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Ed,
Thank you for generating this discussion and providing follow-up on the case.  I had a very similar case recently here in the US.
 
A 5 year old female presented with altered mental status, hypothermia (33.8 celsius), and bradycardia (HR 47).  Her blood pressure was 96/64.  Her glascow coma scale was 9.  She had had intermittent fevers, headache, and abdominal pain over the preceding 3 weeks and had been seen by 4 different physicians (3 visits at our pediatric emergency department and 1 visit at a community clinic).  She had been given a 10 day course of amoxicillin initially for presumed strep pharyngitis (strep culture came back negative) and subsequently trimethoprim/sulfamethoxazole for possible UTI.  On her 2nd visit, she had a normal CBC (WBC 12.6), chemistry panel, liver function tests, and monospot.  On her 3rd visit, she had a normal urinalysis and abdominal x-ray.  On the day that I saw her, her mother reported she had vomited once and had had increasing lethargy and confusion.
 
She had a head CT in the ED which showed acute hydrocephalus which was thought to be most likely secondary to meningitis.  EKG showed a junctional rhythm, and the echo was normal. Her cerebrospinal fluid had 135 wbc (13 neutrophils, 81 lymphocytes, 6 monocytes), 1 rbc, glucose 23, protein 270.  Brain MRI  showed abnormal basilar meningeal enhancement with proteinaceous material involving multiple sulci as well as scattered areas of acute ischemic infarction.  She required an external ventricular drain for 4 days.  Pediatric infectious disease thought that the patient most likely had either tuberculous meningitis or partially treated bacterial meningitis.  She was treated for both.  Unfortunately, all of her cultures were negative.  She was discharged to a rehabilitation facility after a 17 day hospitalization.
 
Sara Skarbek, MD
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