A 2-year-old girl was admitted to the hospital from our emergency department with a 1-week history of intermittently grabbing at her head and intermittently screaming. Her parents had interpreted this behavior as a possible sign of a headache. As a result, she had been evaluated by her pediatrician and had been advised to start ibuprofen for the presumed headache and to return for further assessment if her symptoms did not improve.
The girl had no history of head trauma, and she remained
afebrile and did not display any other signs or symptoms of an infection. The
day prior to her presentation at the hospital, however, she had developed overt
disturbances of vision and an ataxic gait.
Two months prior to her presentation to the hospital, she
had had a partial complex seizure lasting 30 minutes. The seizure had occurred
after a febrile episode of acute unilateral atraumatic otorrhea, which had been
treated with an intramuscular injection of ceftriaxone, 50 mg/kg, and topical
antibiotic ciprofloxin and dexamethasone ophthalmic solution twice a day for 7
days. Because this had been her first provoked febrile seizure, laboratory
testing and imaging of her brain had not been performed at that time. Her
neurologic examination results had returned to baseline prior to discharge.
When the girl was admitted to our hospital, her vital signs
included a temporal artery temperature of 38°C, a heart rate of 110 beats/min,
a respiratory rate of 44 breaths/min, an oxygen saturation of 100% on room air,
and elevated blood pressure for her age of 121/70 mm Hg. Her weight was 13.15
kg, which was in the 65th percentile, and her height was 85 cm, which was in
the 20th percentile.
The child was sleepy, but she was easily arousable. She was
nonverbal with the physician, nurse, and her parents. During the physical
examination, she became irritable but was consolable when soothed by her
parents.
The girl had a head tilt to her left side, but there were no
signs of head trauma or head enlargement. She was noted to have a dysconjugate
gaze and right-sided exotropia. Her pupils were 3 mm in diameter and were
equally round and reactive. In addition, her extraocular muscles were intact.
Examination of the optic disk was not performed.
The findings of physical examination of her ears, nose, and
throat were unremarkable. Her tympanic membranes were nonbulging without overt
perforation, and her nasal passages were patent without congestion or
discharge. The results of an oropharyngeal examination were also unremarkable.
No trismus was noted. Examination of her chest, abdomen, and genitalia yielded
unremarkable results, and no obvious signs of abuse were present.
The patient could sit and stand without support, and her
upper and lower extremities had normal muscle tone and strength. When she was
asked to walk, her gait was noted to be asymmetric with a right-sided limp. Her
deep tendon reflexes were unremarkable at the elbows, wrists, and knees. A
Babinski sign was not elicited, and the examiner was unable to assess tandem
walking or signs of dysmetria.
The girl had a significant past medical history that
included a prior hospitalization at 13 months of age for cervical lymphadenitis
with profound neutropenia. At the time, her absolute neutrophil count was 80
cells/µL, her monocyte count was 2000 cells/µL, her hemoglobin was 10 g/dL, and
her mean corpuscular volume (MCV) was 75 µm3. The child’s parents declined the
hematologist’s strong recommendation for bone marrow aspiration. The anemia was
not further evaluated or treated after the girl had been discharged.
The child had remained well, without skin and soft tissue
infections, until her second hospitalization at 2 years of age for a complex
febrile seizure in the setting of spontaneous acute otorrhea. She had no past
history of recurrent acute otitis media or acute paranasal sinusitis.
She had been discharged from that hospitalization, and she
had had no subsequent medical problems or further laboratory testing performed
until the present admission.
The admission laboratory tests had many notable results. Her
total white blood cell (WBC) count was 9000 cells/µL. She was profoundly
neutropenic, with zero neutrophils, which was confirmed by a manual
differential WBC count. Her total lymphocyte count was 20 cells/µL, and her
monocyte count was 79 cells/µL. The child’s hemoglobin was 7.2 g/dL, and her
MCV was 64 µm3, indicating microcytosis. The red cell distribution width was
19%, and her reticulocyte count was 0.9% of red blood cells. Inflammatory
markers were extremely elevated, with the erythrocyte sedimentation rate at 142
mm/h and the C-reactive protein level at 330 mg/L.
The results of a computed tomography scan of the head
without contrast enhancement (Figure 1) showed an intracerebral mass located at
the right temporoparietal junction, with nonobstructive communicating
hydrocephalic enlargement of her right ventricle. She was quickly admitted to
the pediatric intensive care unit for placement of an external ventricular
drain.
Computed tomography scan of the head showed an intracerebral mass located at the right temporoparietal junction, with nonobstructive communicating hydrocephalic enlargement of her right ventricle.
A head and spine magnetic resonance imaging (MRI) scan with
gadolinium contrast was obtained , and it revealed a diffuse
inflammatory process of the meninges, reported as diffuse meningitis. An
intradermally placed tuberculin skin test was negative after 48 hours.
A head and spine MRI scan with gadolinium contrast revealed a diffuse inflammatory process of the meninges, reported as diffuse meningitis, confirming suspicion for an inflammatory process.
After an external ventricular drain was placed to remove the
excessive ventricular fluid, the cerebrospinal fluid (CSF) had a xanthrochromic
appearance. Spinal fluid cytology results included the following values: WBC
count, 43 cells/mm3; red blood cell count, 2850 cells/mm3; neutrophils, 32
cells/mm3; lymphocytes, 48 cells/ mm3; protein, 330 mg/dL; and glucose, 6 mg/dL. The CSF protein level was very high
and the CSF glucose level was very low, all of which supported the presence of
bacterial infection of the central nervous system.
The CSF neutrophil count was higher than the zero peripheral
blood neutrophil count. The preliminary Gram stain preparation did not contain
any pathogens. Results of blood cultures and stain preparations for common
bacterial pathogens, acid-fast organisms, and pathogenic fungi were negative.
On closer inspection of a stained specimen from the CSF
culture after 12 hours of incubation, small cocci and rods were visualized
within macrophages. Cultures from urine and throat specimens contained a light
growth of Streptococcus dysgalactiae. The final CSF bacterial culture report
stated that there was a light growth of S dysgalactiae susceptible to
penicillin, vancomycin, linezolid, and several cephalosporin antibiotics.
Prior to the positive CSF culture results, a 50-mg/kg dose
of cefepime and a 10-mg/kg dose metronidazole were initiated and administered
intravenously 3 times a day for 2 days. After results of susceptibility tests
were known, cefepime was discontinued, ceftriaxone (50 mg/kg, twice a day for a
12-week duration) was started alone with the metronidazole to eradicate any
undetected anaerobic organisms that had not grown in the initial culture.
The patient received a diagnosis of S dysgalactiae brain
abscess, meningitis, and cerebritis. The origin was possibly from a recent
middle ear infection.
POST-HOSPITAL DISCHARGE
A sample of the child’s agranulocytic blood was sent for
genetic testing for the HAX1 and ELANE genes, which are responsible for most
cases of congenital agranulocytosis. Results were negative for defects in those
2 genes.
A repeat MRI scan of the brain at 6 weeks of treatment
showed no change in the size or appearance of the brain abscess. Several
external ventricular drain clamp trials failed, and as a result, an internal
ventriculoperitoneal shunt procedure was performed. Intravenous ceftriaxone and
metronidazole were continued for the planned 12-week duration. Immediately
prior to the end of antibiotic treatment, a repeat MRI of the brain with contrast
showed marked interval improvement in abscesses and cerebritis involving the
lateral ventricles and the right temporo-occipital region.
The patient did experience some transient motor and gait
deficits after discharge. In addition, after discharge she was noted to have a
wide-based gait that improved to baseline with intensive physical therapy. She
has no behavioral, cognitive, or language residual problems. The
agranulocytosis responded to granulocyte colony-stimulating factor
supplementation, and she will likely stay on this treatment indefinitely...
CONCLUSION
A 2-year old girl who was immunocompromised (by congenital agranulocytosis)
with an acute draining ear had a nonfebrile complex partial seizure. Two months
later, she developed an ataxic gait, visual defects, exotropia, and headaches.
S dysgalactiae was recovered from her CSF culture and from her throat and urine
specimens. She had zero neutrophils in her peripheral blood, and she also had
anemia and highly abnormal acute-phase reactants. She responded well to a
prolonged course of ceftriaxone in combination with metronidazole. The child
may be the youngest reported in the medical literature with an S dysgalactiae
brain abscess.
No comments:
Post a Comment