R.R.

3 year old child, male, Filipino Catholic; born on May 13 2008 currently residing in Antipolo Rizal admitted for the first time in our institution last October 27, 2011. .

fever

22 WEEKS PTA 21 WEEKS and 6 days PTA

Swimming with his family in a public pool

Sudden onset of mild pain on the left ear (+) colds (+) undocumented on and off fever Self-medicated with Paracetamol Fever did not subside No consult was done.

Persistence of the above condition, until..

19 WEEKS and 2 days PTA

(+) on and off fever (+) colds (+) ear pain became quite severe (+) non-foul smelling ear discharge, left (+) hearing difficulties, left Brought to Unciano Medical Center Diagnosed with Otitis Media Admitted for three days and discharged with stable vital signs and without any subjective complaints (+) wading gait. (+) Consultation was done with private physician o advised cranial CT scan, however not done oParents opted to observe patient.

1 WEEK PTA

5 days pta

slipped while running and accidentally bumped his forehead against the floor (+) lump was noted (-)bleeding (-)headache (-)dizziness (-) vomiting or fever No consult was done. Patients mother claimed that his child get bumped his head a lot and usually come out just fine. (+) recurrence of ear pain, left (+)fever documented as 39 C (+) took Paracetamol 250mg/5ml, every 4 hours which temporarily lyses the fever. No consult was done.

2 days PTA

1 day pta

(+)ear pain (+)fever (+) drowsiness (+)dizziness (+)1 episode of vomiting (+)sudden onset of upward rolling of eyeballs with stiffening of extremities lasted for 3 to 5 minutes brought to Antipolo Doctors Hospital. o diagnosed with Benign Febrile Seizure secondary to Otitis Media. o given Co-Amoxiclav at 136 mkd every 8 hours o Paracetamol at 10mkd o Diazepam 0.2mkd PRN. Parents opted to transfer to our institution

Morning pta

(+) apneic with dilated pupils (+) tachycarddic (heart rate of 146 bpm) hence intubated.

Patient was advised transfer for ICU admission in our institution.

Diagnosis Otitis Media

Year 2011

Hospital Unciano Hospital

Medication Unrecalled antibiotics

No

Asthma No Phenylketonuria No Allergy No history of surgical operation.

delivered full term via Normal Spontaneous Delivery unrecalled birthweight last May 13, 2008 in Antipolo Doctors Hospital No fetal complications.

born to a 33 year old mother G4P4 (4004) had regular prenatal checkups initially seen at 8 weeks Age of Gestation had regular intake of multivitamins and ferrous sulfate throughout pregnancy no maternal complications.

 breastfed

for 6 months shifted to milk formula (Bona) Weaning started at 6 months of age Fond of eating fish and junk foods.

(+) (+) (+) (+) (+) (+) (+)

BCG at birth Hepatitis B 1, 2 and 3 DPT 1, 2 and 3 OPV 1, 2, 3 HIB Measles MMR

4 months: was able to reaches and grasps and look for sound source 6 months: responds to name, sits without support 9 months old: holds bottle 12 months: stands and walks alone, searches for hidden objects 16 months: crawls upstairs 2 years old: runs well, toilet trained by day, stands in one foot momentarily 3 years old: rides a tricycle, says 3 word phrases

(+) PTB on Maternal side (-) Hypertension (-) Diabete Mellitus (-)Heart disease (-)Cancer (-)Asthma (-)Allergy

Patient lives with his family. Mother: a housewife Father: a driver Youngest and the only boy among the 4 children has 3 siblings:
Eldest: 11 years old 2nd : 8 years old 3rd : 7 years old

active and playful. No recent travel in provinces and abroad.

General: No weight loss, No chills, (+) fever Skin: No rashes No lesions No pruritus EENT: No visual difficulties, No sore throat, (+) tinnitus, (+) ear discharge, Left, No epistaxis Respiratory: No cough Gastrointestinal: No nausea, no diarrhea, no abdominal pain Genitourinary: No dysuria Musculoskeletal: No muscle pain, no joint pain Neurologic: Presence of seizure, dizziness

 General:

Well developed, Intubated and Comatose Vital Signs:

BP: 90/60 mmHg PR: 110 bpm RR: 30 (MV) T: 35.0 C Wt: 11 kg (Below 50th Percentile) Ht: 95 cm (Above 85th Percentile)

Skin: No rashes, no lesions, warm to touch, no mottling HEENT: anicteric sclerae, pink palpebral conjuntivae, (+) dry lips, (+) Cervicolymphadenopathy, Bilateral, (+) yellowish ear discharge, Left Chest/Lungs: (-)symmetrical chest expansion, (-) retractions, (+) apneic, (+)equal breath sounds Heart: adynamic precordium, No precordial bulge, normal rate and regular rhythm, (-) murmur.

 Abdomen:

flat, normoactive bowel sounds, soft, (-) tenderness, (-) organomegaly N/A.

Genitourinary: Extremities:

No deformities, (-) cyanosis, (+) warm extremities, full pulses, no edema, extremities does not withdraw to pain

Neurological Exam:
Cranial Nerves: I: N/A II: 5-6 mm equal size, fixed dilated III, IV, and VI: (-) dolls eye movement V: (-) corneal reflex, bilateral VII: (-) facial assymetry VIII: N/A IX and X: No gag reflex on ET tug XI: N/A XII: N/A

: 1/5

Motor:
1/5 0

Sensory:
0

Reflexes:

1/5

1/5

Reflexes: (+) hyporeflexia (+) Babinski, Left (-) Clonus Signs of Meningeal Irritation: (-) Kernig (-) Brudzinski

year old male Fever Diagnosed case of Otitis Media Wading gait Frequent head trauma Drowsiness Dizziness 1 episode of vomiting 2 episodes of seizure with stiffening of extremities lasting for 3 to 5 minutes: (+) family history of PTB on Maternal Side

Physical Examination: Intubated comatose Apneic Dilated pupils (+) Papilledema, Bilateral Tachycardic Hypothermic (+) dry lips (+) Cervicolymphadenopathy, Bilateral (+) yellowish ear discharge, Left (+) warm extremities extremities does not withdraw to pain

Neurologic exam: II: 5-6 mm equal size, fixed dilated III, IV, and VI: (-) dolls eye movement (-) corneal reflex, Bilateral (-) facial asymmetry (-) gag reflex on ET tug (-) nuchal rigidity Motor: No spontaneous movement Sensory: loss of sensory Refelexes: (+)hyporeflexia, (+)Babinski, Left GCS: 3/15

Cranial CT Scan with Contrast Diffuse Cerebro-cerebellar edema with impending uncal, transtentorial and tonsillar herniation Undue pachymeningeal density and enhancement are suggestive of infection/inflammatory process as in Meningitis Incidental finding of Otomastoiditis, Left Chest APL Portable X-Ray Atelectasis, Left Concomitant Pneumonic Consolidation is considered Pleural Effusion, Left Magnified Heart

Chronic TB Meningitis is considered based on the following salient features: Age of the patient (3 years old) Febrile episodes Focal Neurologic deficits Cranial nerve deficits Changes in Sensorium Family history of PTB Positive Exposure of PTB Presence of Papilledema, Bilateral Presence of Cervicolymphadenopathy, Bilateral

Cranial CT Scan with Contrast Diffuse Cerebro-cerebellar edema with impending uncal, transtentorial and tonsillar herniation Undue puchymeningeal density and enhancement are suggestive of infection/inflammatory process as in Meningitis Incidental finding of Otomastoiditis, Left No BCG Vaccination Scar

 Examination and culture of the lumbar CSF CSF leukocyte count: 120 cells/mm3 (10 to 500 cells/mm3) Lymphocytes predominate CSF glucose: 19.08 mg/dl (<40mg/dl) Protein level: 110 mg/dl

Rule In

Rule Out

Age of Patient: 3 year old child Diagnosed with Chronic Otitis Media, history of head trauma Presence of focal neurologic deficits Presence of Papilledema, bilateral Pupilary changes and Change in level of consciousness: drowsiness to coma. Had nonspecific symptoms such as fever, dizziness, seizure and vomiting. Lumbar Puncture revealed an elevated WBC and protein and a low glucose level.

No abscess formation found in the CT Scan.

Rule In

Rule Out

had alteration of mental status (comatose), (+)seizure (+) Brudzinski sign (+) apnea (+) fever (+) focal neurologic deficits
cranial nerve palsies gait abnormalitie loss of sensation and movement.

CSF findings showed elevated protein, low glucose level and increased leukocytes, particularly lymphocytes. blood culture revealed no growth after 24 hours of incubation

Rule In

Rule Out

age of the patient clinical manifestation of:

vomiting Papilledema gait abnormality cranial nerve palsies Seizure reflex abnormalitie loss of sensation and movement.

It cannot be ruled out because MRI was not done. For primary brain tumors, MRI is the neuroimaging standard.

Hooked to PNSS Intubated ET5 L16

Labs Requested:
CXR CT Scan with Contrast CBC with Platelet count BUN Urea Na, K, Ca, Cl

Medication:

Admitted to ICU

Ceftriaxone IV Dopamine IV Phenobarbital 20m mkd IV

TB MENINGITIS

TB meningitis is most common in children younger than 6 years of age and usually appears 3 to 6 months after initial infection

Rapid progression tends to occur in infants and young children, who have symptoms for only a few days before the onset of hydrocephalus, seizures, and cerebral edema.
Clinical Course: First Stage: Personality changes, irritability, anorexia, listlessness, and fever Second Stage signs of increased intracranial pressure and cerebral damage appear, specifically drowsiness, cranial nerve palsies, and convulsions Third Stage coma and complete paralysis.

Meningeal signs are not essential for the diagnosis, and the neck is stiff in flexion in only one third of those affected. The PPD test is negative in 10% of the cases, and in 20% to 50% of patients, the chest radiograph yields negative findings. Cerebrospinal fluid (CSF) findings can be striking. Leukocytes: 10 to 500/cu mm, with more lymphocytes than neutrophils; Glucose level: 20 to 40 mg/dL (1.1 to 2.2 mmol/L) Protein level: can be elevated to greater than 400 mg/dL due to hydrocephalus and spinal block

Acid-fast stain and culture are unlikely to be positive if the sample size is less than 5 mL. CT scan and magnetic resonance imaging of the head can produce negative results in the early stages of infection, but as time progresses, they reveal hydrocephalus with signs of cerebral edema or infarction due to metastatic caseous lesions.

Multiple drugs must be used to overcome resistance, and drugs that have good CSF penetration should be used. The initial treatment regimen for drug-susceptible tuberculous meningitis consists of 2 months of isoniazid, rifampin, pyrazinamide, and streptomycin, followed by 7 to 10 months of treatment with isoniazid and rifampin. Therapy must be modified if the strain of Mycobacterium tuberculosis proves to be resistant by laboratory analysis or by failure of the patient to respond. Children who have tuberculous meningitis should be screened for human immunodeficiency virus infection. If they have this underlying condition, treatment may need to be modified.

THANK YOU!!!