Spicy food induced transient ischemic attack: a diagnostic conundrum in a child with moyamoya vasculopathy.

CASE REPORTS

Spicy food induced transient ischemic attack: A diagnostic conundrum in a child with moyamoya vasculopathy.

Benjamin Wei-Liang Ng¹, Jeffrey Soon-Yit Lee², Teck-Hock Toh^1,2.

¹Department of Pediatrics, Sibu Hospital, Ministry of Health Malaysia, Sibu, Sarawak, Malaysia,
²Clinical Research Centre, Sibu Hospital, Ministry of Health Malaysia, Sibu, Sarawak, Malaysia.

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Abstract
Moyamoya vasculopathy (MMV) is a rare progressive stenosis of the intracranial internal carotid arteries (ICA) and its branches with characteristic collateral formation. MMV frequently manifests in children as ischemic stroke or transient ischemic attack (TIA). The recognition of TIA in a child with MMV can be challenging due to the overlapping features seen with stroke-mimics, causing missed or delayed diagnosis. Ischemic symptoms seen in MMV are often triggered by hyperventilation, crying or exercise, but the association with spicy food is rare. We describe a boy with recurrent episodes of TIA associated with eating spicy food. After several misdiagnoses, a thorough re-evaluation and a magnetic resonance angiographic imaging confirmed the diagnosis of MMV. Neurosurgical revascularization surgery was performed with good post-operative outcome on follow-up. This case highlights the unusual association of spicy food and TIA in a child with MMV, and illustrates the conundrum surrounding its diagnosis.

Why this article important?

Our case is unique as the association with spicy food causing ischemic symptoms in patients with MMV is exceeding rare. As spicy foods are a staple in some Asian populations, this association should be carefully regarded to avoid dismissing an important clue to the diagnosis of a possible cerebrovascular occlusive disease. We also endeavored to explain the vasoconstrictive effect of capsaicin, an active component in chilies and how this can precipitate the ischemic symptoms in MMV. We postulate that the precipitation of these symptoms is due to an interplay of various mechanisms rather than an independent factor like hyperventilation alone as described in some literatures. As TIA is an uncommon clinical presentation in children, it can often be missed. Moreover, the overlapping features seen with stroke or TIA-mimics can further complicate the diagnostic process, resulting in delayed diagnosis. Our case illustrates the diagnostic challenges in identifying TIA and discusses the important differential diagnoses to consider along with features to help distinguish them. This case also underscores the need to consider early cerebral vascular imaging despite normal initial brain imaging, especially if the presentation is not typical of the features described in the stroke-mimics

Summary of article

Moyamoya vasculopathy (MMV) is a rare, progressive steno-occlusive disease of the intracranial internal carotid arteries and its branches with characteristic collateral vessels. In children, they commonly present with an ischemic stroke or transient ischemic attack (TIA). The usual triggers for these ischemic symptoms include hyperventilation, crying or coughing. We describe a unique case of a boy who presented with recurrent episodes of transient right sided body weakness associated with spicy food consumption. The symptoms were initially attributed to a functional neurological disorder and later focal seizure before further re-evaluation confirmed the diagnosis of MMV. He went on to have a revascularization surgery with reduction of severity and frequency of symptoms post-operatively.

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