TBM with hyperthermia
 
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Author: Pediatric Oncall
Question
A 4 month old girl presented with lethargy, one episode of tonic clonic convulsion and fever for a day. There was no contact with TB. Patient was hospitalized for pneumonia 14 days back for 6 days and was treated with IV antibiotics for 6 days to which she responded. She was born at full term and had birth weight of 3 kg. She was immunized with BCG, and single dose OPV and Hepatitis B. She was on breast feeds. On examination, pulse was 120, min, respiratory rate was 30, min. length was 57 cm, weight was 4.5 kg and head circumference was 38 cm. She had decerebrate posturing, hypertonia, brisk deep tendon reflexes. Anterior fontanelle was not bulging. Other systems were normal. CT brain showed basal exudates and dilated lateral and 3rd ventricle. She was intubated and ventriculoperitoneal shunt was inserted. CSF showed 142 proteins, 160 cells {98 percent lymphocytes and sugar of 22 mg, dl}. Chest X-Ray showed miliary mottling. She was started on 4 drug antituberculous therapy {ATT} along with steroids and leviracetam. Her condition stabilized and patient was extubated after 1 week but fever persisted. After a month of therapy, she had temperature of 107oF at 4.00 am and subsequently died after 12 hours.
Expert Opinion :
Thanks for your inputs. To answer a few queries: The child was in the hospital at the time of her fever episode. She had no other manifestations after the episode of fever: no unequal pupils, no decerebration or signs of raised ICT. It was assumed that the child had an arrhythmia related to the hyperthermia.
Answer Discussion :
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Ravi Kakkar
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