Comorbidity of chronic fatigue syndrome, postural tachycardia syndrome, and narcolepsy with 5,10-methylenetetrahydrofolate reductase (MTHFR) mutation in an adolescent: a case report

A 16-year-old male adolescent was hospitalized complaining of intermittent dizziness,drowsiness,and fatigue for approximately 2 years.The patient had an episode of fever and pharyngalgia lasting nearly 2 weeks and had undergone appendectomy because of acute appendicitis before the presentation of the above symptoms.He suffered from severe dizziness mostly after switching from a supine to an upright posture when he was getting up in the morning.The symptom of dizziness usually persisted for minutes to hours and could be partially alleviated by recumbency.In addition,he felt drowsy and fatigued all day despite a total sleep duration of 14 to 15 h per day.All the symptoms could be partially mitigated by complete bed rest for 1 or 2 weeks,but he relapsed after taking part in normal school life again.Additionally,the feeling of fatigue was obviously aggravated after exertion or infection.He was unable to focus on his studies and had to withdraw from school for a long time.As a result,there was a decline in academic performance after the onset of illness.He used to benefit from taking carnitine and folate;however,the improvement was limited in enabling him to take part in normal social and school life.He was physically and mentally healthy before the presentation and did not feel disgusted with learning in the past.No family history of cardiovascular or nervous system disease was evident.The study was approved by the Ethics Committee of Peking University First Hospital(No.2020-415).

A survey on pediatric anti-N-methyl-D-aspartate-receptor encephalitis treatment strategies in China

To the Editor:Currently,there is no standardized treatment protocol for the pediatric anti-N-methyl-D-aspartate receptor(NMDAR).There are two surveys by Kahn et al[1]and Bartolini et al[2]that aimed at determining the treatment strategies that are used for pediatric NMDAR encephalitis in other parts of the world rather than China.Bartolini et al[2]performed a worldwide survey involving 199 participants:61 adult neurologists,86 pediatric neurologists,and 52 pediatric rheumatologists.Their survey investigated the differences in anti-NMDAR encephalitis treatment strategies,according to medical specialty,years in practice,and geographical location.[2]The survey of Kahn et al[1]involved 151 pediatric neurologists and focused on identifying the indications for the initiation of immunotherapy,type of the used immunotherapy,length of the first-line immunotherapy,time for the initiation of the second-line immunotherapy,and the preferable options for the second-line immunotherapy.Additionally,they investigated the indications and time for adding a disease-modifying therapy,and how long should patients continue with the immunotherapy once returned to their neurologic baseline.[1]Both surveys did not sufficiently focus on identifying the utility of the modified Rankin Scale(mRS),dosages and duration of the treatments(including the duration of oral prednisone),the utility of Cluster of Differentiation 19 positive(CD19+)B cells in adjusting the dosages of rituximab,the necessity of long-term immunosuppressive treatment(for relapse prevention),and the indications for stopping the immunotherapy.