 kg). There was no fever, headache, diminution of vision, dysphagia or poor appetite. On examination, she was emaciated with weight for height less than-3 standard deviation (SD). Neurological examination revealed bilateral extensor planter reflexes. The routine blood investigations including liver function tests, USG abdomen and upper gastrointestinal endoscopy were normal.

MRI brain revealed patchy congruent areas of altered signal intensity and involving inferior medullary region, cervico-medullary junction and proximal spinal cord. Cerebrospinal fluid (CSF) analysis was normal. Blood serology was positive for aquaporin-4 IgG. Based on MRI findings and child’s presentation a diagnosis of Neuromyelitis Optica Spectrum Disorder (NMOSD) was made.

She was treated with intravenous pulse methylprednisolone therapy followed by oral steroids. Intravenous Rituximab was given along with CD19 levels monitoring to prevent relapse. Child responded to therapy and is currently doing well in follow up.

Key takeaways:-

- NMO is an autoimmune demyelinating disorder of the central nervous system with specific predilection to spinal cord and optic nerves

- Other than typical presentations like visual loss, severe symmetric paraplegia/paraparesis, patient with NMO may present with unusual symptoms like nausea, intractable vomiting, hiccups or severe neurogenic respiratory failure attributed to brain stem and area postrema involvement.

- This case highlights the importance of considering this treatable and potentially disabling condition in children with intractable vomiting.

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