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.