Too young to talk of vertigo?

Abstract

In April, 2003, a previously healthy 5-year-old girl came to our hospital, with vomiting and abdominal pain. She had been vomiting several times an hour, for 8 h; the vomit did not contain blood or bile. Her medical and family histories were unremarkable; growth and developmental milestones were normal. The girl was alert and afebrile; heart rate and blood pressure were normal. General and neurological examination showed no abnormality. We diagnosed gastroenteritis, and prescribed intravenous fl uids. The girl stopped vomiting the next day, and was discharged the day after. However, she subsequently had several similar episodes of illness. On each occasion, she vomited for several hours, was treated with bed rest or intravenous fl uids, and recovered fully within a day; treatment with domperidone was ineff ective. Vomiting was often accompanied by abdominal pain and headache, but not by fever, cough, diarrhoea, or weight loss. Routine blood tests, including concentrations of glucose and ammonia, showed no abnormalities; nor did blood-gas testing. We sometimes found mild ketonuria. We found no abnormalities on electrocardiography, abdominal radiography or ultrasonography, CT of the abdomen and brain, or electroencephalography. We therefore provisionally diagnosed her illness as cyclic vomiting. 13 months after the fi rst episode, the girl’s mother revealed that before vomiting began, the patient often described feeling her head swaying. We surmised that this might be vertigo. Otoscopy showed nothing abnormal. We observed no nystagmus when the patient was at rest; reactive nystagmus was elicted from caloric refl ex testing (with warm and cold water) of the left ear, but not the right ear, implying damage to the semicircular canals of the right ear, or their aff erent nerves. Pure-tone audiometry showed mild sensorineural hearing loss in the right ear (fi gure). Ear-targeted CT showed no abnormalities. We therefore diagnosed Meniere’s disease, according to standard criteria, surmising that perhaps the patient was too young to complain of tinnitus or a sensation of aural fullness. We prescribed isosorbide, an osmotic diuretic; the patient’s vomiting and feeling of dizziness disappeared. A year after treatment started, we noted that her hearing had improved. When last seen, in June, 2008, the patient continued to be free of vomiting and vertigo; she continued to take isosorbide. Meniere’s disease, fi rst described in 1861, is idiopathic endolymphatic hydrops (excess fl uid in the inner ear), causing deafness, tinnitus, and vertigo. The median time of onset is the fourth decade; Meniere’s disease is rare in children. It is also probably underdiagnosed. Children who complain of dizziness tend to be overlooked, perhaps partly because they have diffi culty describing it, and because vaguely defi ned “dizziness” has many possible causes. Therefore, children with Meniere’s disease often present with vomiting—which can easily be misdiagnosed as cyclic vomiting or migraine (including abdominal migraine). Hearing loss sometimes develops after onset of the disease. Audiometry can be useful in identifying the cause of unexplained vomiting or “dizziness”; regrettably, it is not always widely available.