Infantile tremor syndrome (ITS)
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《美国医学杂志》
Department of Pediatrics, Maharaja Agrasen, Medical College and Hospital, Agroha, Hisar 125047, Haryana, India
The articles" Infantile Tremor Syndrome in Iraqi Kurdistan" by Mohammad Amin and Mohammad Zeki [1] and "Scurvy in Infantile Tremor Syndrome" by Ratageri et al[2] make an interesting reading. In this context, may I share the following information and comments with the learned authors and readers of the Indian Journal of Pediatrics .
To begin with, let me take up the article from Iraq.[1] Years ago, during the difficult period of sanctions against Iraq, I, as a member of a visiting delegation, happened to visit southern Turkey where we were shown some infants with movement disorder (some belonging to families that had crossed over from the adjoining Iraq) who were very similar to ITS cases seen by us in India.
This reminded me of ITS cases encountered in Bangladeshi refugees in 1971when I had just embarked on my career as a pediatrician. Now that ITS has been specifically reported from Iraqi Kurdistan (not a surprise though), my feeling that the problem exists in much greater proportion in Iraq, nay several other countries afflicted with malnutrition, is further supported. Way back in 1990, during the 5th International Congress of Child Neurology held in Tokyo, I had tried to drive home this point energetically.[3] At the fagend of my guest lecture, a number of delegates from Latin America, African and S-E Asian countries had admitted seeing cases resembling ITS. Today, existence of ITS as such or identical cases is on record from quite a few countries such as Afghanistan, Pakistan, Bangladesh, Myanmar, Nepal, Sri Lanka, Somalia, Nigeria, Southern Turkey and Iraq. [4]
In my considered opinion, a greater familiarity with the clinical presentation of ITS among the physicians caring for infants and children may unfold many more such cases in several countries and, perhaps, further clues to its etiology which still remains elusive. Several hypotheses regarding etiopathogenesis have been put forward from time to time, namely viral encephalitis, vitamin B12 deficiency, degenerative disorder and metabolic disorder of tyrosine with inadequate support. Currently, zinc deficiency appears to be the hot favourite. Such a deficiency in the hair, other tissues and fluids of ITS cases has been demonstrated by us and others. Since zin deficiency is known to cause practically all manifestations of ITS (growth retardation, tremors, mental dullness, skin changes, irritability, susceptibility to infections, etc), role of zinc in its causation is quite probable. Our clinical observations demonsrtrate gratifying response to zinc supplementation (of course, along with overall nutritional rehabilitation), resulting in reduced morbidity and mortality. We do suggests further well-controlled clinicals trials in different centers, both in India and elsewhere, to establish a cause - and -effect relationship between zinc deficiency and its0 .
Taking up the second article,[2] reporting scurvy in ITS, since undernutrition in one or the other form is always associated with the disorder, micronutrient and vitamin deficiencies are very much expected in ITS. In my experience spread over 3 decades on a large number of ITS cases (in Chandigarh, Shimla, Jammu and now Hisar), these deficiencies are, in fact, encountered in most cases though the emphasis in literature has been primarily on anemia and, recently, on zinc deficiency.[5] Over and above nutritional anemia, the author's have frequently seen subclinical and overt signs of deficienciencies of vitamins A, B-complex, C and D as also hypoproteinemic edema, etc in these infants.[6] It is of interest to quote from a recent review on ITS: "It is usual to find direct or indirect evidence of associated nutritional deficiencies (say protein-energy, vitamin A, D, C and B-complex, iron and other micronutrients ) which should be promptly treated for an adequate response.[7]
References
1.Mohammad Amin NM, Mohammad Zeki J. Infantile tremor syndrome in Iraqi Kudistan. Indian J Pediatr 2005; 72 : 839-842.
2.Ratagei V, Shepur TA, Patil MM, Hakeem MA. Scurvy in infantile tremor syndrome. Indian J Pediatr 2005; 72 : 883-884.
3.Gupte S. Infantile tremor syndrome: A growing Asian problem. 5th Intern Congr Child Neurol ;Tokyo 1990.
4.Gupte S. Infantile tremor sndrome. In Gupte S, ed. The Short Texbook of Pediatrics , 10th edn. New Delh; Japee Brothers, 2004; 716-719.
5.Sharda B. Infantile tremor syndrome. In Gupte S, ed. Recent Advances in Pediatrics , Vol 3. New Delhi; Jaypee Brothers, 1993; 155-164.
6.Gupte S, Pal M, Gupta SK, Sangra KR. Infantile tremor syndrome (ITS). In Gupte S, ed. Textbook of Pediatric Nutrition. New Delhi; Peepee, 2006 : 255-265.
7.Gupte S, Pal M. Trends in infantile tremor syndrome (ITS). Trop Child Hlth Bull 2005; 11 : 235-239.(Gupte Suraj)
The articles" Infantile Tremor Syndrome in Iraqi Kurdistan" by Mohammad Amin and Mohammad Zeki [1] and "Scurvy in Infantile Tremor Syndrome" by Ratageri et al[2] make an interesting reading. In this context, may I share the following information and comments with the learned authors and readers of the Indian Journal of Pediatrics .
To begin with, let me take up the article from Iraq.[1] Years ago, during the difficult period of sanctions against Iraq, I, as a member of a visiting delegation, happened to visit southern Turkey where we were shown some infants with movement disorder (some belonging to families that had crossed over from the adjoining Iraq) who were very similar to ITS cases seen by us in India.
This reminded me of ITS cases encountered in Bangladeshi refugees in 1971when I had just embarked on my career as a pediatrician. Now that ITS has been specifically reported from Iraqi Kurdistan (not a surprise though), my feeling that the problem exists in much greater proportion in Iraq, nay several other countries afflicted with malnutrition, is further supported. Way back in 1990, during the 5th International Congress of Child Neurology held in Tokyo, I had tried to drive home this point energetically.[3] At the fagend of my guest lecture, a number of delegates from Latin America, African and S-E Asian countries had admitted seeing cases resembling ITS. Today, existence of ITS as such or identical cases is on record from quite a few countries such as Afghanistan, Pakistan, Bangladesh, Myanmar, Nepal, Sri Lanka, Somalia, Nigeria, Southern Turkey and Iraq. [4]
In my considered opinion, a greater familiarity with the clinical presentation of ITS among the physicians caring for infants and children may unfold many more such cases in several countries and, perhaps, further clues to its etiology which still remains elusive. Several hypotheses regarding etiopathogenesis have been put forward from time to time, namely viral encephalitis, vitamin B12 deficiency, degenerative disorder and metabolic disorder of tyrosine with inadequate support. Currently, zinc deficiency appears to be the hot favourite. Such a deficiency in the hair, other tissues and fluids of ITS cases has been demonstrated by us and others. Since zin deficiency is known to cause practically all manifestations of ITS (growth retardation, tremors, mental dullness, skin changes, irritability, susceptibility to infections, etc), role of zinc in its causation is quite probable. Our clinical observations demonsrtrate gratifying response to zinc supplementation (of course, along with overall nutritional rehabilitation), resulting in reduced morbidity and mortality. We do suggests further well-controlled clinicals trials in different centers, both in India and elsewhere, to establish a cause - and -effect relationship between zinc deficiency and its0 .
Taking up the second article,[2] reporting scurvy in ITS, since undernutrition in one or the other form is always associated with the disorder, micronutrient and vitamin deficiencies are very much expected in ITS. In my experience spread over 3 decades on a large number of ITS cases (in Chandigarh, Shimla, Jammu and now Hisar), these deficiencies are, in fact, encountered in most cases though the emphasis in literature has been primarily on anemia and, recently, on zinc deficiency.[5] Over and above nutritional anemia, the author's have frequently seen subclinical and overt signs of deficienciencies of vitamins A, B-complex, C and D as also hypoproteinemic edema, etc in these infants.[6] It is of interest to quote from a recent review on ITS: "It is usual to find direct or indirect evidence of associated nutritional deficiencies (say protein-energy, vitamin A, D, C and B-complex, iron and other micronutrients ) which should be promptly treated for an adequate response.[7]
References
1.Mohammad Amin NM, Mohammad Zeki J. Infantile tremor syndrome in Iraqi Kudistan. Indian J Pediatr 2005; 72 : 839-842.
2.Ratagei V, Shepur TA, Patil MM, Hakeem MA. Scurvy in infantile tremor syndrome. Indian J Pediatr 2005; 72 : 883-884.
3.Gupte S. Infantile tremor syndrome: A growing Asian problem. 5th Intern Congr Child Neurol ;Tokyo 1990.
4.Gupte S. Infantile tremor sndrome. In Gupte S, ed. The Short Texbook of Pediatrics , 10th edn. New Delh; Japee Brothers, 2004; 716-719.
5.Sharda B. Infantile tremor syndrome. In Gupte S, ed. Recent Advances in Pediatrics , Vol 3. New Delhi; Jaypee Brothers, 1993; 155-164.
6.Gupte S, Pal M, Gupta SK, Sangra KR. Infantile tremor syndrome (ITS). In Gupte S, ed. Textbook of Pediatric Nutrition. New Delhi; Peepee, 2006 : 255-265.
7.Gupte S, Pal M. Trends in infantile tremor syndrome (ITS). Trop Child Hlth Bull 2005; 11 : 235-239.(Gupte Suraj)