"parents see some petecchia and the child becomes somnolent.The
> child is brought to the ED of a community hospital at 1h30 pm, where
> bloodculture and LP are done and antibiotics are started"
At this point as an ED physician, I would NOT do an LP right away because
of the AMS.
The differential diagnosis of such a presentation is meningococcemia, viral
meningoencephalitis, RMSF, Ehlrichiosis. The causes of AMS in the setting
of meningococcal meningitis are many......"shock" which later you said was
not present; RAISED ICP with diffuse cerebral edema or acute
hydrocephalus; hypoglycemia from stress/sepsis, hyponatremia from SIADH,
"post ictal" but no seizure activity is noted.
So basically, unless I can exclude a pre-herniation state causing
somnolence it is prudent to give antibiotics and then get a CT first and
Moreover, I cannot exclude a coagulapathy from DIC which would also lear me
away from a spinal tap.
"In the following hour, the neurologic situation of the child is described
in varying terms, from "passive" to "not reacting to pain", but there is
> no clear evolution from better to worse."
Sounds like if he is unresponsive to pain, the level of coma is deepening.
Do we know what the state of his pupils, respiratory pattern etc were
during this period?
"pulse rate is remaining quite constant at 105/min"
This is actually "relative bradycardia". With a fever of 39C and sepsis his
heeart rate should have been higher. Thh imporatant point is the trend of
HR. If it was 160 earliar and is now 105 coupled with the HTN this is
"The CT is interpreted as normal"
This is not unusual, since the patient sounds like herniated sometime in
CT. The fixed dilated pupils with flaccid coma suggests tonsillar
herniation at the brain stem level. The other possibility is vascular
thrombosis at the brain stem level. Both these may not be detected by CT
but could be by MRI as you stated below
"possibly some sign of herniation through the foramen
> magnum;" I have also seen lateral sinus thrombosis causing acute
elevation in ICP and herniation. Do you know what the cranial venous
sinuses looked like on MRI??
Rennick et al from Australia [BMJ 306(6883):953-955] retrospectively
reviewed all post mortem herniations amongst their meningitis cases. Out of
400 odd cases 19 heniated and 36 % had normal initial CT's! Also 12 or 13
occured within 12 hours of the LP (OR of 32.6!!) suggesting that LP may
have been causally related to the herniation.
Hindsight is 20-20, but I wonder if the deterioration within 1 hour of the
LP in your case was due to the LP???
Jay Pershad, MD
"Every noble thought in your mind brings you closer to God"
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