Diagnostic Dilemma

Meningoencephalitis


Author: Pediatric Oncall
Question
A 7-month-old boy born of non-consanguineous marriage presented with fever and irritability for 7 days and a staring look one day ago. Subsequently the child had become lethargic and did not recognize the mother and had neuroregressed. There was no focal neurological deficit, vomiting, rash or contact with tuberculosis. His immunization and milestones prior to illness were normal. He was on breast feeds as well as weaning diet. On examination, he was drowsy with Glasgow Coma Scale of 11. His pulse was 148/min with respiratory rate of 36/min. Blood pressure was 80/50 mm of Hg. He had a heavy head with inner table of anterior fontanelle closed. Cranial nerves were normal. Power and tone was normal. He had neck stiffness with brisk deep tendon reflexes. He had hepatosplenomegaly. Other system was normal. Investigations showed:
• Hemoglobin = 9.4 gm/dl
• PCV = 28.7%
• WBC count = 31,400/cumm (80% polymorphs, 20% lymphocytes)
• Platelet count = 70,000/cumm
• Malarial parasites were negative, Leptospira IgM = Negative
• HIV ELISA = Negative
• Blood culture = No growth
• CSF = 15 lymphocytes/hpf, 134 mg% proteins and 65 mg% sugar (corresponding blood sugar = 90 mg %)
• S. creatinine = 0.5 mg%
• Total proteins = 4.1 gm%, albumin = 1.8 gm%
• S. electrolytes = Normal
• SGPT = 44 IU/L, SGOT = 86 IU/L
• PT = 21 sec (prolonged), RTT = 39.7 sec (prolonged)
• MRI brain = Mild ventriculomegaly
• Mantoux test, Chest X-Ray = Normal

A repeat CBC after 3 days showed:
• Hemoglobin = 6.3 gm/dl
• PCV = 19.3%
• WBC count = 11,800/cumm (75% polymorphs, 20% lymphocytes)
• Platelet count = 70,000/cumm

The child was treated with IV antibiotics. 48 hours later CSF was normal. Child improved clinically.



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