LETTERS TO THE EDITOR Dear Editor, Adolescence is a vulnerable period for participation in a lot of risky behaviours, including the choking game, a dangerous prac- tice whose consequences can be fatal. 1 We report a case of an 11-year-old boy referred for ataxia, disorientation and slurred speech. The boy had participated in a game based on bending over, hyperventilating and being hit in the chest. He suffered no loss of consciousness. He denied drug use. Neurological examination revealed incoherent speech, psychomotor agitation with alternating periods of lethargy and ataxia and an amnesia episode. The rest of the physical examina- tion was normal (cranial nerves, pupillary response, strength and muscle tone). Blood count, biochemistry, toxic urine, brain scan, magnetic resonance imaging, and electroencephalogram were all normal. The child’s neurological status improved rapidly, with full recovery of cognitive function after four hours of observation. The choking game is usually performed by teenagers and produces temporary interruption of cerebral perfusion. It can be achieved by different techniques such as bilateral neck compression, throttling themselves with ropes, or holding the breath and getting punched in the chest. The choking game seems to begin in groups. Individual practice is associated with increased risk of mortality. 2 This patient was of particular interest because the mechanism used (holding the breath and getting punched in the chest) is not very common. Most cases reported in the literature describe bilateral neck compression as the principal mechanism to achieve self-induced hypocapnia. 2 This entity can lead to cerebral vasoconstriction, increased cytokines 3 production and hypoxia. Syncope, seizures and cognitive deficits have been reported as immediate side effects. The differential diagnosis of these behaviours should include suicide and auto-erotic asphyxiation. 4 The suicide attempts often occur during late adolescence, while asphyxic games occur during early adolescence and often there is a history of previous attempts. The doctor should examine the patient looking for possible signs of self-injury such as marks on the neck or bloodshot eyes. These practices are becoming more common among adolescents. It is thought that many of the deaths result from engagement in this activity while alone. 2 The internet is a dangerous source of information about such games. Multidisciplinary work with psychologists and educators and participation in community prevention programs is required. Acknowledgement I would like to thank my colleagues for their invaluable help in preparing this case report. Dr Victoria Martínez Arias Dr Miguel Ángel Molina Gutierrez Dr Diego Rodríguez Álvarez Dr Cristina García-Mauriño Alcazar Dr Miriam Nova Sánchez Department of Pediatrics, La Paz University Hospital Madrid, Spain References 1 Andrew TA, Fallon KK. Asphyxial games in children and adolescents. Am. J. Forensic Med. Pathol. 2007; 28: 303–07. 2 Albuhairan F, Almutairi A, Eissa MA, Mohammed N, Maha A. Non- suicidal self strangulation amomg adolescents in Saudi Arabia: Case series of the choking game. J. Forensic Leg. Med. 2015; 30: 43–5. 3 Yan EB, Satgunaseelan L, Paul E et al. Post-traumatic hypoxia is associated with prolonged cerebral cytokine production, higher serum biomarker levels, and poor outcome in patients with severe traumatic brain injury. J. Neurotrauma 2014; 31: 618–29. 4 Baquero F, Mosqueira M, Fotheringham M, Wahren C, Catsicaris C. The choking game in adolescence, between experimentation and risk. Arch. Argent. Pediatr. 2011; 109: 59–61. CLINICAL CONSEQUENCES OF SELF-INDUCED HYPOCAPNIA Dear Editor, IMPETIGO CONTAGIOSA IN A ZOSTERIFORM PATTERN Impetigo is a bacterial infection of the superficial epidermis, common in children. Staphylococcus aureus, alone or in combination with group A β-hemolytic streptococci (Streptococcus pyogenes), is responsible for most cases. We report a case of impetigo with a zosteriform pattern. An 8-year-old girl presented with multiple pustular lesions over her face for 7 days associated with mild pain. The lesions started as pus-filled blisters on her nose, which then progressed within 2 days to involve the left half of her face. She initially pre- sented to her local hospital and was diagnosed as herpes zoster and prescribed oral acyclovir 400 mg five times per day for 5 days. As her symptoms were worsening, she was later referred to our hospital. Cutaneous examination revealed multiple pustules with erosions and crusting over the left half of her face. The pustules were flaccid, confluent and arising on a background of ery- thema (Fig. 1a). Lesions were distributed in a zosteriform Conflict of interest: None declared. Conflict of interest: None declared. doi:10.1111/jpc.13115 684 Journal of Paediatrics and Child Health 52 (2016) 684–686 © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)