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CHILD NEUROLOGY, CRITICAL CARE AND
INFECTIOUS DISEASES: THE INTERSECTION
A multidisciplinary Approach to CNS Infection
July 10, 2014
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To present a case of CNS infection and
discuss the multidisciplinary approach in the
management of CNS infection and its
complications.
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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.
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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
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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
Immunization: completed EPI
During transfer, patient continued to have brief
generalized tonic-clonic seizures without
regaining consciousness. Travel time was
approximately 30 minutes.
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At the ER:
PE: BP 125/80 CR- 128 RR-16 Temp- 38.1 C
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NE
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◦ 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.
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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.
1.
To recognize, diagnose and manage status
epilepticus.
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How would you manage the patient?
Neurology (7-10 min)
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ICU (2 min)
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Open forum (3-5min)
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◦ Define status epilepticus (convulsive/non-convulsive)
◦ Discuss the algorithm for the management of SE
(based on the PCMC CNS algorithm)
1st line: benzodiazepines
2nd 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 admission
◦ ABCs in the mgt of SE
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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.
2. To discuss CNS infections and its
differential diagnoses.
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What is your impression of the case?
Neurology (10 min)
◦ Diagnosis based on the neuro evaluation
 Anatomic:
 Etiologic:
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Open forum (3min)
3. To emphasize the different diagnostic
modalities in CNS infections.
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What diagnostic tests would you request to confirm
your diagnosis?
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Neurology (5 min)
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Neuroradiology (5 min)
◦ CSF studies
◦ Neuroimaging
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What neuroimaging would be appropriate in this case?
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criteria
based on stability, need for contrast, etc
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Infectious (5 min)
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Open Forum ( 3 min)
◦ What specific CSF exam would you request for?
◦ Other ancillary tests: CRP, ESR
◦ TB work-up, work-up family
4. To provide the current management of CNS
infections, and the approach of a multidisciplinary
team in handling the complications of CNS infections.
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Upon admission to ICU:
◦ VS, NVS, I/O were monitored
◦ NPO; venoclysis was started
◦ The following labs were done.
NV
Protime
14.1 secs.
Control
13.8 secs.
INR
1.03
CBC
Results
Hb
85
120-180 g/L
Hct
0.292
0.37-0.54
Prothrombin 1.02
ratio
RBC
6.12
4-6 x 1012/L
activity
96%
WBC
15.7
4-11 x 109/L
aPTT
29.4 secs.
seg
74
50-70%
Normal
28 secs.
lympho
16
20-44%
mono
10
2-9%
platelet
552
150-450 x 109/L
ESR
12
<15
mm/Hr
CRP
10.4
<6 mg/L
Blood
chemistry
BUN
Urinalysis
2.3
2.9-9.3 mmol/L
color
Yellow
turbidity
Hazy
ph
6
Sp. gravity
1.02
pus
2-3
RBC
0-1
+
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
Amorphous
urates
globulin
46
22-34 g/L
bacteria
+
A/G
0.74
1.1-2.2:1
albumin
-
Sugar
++
CXR: Bilateral pneumonia with consolidation,
left; hyperaeration and lymphadenopathies
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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.
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Neurology (5min)
◦ Based on the CT, give your impression.
◦ Recognizing signs of increased ICP
◦ How would you manage the elevated OP?
 Pharmacologic: decompressants, steroids
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ICU (3 min)
◦ Other pharmacologic agents: Totilac, hypertonic
saline
◦ Non-pharmacologic: correction of blood gas,
elevate head, fluids, hyperventilation
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Open forum (3 mins.)
Opening pressure
30 cm H2O
color
Straw-colored, clear
RBC
crenated
non-crenated
16.67 x 109/L
0.10
0.90
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
Normal value
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Neurology (3-5 mins.)
◦ give basis for diagnosis
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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
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Open forum (3-5min)
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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.
CBC
Urinalysis
Hb
106
color
Dark yellow, cloudy
Hct
0.358
RBC
6.47
Pus cells
3-6/hpf
WBC
20.2
RBC
0-1/hpf
seg
76
Amorphous PO4
Few
lymphos
16
bacteria
Few
monos
1
albumin
Trace
eosinos
2
Sugar
+++
bands
6
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platelet
391
Budding yeasts
with hyphae
◦ Rpt CXR: consolidation of the right lower lung.
◦ Blood culture: negative
◦ Patient was shifted to Piperacillin-tazobactam, and
diflucan.
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Discussants: ICU, Infx (5 mins.)
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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.
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What are the possible complications of TB
meningitis? ( 3 mins. Each)
◦ Neurology
◦ Infectious disease
◦ ICU
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Neuroradiology (5 mins.)
◦ Comments on the CT with extensive vasculitis,
hydrocephalus, abscesses (?)
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Patient was then referred to Neurosurgery for
the progressive hydrocephalus and
development of abscesses(?)
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Neurosurgery
Neurology
Infectious disease
(3 mins. Each)
Open forum (5 mins.)
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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
5. To design a framework for the long term
management of post-CNS infectious cases
with sequelae by the different members of
the multidisciplinary team.
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Neurology- AEDs
Infectious- anti-koch’s
Rehabilitation med
Pediatric Palliative care
OPEN FORUM
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Diagnosis
Treatment
Complications
Long term care
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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.