Dr.Rithwik Sunil, Dr.Praveena N B, Dr C Jayakumar
One year 7-month girl, of a non-consanguineous parentage , presented with complaints of altered sensorium and seizures following an acute febrile illness. History of high-grade fever and altered stools with blood was also present. History of similar complaints in sibling and children of neighbourhood were noted.She was on more than one antiepileptics from near hospital, intubated and referred to AIMS for further management.
Perinatal history were stormy with breech ,PROM ,LSCS prematurity andCPAP
But a ll milestones were attained as per age and immunised as per NIS schedule
CLINICAL EXAMINATION :
Child is afebrile, alert
Vitals:Temp-98F; Pulse-108/min ;RR-26/min ;SpO2-98% at room air BP-98/60mmhg.
showed no rashes, no significant lymphadenopathy, no peri anal excoriation. Auxology
Weight:10kg(btw 25th and 50th centile) Height: 75cm(less than 3rd centile) HC:44cm(btw 3rd and 10th centile)
Systemic Examination:
CNS examination :GCS E2VTM2 Bilateral pupils were equal and reactive.
P/A- soft non tender,. Bowel sounds normal
RS- URT- normal. No distress. NVBS, equal BL, chest clear.
CVS- S1, S2+, no murmurs
Differentials considered
Hemolytic uremic syndrome (HUS)
Inflammatory bowel disease
Shigella encephalopathy Salmonella infection with delirium
Heavy metal poisoning (e.g., lead)
Ingestion of toxic substances (e.g., certain plants, medications)
Hyperammonaemia (e.g., urea cycle disorders)
Hypoglycaemia
Investigations
Meningoencephalitis panel:No organism detected
CSF cytology :Normal
Respiratory virus panel : no organism detected
CULTURE URINE : No growth
STOOL CULTURE: No growth
STOOL ROUTINE EXAMINATION : normal
MRI BRAIN :Normal
Widal : Negative
Rapid Gastroenteritis Multiplex Test : Shigella/EnteroinvasiveE. coli (EIEC) :Detected
Course in the hospital:
At admissions she was sedated and intubated. Patient was initially admitted in PICU under Pediatric Neurology.GCSE2VTM2 at admission.
In view of an acute encephalopathy following a diarrheal/dysentery illness, a possibility of a Shigella toxin induced encephalopathy or an acute meningoencephalitis was considered. She was initiated on ceftriaxone and acyclovir
Stool multiplex PCR was positive for Shigella/EIEC.
She was extubated on day 3 of hospital stay. Serial blood count, CRP monitoring showed decreasing trend. She was afebrile during her stay in the ICU. She had no further episodes of blood in stools. She responded well to Ceftriaxone
Shigella Encephalopathy
Shigella infection is a common problem in developing countries. It is one of the major causes of mortality and morbidity particularly in children under five years of age. Encephalopathy, defined altered mental status, is a life-threatening presentation in children having shigellosis. The most common presentations of Shigella encephalopathy are seizure, altered consciousness and coma. If the treatment is delayed, deaths in children having Shigella encephalopathy are very high.
Ekiri syndrome or lethal toxic encephalopathy is a complication of shigellosis with dysentery, hyperpyrexia, seizures, headache and altered level of consciousness, which rapidly progresses to death. These children die at the beginning of the disease (8-48 hours from the beginning of symptoms), from brain edema. However they had no symptoms or signs of sepsis, dehydration, DIC or Hemolytic Uremic Syndrome (HUS).
Treatment:
1. Azithromycin: This is often preferred for children due to its safety profile and ease of dosing.
2. Ceftriaxone: This is used for more severe cases and is given via injection, particularly when oral antibiotics are not feasible or effective.
3. Ciprofloxacin: This antibiotic is sometimes used for older children and adults, but its use in younger children is more restricted due to potential side effects.
4. Ampicillin or Amoxicillin: These are sometimes used, but their effectiveness has decreased in many areas due to resistance.
5. Trimethoprim-sulfamethoxazole (TMP-SMX): This antibiotic is occasionally used, though resistance is also common in some regions.