The significance of case reports includes sharing personal experiences, education/training, and providing first-line evidence. The reportability of a case is not solely based on its rarity. Case reports require clear learning points for readers, including pitfalls in clinical practice, suggested pathophysiology, and objections to current theory. Consider answering questions, such as “what lessons were learned from this case?,” or “what information does this case add to the existing knowledge?” The introduction of a case report should include what is known about the topic, what is unknown, and the importance of the case. The case description should be concise and exclude unnecessary information. In the discussion section, focus on the learning points of your case. Do not include general statements in the introduction and discussion sections. Do not use phrases, such as “we report this case because it is a rare, valuable/worthy case,” or “we report this case, adding discussion with the literature.” Young physicians may experience the following three key effects throughout the process of writing a case report : (i) enjoyment in discovering the learning points of the case and summarizing them, (ii) delight in publishing the case, and (iii) fruitfulness in increasing their clinical ability.

  Objective: This study aimed to clarify the reality and issues of decision-making to sedate children during MRI examinations. Methods: This observational study consisted of 321 MRI examinations performed on children at a single university hospital. Study variables included image quality, age, sex, previous MRI examinations, and the specialty of the attending physicians (pediatrician team and a collaborative team of pediatricians and neurosurgeons) in the sedation and nonsedation groups. A questionnaire was given to families before the scan to determine to examine the responses associated with poor image quality. The collaborative team selected the cases for MRI preparation. Results: Sedation was performed in 38.7% of cases and good image quality was achieved in 85.7% cases. The sedation rate in this study was lower in patients aged 3-6 years compared with that in the Japanese outpatient MRI survey. Furthermore, pediatrician teams were more likely to sedate 95% of children aged 3-6 years, while collaborative teams sedated only 50% of them, with the sedation rate differing significantly by physician group. The proportion of patients with good postsedation image quality was significantly lower in children aged 3-6 years than in those of other age groups. Three factors including younger age, phonophobia, and claustrophobia were associated with poor image quality in the sedation group. However, no factors were associated with poor image quality in the nonsedated group. Conclusions: The findings suggest that there are large individual differences among attending physicians in the decision-making of sedation for MRI scans in children aged 3-6 years. Even when sedation was employed in children aged 3-6 years, the image quality was frequently inadequate. Children who were sedated and exhibited poor image quality, tendencies noted were a fear of dark places and loud noises. Therefore, caution is recommended while sedating children with such fears.

  Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune demyelinating disease characterized by the presence of myelin oligodendrocyte glycoprotein (MOG) antibodies. Most children presenting with MOGAD exhibit clinical phenotype comprising ADEM, optic neuritis, and transverse myelitis, as well as the presence of cortical encephalitis. A 12-year-old male patient presented with a history of three episodes of tonic-clonic seizures. On the 9th day after onset, he experienced fever and headache. An MRI scan revealed cortical edema in the right frontal lobe, FLAIR hyperintensity, and leptomeningeal enhancement. EEG indicated right frontal lobe high-amplitude slow waves. As MOGAD was suspected, the patient was treated with steroid pulse therapy. The headache and fever rapidly ameliorated after the treatment. The MOG antibodies tested negative with IgG1-specific secondary antibodies (IgG1 method) in the serum and spinal fluid ; however, they tested positive with IgG (H＋L) -specific secondary antibodies (total IgG method). Moreover, the test results for aquaporin-4 antibodies were negative. The disease course and laboratory findings led to the diagnosis of MOG antibody-associated cortical encephalitis. The steroid pulse therapy was followed by 6 months of post-steroid therapy, and the patient experienced no sequelae or recurrences. In 2023, the international MOGAD panel established diagnostic criteria for MOGAD and listed methods of testing for MOG antibodies. It is essential to understand the differences in sensitivity and specificity associated with secondary antibodies and to be aware of false positives and negatives.

  Thymectomy is a low priority as a standard treatment for preadolescent cases of immunotherapy-resistant myasthenia gravis because of the lack of evidence on its efficacy in the clinical guidelines in Japan. The number of preadolescent patients undergoing thymectomy remains limited, owing to concerns about the invasive nature of the procedure and possible complications. Case is a male patient presented with ptosis at the age of 8 years and 3 months. He was diagnosed with ocular myasthenia gravis and tested positive for anti-acetylcholine receptor antibodies. The patient was initially treated with oral distigmine bromide ; however, he developed dysarthria and dysphagia. He subsequently experienced a myasthenic crisis during intravenous immunoglobulin administration, which recurred during steroid pulse therapy. Despite gradually increasing the steroid dosage and adding tacrolimus, the clinical improvement was insufficient, and mild bulbar symptoms persisted. When steroids were titrated up to 1.75 mg/kg daily, the bulbar symptoms improved. However, tapering steroids was difficult, and the patient developed hyperglycemia, obesity, and growth retardation. After a thoracoscopic thymectomy at the age of 9 years and 10 months, the remission status stabilized, and steroid tapering was successfully initiated. Anti-acetylcholine receptor antibody titers also decreased rapidly after surgery. Although many childhood cases of myasthenia gravis show improvement with immunotherapy alone, the adverse effects of steroids are often clinically significant, particularly in drug-resistant cases. Thymectomy should be considered during the early stages of the disease in immunotherapy-resistant cases that do not show a decrease in antibody titers during treatment, even in the preadolescent stage.

  Although various neurological complications have been reported to occur with coronavirus 2019 disease (COVID-19), the details of the symptoms and foci of these complications remain unclear. We report two cases of children with delayed central and peripheral neurological symptoms and F-wave abnormalities after COVID-19. Case 1 was a 13-year-old boy who developed fever, abdominal pain, and diarrhea 1 month after COVID-19. He was admitted to our department with a diagnosis of pediatric COVID-19-related multisystem inflammatory syndrome. After treatment with high-dose immunoglobulin and intravenous steroids, he became unable to walk due to limb pain, muscle weakness, and abnormal sensations. Cerebrospinal fluid (CSF) analysis exposed elevated cell counts, and a peripheral nerve conduction study revealed prolonged latency, decreased conduction velocity, and decreased frequency of F waves. Head and spinal cord MRI showed multiple scattered signal abnormalities. These neurological symptoms improved without treatment. Case 2 was a 14-year-old boy who developed low back pain 1 month after COVID-19. He was admitted to our hospital due to persistent muscle weakness and a decreased sensation of warmth, pain, and touch in the right side of his body. Imaging studies, blood and spinal fluid tests showed no abnormalities. A peripheral nerve conduction study showed a decreased frequency of upper limb F waves and prolonged latency. The above symptoms improved without treatment. In the two patients, muscle weakness and sensory abnormalities were observed more than 1 month after COVID-19. F wave abnormalities were observed on electrophysiological examination, and the neurological prognosis was good, suggesting nerve root damage near the anterior horn of the spinal cord as one of the foci of the disease.

  One of the most frequent complications of tracheostomy is the development of granulation tissue, which may cause airway occlusion, necessitating an urgent response. We used the polygonal area on chest computed tomography scans, to show the percentage of the lumen that remains open and predict clinical emergencies. We report a case with severe motor and intellectual disabilities who was able to avoid the danger of suffocation. The patient was a 20-year-old female admitted to our center three years after tracheostomy (lumen : 92% open). We observed frequently convulsive attacks and coughing fits, and the patient developed pneumonia three times in the first year of admission. Nine months later, the lumen was only 25% open. Therefore, we developed preventive and coping therapies to avoid predictable emergencies. Two and three years after admission, we noticed difficulty in passing a suction catheter and narrowing of the tracheal lumen on CT. The lumen was 3% open on the scan after two years admission and 30% open after three years. At time of the latter scan the patient developed cyanosis, and an uncuffed thin tracheal cannula was emergently inserted along the tracheostomy tube to secure the airway. Four years after admission, a made-to-order short tracheostomy tube was inserted to prevent granular growth, then there was a significant improvement in the stenosis (lumen 85% open). Axial CT images can correctly detect stenotic sites, quantify the degree of airway narrowing, and evaluate the airway beyond highly stenotic areas of the bronchial lumen. However, concomitant use of bronchoscopy was recommended, for findings of airway stenoses on axial CT tend to be affected by exhalation and secretions. To reduce the risk of tracheal obstruction, calculation of the percentage of the lumen that remains open on chest CT and monitoring of the situation are useful for predicting events and evaluating treatment. It should be kept in mind that an opening of 30% is a red flag. In such cases, physicians should anticipate emergencies and consider appropriate countermeasures.