Case Conference
Myra Lalas
PGY 2
CC: seizures
HPI: 8 Y F with no significant PMH transferred to CHAM 10 from Jacobi for status epilepticus
1/15- malaise1/17- fever started1/18- several episodes of NBNB emesis1/19- went to PMD with T= 105.3 and started on
Cefprozil 500 mg BID for b/l AOM
1/21- went back to PMD for persistent fevers- switched to Augmentin
1/22- full body shaking (2 mins) followed by confusion and fecal incontinence
On the way to Jacobi ER, had 2nd seizure episode. Given Ativan and loaded with Dilantin.
In Status- was transferred to CHAM PICU for EEG monitoring
No sick contacts; no recent travelPMH: unremarkableImm Hx: UTDNKDAFMH: no epilepsy, no asthmaP/S Hx: in 3rd grade; does well in school; lives
with both parents; recently acquired 2 new vaccinated dogs
Physical Exam
VS T= 39.1 P 120 R 21 101/71 98% RA
Gen responds to painful stimuli, nonverbal, GCS 9
HEENT PERRLA, TM’s normal b/l, clear OP, no
LAD, (+) erythematous patches across
cheeks
Chest CTA b/l
Heart N S1/S2, no murmurs
Abd soft, ND, (+) BS, no HSM
Ext FEP, CRT < 2 secs, (+) blister on R heel
Labs
CBC H/H 10.9/33.1 Plt 137 WBC 5.2 N 29 L 32 M 30• BMP Na 136 K 3.8 Cl 102 HCO3 21 BUN 6 Crea 0.5 Glucose 111 Ca 8.8 Mg 1.6 P 2.4• LFT’s alb 3.3 TP 5.7 AST 89 ALT 104 alk phos 93 TB 0.2 DB 0.1• Dilantin 14
ABG pH 7.42 pCO2 37.2 pO2 200 BE -0.3 HCO3 23.6• RSV (+)• Flu neg• HSV ½ neg• RVP neg• Cultures: Blood Culture 1/27 NG
1/31 NG
Respiratory Culture 1/27 NG
1/31 NG
Urine Culture 1/27 NG
1/31 NG
CSF Culture 1/26 NG
AFB CSF Culture 1/29 neg
Wound Culture 1/25 NG
ANA negParvovirus B19 IgM and IgG WNLBartonella IgM and IgG WNLCryptococcal Ag serum NRIMAGINGCXR no effusions of consolidationsRepeat: inc LL opacity (atelectasis or
consolidation)US Abd/Pelvis hepatomegaly, ascites, b/l trace
pleural effusions, gallbladder
sludgeCT Head negMRI neg
EEG
1. Electrographic sz patterns, b/l independent L>R, posterior quadrant
2. Spikes and polyspikes, multifocal
3. PLED’s, generalized
4. Burst suppression, generalized
Differentials?
Anoxic/ Ischemic EncephalopathyMetabolicToxicSystemic InfectionVasculitisReye’sParaneoplasticTraumaLupus
Viral Encephalitis
Acute CNS dysfunction with radiographic or laboratory evidence of brain inflammation.
HSV encephalitis is the most common diagnosed cause of sporadic encephalitis
Majority have no etiologic identified.
Causes of viral encephalitis
Herpes simplex virus (HSV-1, HSV-2)
Other herpes viruses: VZV, CMV, EBV, HHV6
Adenoviruses
Influenza A
Enteroviruses, poliovirus
Measles, mumps and rubella viruses
Rabies
Arboviruses—for example, Japanese B encephalitis, St Louis encephalitis virus, West Nile encephalitis virus, Eastern, Western, and Venezuelan equine encephalitis virus, tick borne encephalitis viruses
Bunyaviruses—for example, La Crosse strain of California virus
Reoviruses—for example, Colorado tick fever virus
Arenaviruses—for example, lymphocytic choriomeningitis virus
HSV Encephalitis
Fever, personality change, autonomic dysfunction, dysphagia, seizures, headache
Mildly elevated WBC, lymphocyte predom, mildly elev protein
Bilateral temporal lobe involvement of CT or MRIDx test of choice: HSV DNA PCR of the CSFTx: Acyclovir 10 mg/kg per dose q8 for 2-3 wks
HSV MRI findings
Note left temporal lobe involvement
EBV
Adolescents and young adults
Fever, altered mental status, headache, seizures, focal neurologic deficits
Dx: EBV DNA by PCR of the CSF
M. pneumoniae
Fever, headache, vomiting, seizures, altered level of conciousness
Dx: CSF or brain tissue PCR + culture; serology
Cat- Scratch Disease
B. Henselae
Both CSF exam and brain imaging results usu are normal
Dx: detection of antibodies in the serum
Most patients recover w/o tx in 1-3 mns.
Rabies
75% of children develop illness within 3 mns of exposure
Fever, sore throat, chills, malaise, dyspnea, cough, paresthesia at inoculation site, paralysis, hydrophobia, delirium
Fatal
Acute Disseminated EncephalomyelitisPostinfectious encephalitisAltered level of consciousness, fever, headache,
neck stiffness, CN abnormalities, ataxiaMRI: multifocal, patchy, high signal lesions on
T2-weighted images (white matter > gray matter)Inc CSF WBC but no oligoclonal bands
suggestive of MSMonophasic (vs MS)Tx: high dose glucocorticoids
ADEM MRI
Bilateral asymmetric lesions with open ring enhancement characteristic of demyelination
Initial Laboratory Testing
Cerebrospinal Fluid
● Glucose, protein, cell count, differential count
● Routine bacterial culture
● Viral culture
● Herpes simplex virus polymerase chain reaction (PCR)
● Cryptococcal antigen
● Enteroviral PCR
● Mycoplasma PCR
● Tuberculosis culture and PCR
● Epstein-Barr virus PCR
● West Nile virus immunoglobulin (Ig) M
Blood
● Bartonella henselae Ig G
● Epstein-Barr virus serology panel
● Lyme IgG (in endemic areas if cranial neuropathy present)
● Mycoplasma IgM
● West Nile virus IgM (during mosquito season)
● CBC with dc
● Serum to be saved for comparison with convalescent specimen
Other
● Viral cultures of nasopharynx and stool
● PPD
Course in the PICU
EEG showed status epilepticus: improved on Fosphenytoin, VPA and Levatiracetam
However, seizures recurred and pt was placed on Pentobarbital coma.
Started on Acyclovir, Ceftriaxone, and Vancomycin
Cultures negative- CFTX and Vanco stoppedStarted on Moxifloxacin x 7 days to cover for
intracellular atypical bacteria causing CNS disease (due to inc LL opacity and fever and concern for Mycoplasma)
On week 2 of PICU stay, patient was started on IVIG (12mg/day) x 5 days
Needs convalescent mycoplasma serology, CSF state enceph panel follow up
For MRI/ MRA
References
Kennedy, PGE. Viral encephalitis: causes,
differential diagnosis, and management. J Neuro
Neurosurg Psychiatry 2004;75: i10-15.
Lewis, P and C Glaser. Encephalitis. Pediatrics
in Review 2005 26; 26: 353-363.