Dr.Ch. Venkat Kumar Raju, Dr. Praveena Bhaskaran, Dr. Vaishakh Anand, Dr.C. Jayakumar AIMS KOCHI
Three year 11-month-old fully vaccinated child presented with non-bilious vomiting associated with multiple episodes of large volume, watery and foul-smelling loose stools.
Sibling also had fever and was getting in patient care three days back .Child was on family pot diet and not using bottle
At admission child was
alert, conscious with stable vitals except fever of 104 degree and not dehydrated
Labs were normal
The child was initially managed with parenteral fluids fluids, Zinc and ORS
On Day 4 of illness, he had altered sensorium and stopped talking
The child was noted to have a GCS of 9 (E3V2M4)
Differentials
1.Venous thrombosis
- Shigella encephalopathy
- Viral Encephalitis
- Electrolyte imbalances
- 5. Renal failure
6.Autoimmune encephalitis
7.Toxin exposure
8.Japanese Encephalitis
Electrolyte imbalance and toxin exposure were ruled out.
A CSF Study was done, which showed mild pleocytosis,
Urine Culture was negative
Blood and stool cultures were negative
Serum NMDA, CSF NMDA negative Meningoencephalitis panel were negative
MRI Brain showed symmetrical areas of diffuse restriction seen in B/L cerebellar white matter
The child was given IVMP and IVIG suspecting Autoimmune encephalitis (due to sudden onset .
Video-EEG showed non-specific electrical dysfunction over B/L posterior head regions
The child was negative for JE.
Multiplex Stool PCR for stool came positive for Rota-Virus
The child was discharged after 10 days, still encephalopathic and on RT feeds
Diagnosed as
Rota Virus Associated encephalopathy with cerebellar mutism
Was on follow-up after 8 months
Currently came back to baseline, Speech still scanning a little bit, Going to Anganwadi
Efficacy of rota virus
Two clinical trials found vaccine to have 85 to 96% protection against severe rotavirus gastroenteritis through two rotavirus seasons (December through June).
One study found to be 96% effective in reducing hospitalizations through two rotavirus seasons.
Four oral, live, attenuated rotavirus vaccines, Rotarix™️ (derived from a single common strain of human rotavirus); RotaTeq™️ (a reassorted bovine-human rotavirus); Rotavac™️ (naturally occurring bovine-human reassortant neonatal G9P, also called 116E); and RotaSiil™️ (bovine-human reassortant with human G1, G2, G3 and G4 bovine UK G6P[5] backbone) are available internationally and WHO prequalified.
All four vaccines are considered highly effective in preventing severe gastrointestinal disease. In low income countries, vaccine efficacy can be lower than in industrialized settings, similar to other live oral vaccines.
Even with this lower efficacy, a greater reduction in absolute numbers of severe gastroenteritis and death was seen, due to the higher background rotavirus disease incidence.
It is given at 6,10 and 15 weeks , orally , dose of 5 drops
Maximum age group to administer vaccine is before seventh month
Rotavirus Infection associated CNS complications
- Benign convulsions with mild gastroenteritis
- Acute encephalopathies and encephalitis
Findings include
a. Mild encephalopathy with a reversible splenial lesion (MERS)
b. Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD)
c. Acute Necrotizing encephalopathy (ANE) - Acute cerebellitis
- Neonatal rotavirus-associated leukoencephalopathy
- Other rarer ones (Posterior reversible encephalopathy (PRES), Opsoclonus-myoclonus syndrome, Hemi convulsion-hemiplegia-epilepsy syndrome
Take Home message- While treating diarrhea in a child who goes encephalopathic, after ruling out meningitis and bacterial causes, always Consider Viral Diarrheal encephalopathies like Rota virus infection even the child is vaccinated.