Pediatric Encephalitis

[Praziquantel86]

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Another case:

Six year-old Asian male came to the ED complaining of diffuse abdominal pain (8/10), nausea and vomiting. No past medical history, immunizations are all up to date. No recent travel out of the country, although his parents were born in China. No contributing family history. His parents own a local sushi restaurant, and he spends a lot of time there. Parents have no similar symptoms.

Admitted to the floor for the standard workup. Spent a day there, then was transferred to the PICU after developing a bizarre neurological symptom, where his eyes and forehead were locked in an upward gaze. Rest of neuro exam is normal. CT scan showed signs of mild encephalitis, so he was started on acyclovir, vanco and ceftriaxone. Tests for enterovirus and herpesvirus were negative, blood cultures show no growth. LP is done, few RBC and protein of 150. No elevated white count, slightly increased bands. The patient is still talking in full, coherent sentances at this point, and aside from a headache and the eye issue, no significant major symptoms.

Patient is electively intubated for an MRI, which shows no lesions and slight signs of encephalitis. Extubated with no problem, returned to the PICU. Over the course of the afternoon, neuro function decreases. He begins responding to questions with one word answers, and is unable to follow commands. Slightly later, he seizes and has a cardiac arrest. Labs show Na of 123, CO2 of 100 and pH of 6.9. White count is elevated to 23, with 27% bands. He is reintubated, and resusciated after two shots of epi and chest compressions. Repeat MRI shows massive cerebral edema and multiple lesions in the brain indicitave of diffuse demyelination. Neuro exam has a complete loss of deep-tendon reflexes and flaccid paralysis. Intubation was reported to be difficult due to a tightly clenched jaw. EEG shows minimal brain function.

He is started on hypertonic saline, acute spinal injury protocol methylprednisolone and IVIG. Neurosurgery was consulted, but won't take the case. Repeat EEG several hours later shows mild improvement.

Any ideas?

 

[Old Timer]

Spinal tap and look for parasites.....

 

[Praziquantel86]

Spinal tap and look for parasites.....

They won't do the tap with the elevated ICP.

 

[avuong]

http://pediatrics.aappublications.org/cgi/content/abstract/120/2/305

 

[group_theory]

You have to work on your presentation. Lab values are all over the place, and you are excluding or ignoring certain numbers which are important.

Admitted to the floor for the standard workup. Spent a day there, then was transferred to the PICU after developing a bizarre neurological symptom, where his eyes and forehead were locked in an upward gaze. Rest of neuro exam is normal. CT scan showed signs of mild encephalitis, so he was started on acyclovir, vanco and ceftriaxone. Tests for enterovirus and herpesvirus were negative, blood cultures show no growth. LP is done, few RBC and protein of 150. No elevated white count, slightly increased bands. The patient is still talking in full, coherent sentances at this point, and aside from a headache and the eye issue, no significant major symptoms.

Admited to the floor for standard workup of what? Abdominal pain? Sepsis? Acute abdomen? Dehydration?

Patient was transfer to the PICU for just change of neurological symptoms? Is that the only reason - for more frequent neurological checks? Any other concerning symptoms like hemodynamic instability, respiratory distress, etc?

And you said the rest of the neuro exam is normal except for eye gaze and "forehead" gaze? What exactly is a forehead gaze? And can you describe the eye gaze better (more details please). And neurological examination was done that was supposedly normal - but what was checked? Cranial nerves? Mini-mental? Motor? Sensory? Reflex? Cerebellar functions? Was an EEG done at this point to look for status epilepticus?

And how can a CT scan show evidence of encephalitis?
And the LP was done - was it a bloody tap? You reported RBC and protein but what about the other values - nucleated cells, differentials, glucose level - kinda important to know these values.

You mentioned no elevated WBC but increased bands - is this a CBC or from the LP (it's unclear from your presentation)

Patient is electively intubated for an MRI, which shows no lesions and slight signs of encephalitis. Extubated with no problem, returned to the PICU. Over the course of the afternoon, neuro function decreases. He begins responding to questions with one word answers, and is unable to follow commands. Slightly later, he seizes and has a cardiac arrest. Labs show Na of 123, CO2 of 100 and pH of 6.9. White count is elevated to 23, with 27% bands. He is reintubated, and resusciated after two shots of epi and chest compressions. Repeat MRI shows massive cerebral edema and multiple lesions in the brain indicitave of diffuse demyelination. Neuro exam has a complete loss of deep-tendon reflexes and flaccid paralysis. Intubation was reported to be difficult due to a tightly clenched jaw. EEG shows minimal brain function.

What was the exact MRI findings? Were there leptomeningeal enhancement or other findings?

And the labs after the cardiac arrest - I assume it's from an i-stat although you don't mentioned it. Was that done during a code or immediatley afterwards? Is it from arterial or venous? Did the patient show signs of respiratory distress or respiratory irregularities prior to the code? What's the bicarb and base deficit? And did someone get a serum glucose level?

Also important is why is he so severely hyponatremic? What was his previous sodium level? How quickly did it drop? Why is he hyponatremic?

And MRI showing massive cerebral edema makes sense with the hyponatremia. The loss of deep tendon reflex does not. And the EEG - was that done while the patient was intubated and sedated?


If you want a good differential of what could be going on - you need to present a better history of present illness besides "abd pain, n/v". What part of the country is he from? What time of year is it? Any recent tick bites or mosquito bites? Any rodent exposure? Any accidental ingestions?

You are asking "any ideas" but leaving large gaps in the story. You want to give enough information to generate a focus differential - otherwise people will give you random causes of pediatric encephalitis (and I'm still not convinced from what you presented that it is encephalitis)

And is this a real situation, a mock situation, or a case study? And just curious - have you spent any time yet with a medical team rounding (either on the floor or ICU)?

 

[Praziquantel86]

You have to work on your presentation. Lab values are all over the place, and you are excluding or ignoring certain numbers which are important.

Sorry for the poor presentation...I'm doing it from memory so I don't have all the information in front of me.

He was admitted for the workup of abdominal pain, as far as I know the neurological status changes were the reason for the transplant to the PICU. There was no hemodynamic instability at the time, although that later developed (sorry, that was a big omission. I just completely forgot on that one). From what I remember, he was prone to tachycardia, with swings up to about 150 or so. He was started on labetalol for HR control. No respiratory distress.

His eyes were locked into an upward position. Almost as if he were straining to see something directly above him, without having to move is head up or down. He was oriented to person place and time, and was able to converse with his parents. This information wasn't on rounds, so I didn't hear the full workup. The changes noted later (also not on rounds) were reported as a change from baseline. The EEG was performed to check for seizure activity. As far as CT goes, the radiology report indicated mild inflammation. The neuro resident interpreted this as consistent with encephalitis.

The LP was not a bloody tap. All other values were within the institution's reference ranges (I don't have the exact values, I only remembered the abnormal ones). The elevated white count was from the CBC, sorry about the confusion.

The neuro resident said that the second MRI had diffuse areas of demyelination, but not aligning with any infectious process she had ever seen. No leptomeningeal findings were mentioned.

The labs post cardiac arrest were venous blood, done after compressions were started but before epi was pushed. I don't remember the bicarb values or gap, just that pH value and CO2. Sodium levels had been at the low end of normal prior to that chem panel. Glucose was another thing I forgot to mention (sorry about that) was around 160. The EEG was performed after intubation.

As far as time and location go, early August and Western New York. Parents reported (and no one could find) signs of any insect or animal bites. ID doc couldn't identify and sick contacts or obvious reasons for an infectious source. They also were not sure that it was encephalitis, especially after the second MRI.

Again, I apologize for the poor presentation of the information. I'm new to this right now. I have done some rounding, both on the floors and ICU. Not much, but some. I'm still learning at this point.

 

[Bears683]

-What was his fluid and electrolyte status when he was admitted to the floor and did they try to put him on an IV line. If he was having symptoms of vomitting he may be dehydrated and put on IV. I'm thinking the demyelination could come from trying to correct the electrolyte status too quickly