Diagnostic Dilemma

Ventriculitis with basal exudates in a 2 ½ months old.


Author: Pediatric Oncall
Question
A 2½ month old girl presented with enlarging head size, inability to move the right side of body and deviation of face on left side for 1 month. The child was born of a caesarean delivery in-view of oligohydramnios and cried immediately after birth but was hospitalized for 15 days and treated with IV injections. Details of previous admission are not available. The mother had undergone medical termination of pregnancy in previous pregnancy at 5 months of gestational age in view of non-immune hydrops with right sided congenital diaphragmatic hernia. On examination, the child was malnourished (Total length = 49 cm, weight = 3 kg, head circumference = 41.5 cm), had macrocephaly, wide open non-bulging anterior fontanelle with sun-setting sign, maculopapular rash all over body, left sided facial palsy, right sided hemiparesis and brisk reflexes with extensor planters. Other systems were normal. Investigations showed:
• Hemoglobin = 13 gm/dl
• WBC count = 23,300/cumm (64% polymorphs, 34% lymphocytes, 2% eosinophils)
• ESR = 15 mm at end of 1 hour
• Platelet count = 3,15,000/cumm
• Renal and liver function tests = Normal
• CSF = 480 cells (15% polymorphs, 85% lymphocytes), Sugar 20/110 mg% and proteins of 172 mg%.
• CSF latex for E.coli, H.influenza, pneumoniae = Negative
• VDRL = Negative
• Toxoplasma IgG & IgM in blood and CSF = Negative
• CRP = 15 mg/dl
• MRI brain = Hydrocephalus (arrested) with ventriculitis with basal exudates and perventricular nodules in bilateral frontal and left parietal areas suggestive of Tuberculosis, Congenital CMV, Toxoplasma or HIV.
• HIV PCR = Negative
• CMV IgG - positive.
• CSF TB Bactec = Negative
• CSF ADA = Normal
• Fundus examination = No chorioretinitis
• Chest X-Ray = Normal

Child was treated with antituberculous therapy (ATT) and antibiotics to which child responded.


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