Dr Adeena ,Dr Greeshma(Paed Intensivist),Dr Jayakumar
Department of Pediatrics,AIMS Kochi
Two month 20 day old male child ,known case of closed meningomyelocoele under follow up from outside health care facility presented with with high grade fever and noisy breathing of 1 day and 1st episode seizure lasting for 45 minutes.
The seizure was associated with fever, uprolling of eyeball,stiffening of all limbs.
The ba had been started on oral augmentin. When the seizure began,ba was taken to a local hospital loaded with midazolam and phenytoin and referred to AIMS.
No history of cough,fast breathing, chest retractions/abdominal symptoms /rashes. No history of alteration of sensorium at the onset
He is the first child of NCM.Mother was not folic active d prior to conception No history of poly hydramnios either
Ani natal scan didn’t pick up any anomaly
Born term/2.9kg birth weight. Closed spinal dysraphism was noted at birth,ultrasound spine showed cord terminating at normal level.
Development normal,social smile was present
Vaccinated upto 6 weeks age as per NIS
Exclusively breast fed ba
Family h/o-seizure disorder in maternal grandmother and is on AED.
O/E- Sick child
HR-156/min,peripheral pulse not palpable,central pulses not felt
RR- irregular repsiration with apnoea in between
CRT 4sec
Spo2-98%on 5 litre oxygen via mask
GRBS. 225mg/dl
GCS poor
Bulging AF
Bilateral pupils constricted, no reaction appreciated
Persistent perioral movements were present
Wt 4.5 kg, HC 39cm
Obtunded,pale and in shock.
Bradycardia and gasping noted.
Bag and mask ventilation followed intubation done with 4mm uncuffed Endotracheal tube ,air entry bilaterally equal.
IV NS Bolus was given.
ABG -ph6.47/pco2-203/po2-13.9/lactate 8.8/HCO3-13.9.
Following intubation the HR and peripheral pulses were picked up.spo2-97% on IPPV. IV noradrenaline, NaHco3 and 1 dose IV ceftriaxone was given.
IV 3 % NS and mannitol given.However he started developing sustained bradycardia refractory to adrenaline and CPR, desaturated progressively and went into cardiac arrest despite resuscitative measures.He also developed bleeding from nose and NG tube.
Ba was declared dead 50 mins after arrival to ER.No blood investigations could be done.
DD:
– meningitis with septoc shock and DI
-pneumonia with sepsis
-hydrocephalus with raised ICP
-status epilepticsu due to underlying structural brain anomaly
-IEM causing Status epilepticus
-IC Bleed
Post mortem Lp was done.
TC 200 Cells/mm3, glucose 107,protein 55
CSF c/s was sterile but CSF PCR showed enterovirus positive.
Hence the diagnosis of Enteroviral meningitis as a cause of death.
Enteroviruses are associated with HFMD in children.
However,sometimes it involves the CNS, and induces diverse neurological complications. The majority of patients with neurological complications of EV71 infection have been under the age of 5 years.
Neurological symptoms or signs appear within 3 to 5 days after the onset of fever or skin lesions or even without the skin or oral mucosal lesions typical of HFMD.
Some neurological manifestations are brainstem encephalitis, aseptic meningitis , brainstem encephalitis with cardiorespiratory dysfunction.EV71 brainstem encephalitis – occasionally induces autonomic dysfunction, such as fluctuating blood pressure and pulmonary hemorrhage/edema, due to the injury to the vasomotor center of the brainstem.
Most deaths caused pulmonary hemorrhage and usually occur within 24 hours after admission because the disease rapidly progresses to the critical stage.Gold standard for diagnosis is virus isolation via viral culture(7-10 days).Molecular sequencing using PCR also aids the diagnosis.
What is new
Pleconaril is an orally active antipicornaviral agent and inhibits replication of most isolated enteroviral serotypes.Treatment 15 mg/kg/day [children] in divided doses for 7 to 10 days) seems to be beneficial in some patients with severe or life-threatening enteroviral syndromes, including chronic enteroviral meningoencephalitis in agammaglobulinemic patients and possibly neonatal enteroviral sepsis.