Pediatric Infectious Diseases City-wide Round

Dr. Daifallah Al MalkiFellow, Pediatric Infectious Diseases

Department of PediatricsCollege Of Medicine

King Khalid University HospitalKing Saud University

Octobe 16, 2012

Patient’s History15 month old Saudi boy admitted on 06/05/12 Presented with: Fever Vomiting Loose motion for 5 days

Patient’s HistoryNo skin rashNo contact with sick patient or travelling history Systemic review unremarkableNo previous medical or surgical problems

History

Normal neonatal historyDevelopmental and vaccination history up to ageHas other two-siblings –normal, consanguineous parents

HistoryPatient was seen 3 days prior to admission in ER with: Same complaint History of lower back discharge

Course In the ERThe patient was seen again with the same symptoms

highly febrile, sick-looking and his first visit investigations including blood culture and urine culture were negative.

The ER team decided to do lumber puncture before starting antibiotics so CT brain and spine X-rays were done.

Lumber puncture was done and pus was coming out, thus the patient was admitted to PICU and started on ceftriaxone and vancomycin.

Patient

Work Up In PICUCT-brain/spine done on admission…. CSF study on 6/5 : PUS cells ??? G.stain – G+ve cocci + G-ve rod Culture – TF

ConsultationSeen by I.D. team on 07/05 ..Patient was clinically stable, afebrile, conscious, active on room air Neck stiffness , increase reflexes,Dimple dry no discharge Impression -meningitis - possible collection with tract connection. Advice- -MRI- brain/spine -continue same antibiotics -neurosurgery consult

Course in hospitalRemained stable, afebrile, room air, till early morning of 08/05 at 3AM patient spike 38.5 ,HR 150-210b/min BP 125/80Again at 5.30 AM , HR 210 , T 39.3 BP 145/75 with mottling Skin poor perfusion weak pulses irregular breathing so patient intubated connect to M.V. given 3 boluses of Ringer Lactate Inotropic agents. Antibiotics changed by picu to tazocin and vanco.And urgent CT brain/spine.

CT Spine showing dermal sinus tract communicating the skin to the thecal sac

CSF Culture:….. 1.) Bacteroides Fragilis

2.) Streptococcus milleri 3.) Staph.epidermidis.

BLOOD CULTURE : 6/5 and 8/5 -- Negative

Urine c/s -- negative

I .D. F/Uon 8 /5 seen by I.D. team as f/u…Impression: Polymicrobial meningitis with possibility of local collection at lower spine with tract connection need further study. Advice: 1- Repeat CSF study from ant. fontanelles 2- Stop tazo 3- Start meropenem + vancomycin + metronidazol 4-MRI brain/ spine

MRI lumbo-sacral spine Sagittal T2WI showing high signal intensity space occupying lesion in the conus medullaris and lumbar thecal sac (arrow) and the dermal sinus tract (double arrows)

MRI lumbo-sacral spine Sagittal T1WI pre (A) and post contrast (B) showing low signal intensity space occupying lesion in the conus medullaris and lumbar thecal sac which is peripherally enhanced in post contrast sequence

MRI cervical / thoracic spine Sagittal T1WI post contrast (c) showing diffuse leptomeningeal enhancement surrounding the spinal cord

A B C

MRI brain axial T1WI post contrast showing diffuse meningeal enhancement (arrow) as well as enhancement of 5th cranial nerve (double arrows) indicate diffuse meningitis

Radiology Results:

MRI-brain / spine Spine- finding goes with intraspinal mass lesion (dermoid) with dermal sinus complicated by abscess formation in the lower spinal canal and meningitis (spinal,brain) .

Laboratory findings:NEUT. PLT HB WBC DATE

79% 186 10 15.8 7/5

63 196 8.2 18.5 8/5

77 177 8 18.6 9/5

transfusion

75 221 7.5 17.2 10/5

92 218 15.1 42.2 11/5

74 260 14.2 24 12/5

LABORATORY FINDINGS:

Sugar Alb CL K Na Creat.

Urea Date

8.4 21 100 4.5 137 41 3.6 8/5

24 130 43 3.1 10/5

14.2 22 143 3.1 173 48 2.8 11/5

41 17 144 2.7 184 89 3.3 12/5

CSF on 8/5 – from Anterior fontanelle : Clear WBC 15 , RBC 20 , Polymorph 30% ,lymphocyte 70%, G.S. – NOS, Culture – No growth.

CSF on 10/5 - L.P. : Bloody sample WBC 10, RBC 1280, lympho 100% , G.S. - NOS, culture – no growth.

CoursePatient continue s to deteriorate since early morning of 8/5 with deterioration of GCS According to MRI finding on 9/5 Patient taken to OR on 12/ 5 Drainage of abscess formation in the lower spinal canalAnd sacral sinus excision = laminectomy of L 3 , 4 , 5 Patient received from OR showing 2hr later sign of increase ICP, HTN, bradycardia ,.Patient on same day arrested 2 times , on the 2nd time at 23.06pm of 12/5 He did not respond to resuscitation.

Final diagnosis

Polymicrobial meningitis with infected dermoid cyst + dermal sinus complicated by abscess formation in the lower spinal canal and meningitis (spinal, brain).