Sandifer’s Syndrome in a 3-Month-Old Male Infant: A Case Report

Background: Sandifer syndrome (SS) is the association of gastroesophageal reflux disease (GERD) with neurological manifestations (spastic torticollis and paroxysmal dystonic postures with arching of the back and rigid opisthotonic posturing. Case presentation: A 3-month-old male infant presented to our emergency department with torticollis and dystonic episodes for two months associated with vomiting. These movements were observed during or just after feeding. Since the patient developed regurgitations with torticollis and dystonic episodes with arching of the back and rigid opisthotonic posturing. The electroencephalogram was normal. Barium swallow/meal examination revealed GERD without evidence of hiatus hernia. Apgar scores were 7 at 1 min and 9 at 5 min. Conclusion: Early recognition and treatment of GERD in patients with Sandifer syndrome enhance the success of medical management and contributes to improved quality of life for patients with brain damage. The paroxysmal dystonic behaviors were dramatically disappeared completely after medical management in this patient.

children with GERD [4]. The exact pathophysiology of the movements in SS is still unclear [5] [6]. SS may be due to GER even without hiatal hernia, macroscopic esophagitis, or reflux symptoms, neural axis abnormalities [7] and food allergy to dietary proteins of lactating mother may play a role [2] [8]. SS was seen either in patients with Brachman-de Lange syndrome [9]. SS is under recognized, and delays in diagnosis are due to atypical presentations [10]. The neurological manifestations are thought to be a response to the pain associated with GERD, to protect the airway or reduce acid reflux-associated pain [11]. SS is supported by the resolution of the manifestations on successful treatment of GERD [12].
We report a 3-months-old male patient presented to our ED with torticollis, dystonic episodes with severe arching of the back and rigid opisthotonic posturing since birth associated with vomiting. SS was suspected and the above symptoms resolved completely after medical treatment.  These movements were observed during or just after feeding and associated with vomiting. The milestones of motor and mental development were normal.

Case Presentation
Physical and neurological examinations were normal. The patient is a product of normal spontaneous vaginal delivery, Apgar scores were 7 at 1 min and 9 at 5 min, birth weight was 2700 gm, actual body weight 4700 gm. Breastfeed baby and no history of physiological jaundice.
Vaccination was given by age. No history of similar conditions and no chronic illness in his family. Routine laboratory tests were normal. The patient was seen by a pediatric epilepsy clinic to exclude infantile spasm and the electroencephalogram (EEG) study was normal.
Barium swallow/meal examination revealed GER without evidence of hiatus hernia ( Figure 2). Twenty-four hours of pH monitoring was not done, due to the lack of availability in our hospital.
Therefore, the diagnosis, in this case, was based on typical clinical features and on response to medical measures trail.
We started conservative management with feeding and posture modifications (lateral and head elevation 30 -45 degree), small, frequent, thick special anti-regurgitation formula. After four days of these measures, the infant still owns the above attacks and vomiting. We added proton pump inhibitor (PPI) as omeprazole 1 mg/kg/day in two divided doses, after four days the mother mentioned that her baby get well and the frequency of the attacks decreased from 10 -15 attack per day to one or two attacks per day. The above symptoms resolved completely after three weeks of treatment, we followed this patient for a total eight weeks and he was free of SS symptoms and signs completely.

Discussion
Sandifer syndrome is a syndrome characterized by paroxysmal dystonic posturing with opisthotonus and unusual twisting of the head and neck (resembling torticollis)  - [20]. The onset usually occurs in infancy and early childhood [21], with a peak prevalence at 18 -36 months [4].
GERD in infants may cause paroxysmal attacks of generalized stiffening and opisthotonic posturing that may be accompanied by apnea, staring, and minimal jerking of the extremities [22]. SS is a rare cause of torticollis related to hiatal hernia and approximately one case of SS occurs for every 100 children with symptomatic hiatal hernia [23]. The dystonic body movements are described as atypical seizures or abnormal body movements and take place in the paroxysmal form as attacks with irritability, head and eye version, extensor spasm, rectus abdominis muscle contractions, and dystonic posture [24]. The classical symptoms of the syndrome are spasmodic torticollis and dystonia [23]. Nodding and rotation of the head, neck extension, gurgling sounds, writhing movements of the limbs, and severe hypotonia have been reported [19] [25]. The head positioning may be a mechanism to protect the airway or reduce acid reflux [26].

Conclusion
Healthcare providers should be aware of SS when evaluating a child with torticollis, dystonic episodes or atypical seizures. Early recognition and treatment of GERD in patients with SS enhance the success of medical management, are curative for patients without other disorders, and contribute to improved quality of life for patients with brain damage. The paroxysmal dystonic behaviors were dramatically disappeared completely after medical management in this patient. Open Journal of Pediatrics participation in the study. In addition, they are grateful to the family of the case child for providing us the better opportunity for conducting the research.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Ethics Approval and Consent to Participate
Written informed consent was obtained from the patient's parent for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.