Article, Neurology

Is S100B protein level really not an indicator of brain damage due to carbon monoxide poisoning in children?

S100B protein level really not an ind”>Correspondence / American Journal of Emergency Medicine 31 (2013) 15251534

Is S100B protein level really not an indicator of brain damage due to carbon monoxide poisoning in children??

To the Editor,

1531

Emre Zorlu MD

Neurosurgery Department GATA Haydarpasa Education Hospital

Istanbul, Turkey

We read with great interest the article “Neuron-specific enolase and S100B protein in children with carbon monoxide poisoning: children are not just small adults” written by Akelma et al [1]. The authors aimed in this study to evaluate the role of S100B protein and Neuron-specific enolase in children with Carbon monoxide poisoning. They concluded that NSE levels increase in CO-associated Hypoxic brain damage in accordance with clinical findings and contrary to the studies conducted on adults, S100B protein levels do not increase in response to hypoxic brain damage. We appreciate the authors for sharing their enlightening study with us. We believe that this study will act as a guide for further studies regarding the CO- associated hypoxic brain damage, which is a common and important problem. We wish to make a minor criticism about this study.

Serum S100B is a calcium-binding protein released into the blood from astroglial and Schwann cells. Elevated serum or CSF level of this protein is often observed in patients with traumatic or hypoxic brain damage and hemorrhagic and ischemic stroke. Some authors have described S100B protein as an ischemic damage marker of central nervous system and investigated it as a clinical marker for prediction of outcome after brain injury in adult and pediatric patients [2,3]. In addition, several studies performed on adults reported that S100B protein and NSE might act as an indicator of CO- induced hypoxic brain damage [4-6]. In this study, the authors declare that that S100B protein level is not a good indicator of brain damage in pediatric patients with CO poisoning, contrary to the studies conducted on adults.

The authors reported that the patients have complained from headache, dizziness, nausea and vomiting, syncope, and convulsion, and they found severe neurologic findings such as consciousness, coma, focal neurologic deficit, and seizure in a few patients. However, these complaints and findings are not a definitive indicator of ischemic brain damage every time. Therefore, we believe that most of the patients in this study did not have an ischemic brain damage and the level of S100B protein, which is accepted as an indicator of brain damage, was low due to the absence of brain damage in patients with CO poisoning in this study.

It is possible to diagnose the ischemic brain injury caused by various reasons such as CO poisoning by diffusion magnetic resonance imaging [7,8]. We believe that if patients with CO poisoning are performed diffusion magnetic resonance imaging, the existence of ischemic brain injury can be diagnosed exactly, and in this study, if only the S100B protein level of patients whose ischemic brain injury was proved with such kind of diagnosing technique was compared with the control groups, S100B level would be higher as in adult patients.

Yusuf Emrah Eyi MD Emergency Department Hakkari Military hospital

Hakkari, Turkey

Yakup Aksoy MD Ophthalmology Department Hakkari Military Hospital

Hakkari, Turkey E-mail address: [email protected]

Abdullah Kaya MD

Ophthalmology Department GATA Haydarpasa Education Hospital

Istanbul, Turkey

Kadir Ozturk MD Internal Medicine Department Hakkari Military Hospital

Hakkari, Turkey

Kadir Colakoglu MD Ophthalmology Department Kasimpasa Military Hospital

Istanbul, Turkey

http://dx.doi.org/10.1016/j.ajem.2013.07.015

References

  1. Akelma AZ, Celik A, Ozdemir O, et al. Neuron-specific enolase and S100B protein in children with carbon monoxide poisoning: children are not just small adults. Am J Emerg Med 2013;31:524-8.
  2. Berger RP, Kochanek PM. Urinary S100B concentrations are increased after brain injury in children: a preliminary study. Pediatr Crit Care Med 2006;7:557-61.
  3. Selakovic V, Raicevic R, Radenovic L. The increase of neuron-specific enolase in cerebrospinal fluid and plasma as a marker of neuronal damage in patients with acute Brain infarction. J Clin Neurosci 2005;12:542-7.
  4. Cakir Z, Aslan S, Umudum Z, et al. S-100beta and neuron-specific enolase levels in carbon monoxide-related brain injury. Am J Emerg Med 2010;28:61-7.
  5. Yardan T, Cevik Y, Donderici O, et al. Elevated serum S100B protein and neuron-specific enolase levels in carbon monoxide poisoning. Am J Emerg Med 2009;27:838-42.
  6. Ide T, Kamijo Y, Ide A, Yoshimura K, et al. Elevated S100B level in fluid could predict poor outcome of carbon monoxide poisoning. Am J Emerg Med 2012;30:222-5.
  7. Fujiwara S, Beppu T, Nishimoto H, et al. Detecting damaged regions of cerebral white matter in the subacute phase after carbon monoxide poisoning using voxel-based analysis with diffusion tensor imaging. Neuroradiology 2012;54:681-9.
  8. Sundgren PC, Reinstrup P, Romner B, Holtas S, et al. Value of conventional, and diffusion-and perfusion weighted MRI in the management of patients with unclear cerebral pathology, admitted to the intensive care unit. Neuroradiology 2002;44: 674-80.

    S100B protein in children with carbon monoxide poisoning?

    To the Editor,

    S100B has been shown to increase in patients with cardiac arrest, stroke, subarachnoid hemorrhage, and traumatic and hypoxic brain damage [1-4]. In contrast to adult studies, we found that serum S100B protein levels did not increase in pediatric patients with carbon monoxide poisoning [5]. Patients with a positive history of CO exposure and elevated Blood carboxyhemoglobin (N 10%) levels associated with relevant clinical findings were diagnosed with CO poisoning. The most common complaints were headache (n = 27), dizziness (n = 27), nausea and vomiting (n = 28), syncope (n = 7), and convulsion (n = 2). In addition, we also classified patients into 2 groups depending on their state of consciousness (conscious or unconscious). We have demonstrated that S100B protein levels were similar between the groups. The clinical findings observed in patients within our study population are consistent with the clinical picture of CO poisoning. Most of the clinical signs and symptoms were of central nervous system (CNS) origin. Furthermore, some of the patients were unconscious and experienced convulsive seizures.

    ? We have no support in financial or other relationships that might lead to a conflict

    of interest. ? The authors declare no conflicts of interest.