Philippine Children's Medical Center

26th 3-in-1 Postgraduate Course

CHILD NEUROLOGY, CRITICAL CARE AND INFECTIOUS DISEASES: THE INTERSECTION

A multidisciplinary Approach to CNS Infection

July 10, 2014

To present a case of CNS infection and discuss the multidisciplinary approach in the management of CNS infection and its complications.

Objective

1. To recognize, diagnose and manage status epilepticus which is a usual co-morbidity of CNS infection.

2. To discuss CNS infections and its differential diagnoses.

3. To emphasize the different diagnostic modalities necessary in the approach of CNS infections.

4. To provide the current management of CNS infections and its complications.

5. To design a framework for the long term care of post-infectious cases with CNS complications by a multidisciplinary team.

Specific objectives:

ID: JBU,4/M from Bulacan admitted for the first time

CC: depressed sensorium HPI:

◦ 2-week history of fever (T max: 39.6 C) relieved with Paracetamol

◦ No other associated S/S◦ Fever persisted until 3 days PTA, there was

decreased appetite and increased sleeping time◦ Admitted in a local hospital. Imp: Kawasaki disease◦ Patient then developed GTC seizures. Diazepam was

given at 0.3mg/kg/dose.◦ Transfer to PCMC

Case Protocol

Past Medical History: unremarkable Family History: (-) PTB Social History: youngest of 5 siblings (only boy); enrolled

in Nursery class prior to illness Birth/Maternal History: non-contributory Developmental History: at par for age Feeding: eats regular table food 3x/day Immunization: completed EPI

During transfer, patient continued to have brief generalized tonic-clonic seizures without regaining consciousness. Travel time was approximately 30 minutes.

At the ER: PE: BP 125/80 CR- 128 RR-16 Temp- 38.1 C

◦ No dermatosis; Pinkish palpebral conjunctiva, anicteric sclerae, no CLN palpated, clear breath sounds, distinct heart sounds, no murmur; no hepatosplenomegaly; full and equal pulses, no cyanosis.

NE◦ Stuporous◦ No eye opening, minimal withdrawal to pain◦ Pupils 2-3mm EBRTL, normal fundoscopy◦ (+) corneals, (+) Doll’s◦ (+) withdrawal to pain bilaterally◦ (+) Babinski bilateral◦ (+) nuchal rigidity

At the ER, patient developed another GTC seizure. Another diazepam (0.3mg/kg/dose was given.

Case Protocol

Objectives1. To recognize, diagnose and manage status

epilepticus.

How would you manage the patient? Neurology (7-10 min)

◦ Define status epilepticus (convulsive/non-convulsive)◦ Discuss the algorithm for the management of SE

(based on the PCMC CNS algorithm)1st line: benzodiazepines2nd line: long-acting AEDs (Pb, Phy, VA, LEV)

3rd line: Refractory SE (ICU) (MDZ drip, Pentobarbital, Thiopental, Propofol)

◦ Define subclinical status and the role of EEG

ICU (2 min)◦ ICU admission◦ ABCs in the mgt of SE

Open forum (3-5min)

Moderator

After diazepam, patient continued to have seizures lasting for more than 5 minutes. He was loaded with Phenobarbital with a loading dose of 20 mg/kg/dose, then maintained at 5 mg/kg/day.

Patient’s sensorium continued to deteriorate. Patient still has no eye opening with extension of the right extremities on pain stimulation. Pupils were 2 mm SRTL, with no corneals and no Doll’s. He was intubated using a 4.5 tube at level 15 and was hooked to the mechanical ventilator.

Case Protocol

Objectives2. To discuss CNS infections and its differential diagnoses.

What is your impression of the case? Neurology (10 min)

◦ Diagnosis based on the neuro evaluation Anatomic: Etiologic:

Open forum (3min)

Moderator

Objectives3. To emphasize the different diagnostic modalities in CNS infections.

What diagnostic tests would you request to confirm your diagnosis?

Neurology (5 min)◦ CSF studies◦ Neuroimaging

◦ Neuroradiology (5 min) What neuroimaging would be appropriate in this case?

criteria based on stability, need for contrast, etc

Infectious (5 min)◦ What specific CSF exam would you request for? ◦ Other ancillary tests: CRP, ESR◦ TB work-up, work-up family

Open Forum ( 3 min)

Moderator

Objective4. To provide the current management of CNS infections, and the approach of a multidisciplinary team in handling the complications of CNS infections.

Upon admission to ICU:◦ VS, NVS, I/O were monitored◦ NPO; venoclysis was started◦ The following labs were done.

Case Protocol

CBC Results NV

Hb 85 120-180 g/L

Hct 0.292 0.37-0.54

RBC 6.12 4-6 x 1012/L

WBC 15.7 4-11 x 109/L

seg 74 50-70%

lympho 16 20-44%

mono 10 2-9%

platelet 552 150-450 x 109/L

Protime 14.1 secs.

Control 13.8 secs.

INR 1.03

Prothrombin ratio

1.02

activity 96%

aPTT 29.4 secs.

Normal 28 secs.

ESR 12 <15 mm/Hr

CRP 10.4 <6 mg/L

Blood chemistry

BUN 2.3 2.9-9.3 mmol/L

creatinine

29 80-115 umol/L

Na 131 135-145 mmol/L

K 4.5 3.6-5.5 mmol/L

Ca 2.33 2.2-2.55 mmol/L

TP 80 62-80 g/L

albumin 34 38-54 g/L

globulin 46 22-34 g/L

A/G 0.74 1.1-2.2:1

Urinalysis

color Yellow

turbidity Hazy

ph 6

Sp. gravity 1.02

pus 2-3

RBC 0-1

Amorphous urates

+

bacteria +

albumin -

Sugar ++

CXR: Bilateral pneumonia with consolidation, left; hyperaeration and lymphadenopathies

Initial CT scan (Nov. 26, 2013)call on the neurorad

Neuroradiologist to give his comments and impression with differential diagnoses. (5 mins.)

CT scan of the head◦ Ill-defined hypodensity is seen in the left basal

ganglia with mass effect on the ipsilateral ventricle.

◦ Ventricles are dilated. ◦ Meningeal enhancement is noted, particularly in

the basal cisterns.

Moderator

Neurology (5min)◦ Based on the CT, give your impression.◦ Recognizing signs of increased ICP◦ How would you manage the elevated OP?

Pharmacologic: decompressants, steroids ICU (3 min)

◦ Other pharmacologic agents: Totilac, hypertonic saline

◦ Non-pharmacologic: correction of blood gas, elevate head, fluids, hyperventilation

Open forum (3 mins.)

Moderator: A. Management of increased ICP

Opening pressure 30 cm H2O Normal value

color Straw-colored, clear

RBCcrenatednon-crenated

16.67 x 109/L0.100.90

WBC lymphocytes

10 x 109/L 100%

Sugar 1.10 mmol/L(12% of RBS)

2.78-3.89 mmol/L

Protein 138.7 mg/dl 8-32 mg/dl

GS (-)

AFB (-)

India Ink (-)

Culture Negative after 5 days

TB PCR negative

CSF studies

Neurology (3-5 mins.)◦ give basis for diagnosis

Infectious (5 min)◦ Current WHO recommendations

(Tabulate recommendations of WHO, PPS, PIDSP, CNSP)

◦ Can you rule out bacterial meningitis based on the CSF findings?

◦ Steroids Open forum (3-5min)

Moderator: B. Management of TBM

On the 16th day of the hospital stay, patient developed on and off low to moderate grade fever, desaturations, apneic episodes. Septic work-up was done.

Case Protocol

CBC

Hb 106

Hct 0.358

RBC 6.47

WBC 20.2

seg 76

lymphos 16

monos 1

eosinos 2

bands 6

platelet 391

Urinalysis

color Dark yellow, cloudy

Pus cells 3-6/hpf

RBC 0-1/hpf

Amorphous PO4 Few

bacteria Few

albumin Trace

Sugar +++

Budding yeasts with hyphae

++++

◦ Rpt CXR: consolidation of the right lower lung.◦ Blood culture: negative◦ Patient was shifted to Piperacillin-tazobactam, and

diflucan.

Discussants: ICU, Infx (5 mins.)

Moderator:C. Health-care associated infections

There was difficulty weaning the patient inspite of improving clinical and radiologic findings of the lungs. Patient remained vegetative with minimal eye opening, no regard, with roving eye movements. He also became quadrispastic.

What are the possible complications of TB meningitis? ( 3 mins. Each)◦ Neurology◦ Infectious disease◦ ICU

ModeratorD. Complications of TB meningitis

MRI of the brain (Jan. 3, 2014)

Neuroradiology (5 mins.)◦ Comments on the CT with extensive vasculitis,

hydrocephalus, abscesses (?) Patient was then referred to Neurosurgery

for the progressive hydrocephalus and development of abscesses(?)◦ Neurosurgery◦ Neurology◦ Infectious disease◦ (3 mins. Each)

Open forum (5 mins.)

Moderator:

Patient was referred to Rehabilitation medicine for PT and OT.

Medical management was continued. Patient was eventually weaned off and extubated.

He was discharged improved with the ff. PE and NE:◦ Awake, occasional smiling and crying◦ Decreased spasticity on all extremities, but no

purposeful movement◦ (+) Withdrawal to pain◦ Bilateral Babinski

Case Protocol

Objectives5. To design a framework for the long term management of post-CNS infectious cases with sequelae by the different members of the multidisciplinary team.

Neurology- AEDs Infectious- anti-koch’s Rehabilitation med Pediatric Palliative care

OPEN FORUM

Plans of the different services (15min)

Diagnosis Treatment Complications Long term care

Summary

After a month, MRI was repeated which showed resolution of the abscesses. Ventriculomegaly persisted.

On follow-up, patient has no regard, with roving eye movement, smiles occasionally, sits with support in his wheelchair (with contraptions), fed per orem. He undergoes PT 3x a week, and OT 2x a week.

Update

The End