Case presentation

Patient’s History

15 mo old saudi boy DOA 06/05/12 Presented with

fever vomiting

loose motion for 5days

Patient’s History

no skin rashno contact with sick pt , or travelling history systemic review unremarkableno previous medical or surgical problemsnormal neonatal historydevelopmental and vaccination history up to age

has other two-sablings –normal , unconsanguineous parents

Question..??

D. Diagnosis…

Patient’s History

Patient was seen 3 days back in ER same complain

lower back discharge

Examination

On 03/05…… stable . Dehydrated , v/s- T-38.2

Meningeal signs?- Redness over lower back Yellowish to green discharge Sacral dimble –drayWbc 20.4 , Neut. 73%

Hb 10.5 PLT 473

blood c/s –no growth Urine – n

Treatement.…

Any idea.……

Examination

on 06/05…… lethargic , sick , dehydrated

v/s- T- 39CNS ..neck stiffness , increase reflexes in U. , L. limb

CT-brain and spine CSF STUDY :

On 6 / 5 L.P. ---- PUS cells G.stain – G+ve cocci

Culture – TF CBC … 15.8 -- Neu. 79% PLT 186

Ceftriaxon + vancomycin

picu

For I.D. Consultation……

Consultation

Seen by I.D. team on 07/05 ..pt was clinically stable , afebrile , conscious , active on room air

nick stiffness , increase reflexes , dimble dray no discharge

impression – possible collection with tract connection.

- meningitis advice- continue same medication

- MRI- brain , spine seen by neurosurgery on call 6/5 advice for MRI brain /spine

Radiology

CT-brain and spine without contrast on admission:

bilat.decrease cerebral white matter with prominent ventricular system goes with hypoxic ischemic insult - no evidence of increase ICP or HGEOr mass lesion

Spine-preserved disc spaces – spina bifida at sacrum.

Coarse in hospital

Remain stable, afebrile , room air , till early morning of 08/05

at 3am pt spike 38.5 , HR 150-210b/min BP 125/80 ….so kept NPO , paracetamol given

HR 130 , BP 110/70 , T 37

So antibiotics changed by picu to tazocin and vancoAgain at 5.30 am , HR 210 , T 39.3 BP 145/75 with motlling skin poor perfusion weak pulses irregular breathing so pt intubated connect to M.V. given 3 boluses of R.L .Inotropic agents.

For I.D. Follow up..…

Lab Report On 8 / 5………

B. Fragalis + S. millarae + Staph epid.

I .D. F/U

on 8 /5 seen by I.D. team as f/u…Immpresion :

polymicrobial meningitis with possibility of local collection at lower spine with tract connection need further study.

Advice: 1 -Repeat CSF study from ant. fontanelle

2-stop tazo 3-start meropenem + vancomycin +

metronidazol 4-MRI spine

ECHO – N CSF on 8/5 – from Anterior fontanelle:

clear WBC 15 , RBC 20 ,

polymorph 30%, lymphocyte 70% ,

G.S. – NOS , culture – no growth.

CSF on 10/5 - L.P: . Bloody sample

WBC 10 , RBC 1280 , lympho 100%,

G.S. - NOS , culture – no growth .

coarse

Pt continue deteriorating since early morning of 8/5 with deteriorate of GCS

According to MRI finding on 9/5 pt taken to OR on 12/ 5

for abscess drinage and sacral sinus excision = laminectomy of L 3 , 4 , 5

Done after dropping of GCS from 7/15 to

3/15 Pt received from OR showing 2hr later sign of

increase ICP HTN , bradycardia., Pt on same day arrested 2 times , on the 2nd time at 23.06pm of 12/5 he did not response to resuscitation.

Radiology 1-CT- brain without contrast and spine on

admission 6/5 ….. bilat.decrease cerebral white matter with prominent ventricular system goes with hypoxic ischemic insult - no evidence of increase ICP or HGEOr mass lesionSpine-preserved disc spaces – spina bifida at sacrum.

2 -CT – brain and spine on 8/5:

Spine- track extending from skin in the sacral region to the spinal canal , need MRI for further evaluation.Brain- hemorrhage in Lt lateral ventricule with increase density along the right side of the falx suggest subdural hemorrhage .

Radiology

MRI-brain / spine on 9/5: spine- finding goes with intraspinal mass

lesion (dermoid) with dermal sinus complicated by abscess formation in the lower spinal canal and meningitis (spinal,brain).

brain- evidance of small subdural and intraventricular hemorrhage.

Also images of lower spine shows subcutaneous soft tissue swelling with sinus tract extending from the subcutaneous tissue to the spinal canal at the level of the sacral vertebrae S3 associated with spina bifida.MRV- no evidence of dural sinus thrombosis.

Radiology

CT- brain on 12/5: generalized brain edema with

hemorrhage in Lt lat. Ventricule and subdural hemorrhage and mild subarachnoid hemorrhage in right frontal lobe.

Lab findingNEUT. PLT HB WBC DATE

79% 186 10 15.8 7/5

63 196 8.2 18.5 8/5

77 177 8 18.6 9/5

transfusion

75 221 7.5 17.2 10/5

92 218 15.1 42.2 11/5

74 260 14.2 24 12/5

LAB

Sugar Alb CL K Na Creat.

Urea Date

8.4 21 100 4.5 137 41 3.6 8/5

24 130 43 3.1 10/5

14.2 22 143 3.1 173 48 2.8 11/5

41 17 144 2.7 184 89 3.3 12/5

Coagulation profile : 9/5 --- PT 13.7 - PTT 40.8

D-Dimer 3.45

12/5 --- PT 21.1 - PTT 35 Ratio 1.8

D-Dimer >20

BLOOD CULTURE : 6/5 and 8/5 -- Negative

Urine c/s -- negative S. Ammonia - 25

Final diagnosis

polymicrobial meningitis with infected dermoid cyst + severe cerebral edema and global brain ischemia + severe brain injury.