Grand Rounds

Excessive sleepiness

Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India

Clinical Problem :
A 15 month old girl born of non consanguineous marriage presented with excessive sleepiness for 3 days and fever for 1 day. She had a boil over left lower abdomen 8 days back which has ruptured and left behind an ulcer over the abdomen for past 3 days. There is no history of contact with TB. Birth history, milestones are normal. The child is immunized till date and is on breast feeds and weaning food. On examination, she is drowsy, has no BCG scar, has an ulcer of 1 cm x 1 cm over left abdomen, no meningeal signs, right sided lateral rectus palsy and hepatomegaly. Other systems are normal. Reflexes and tone are normal. Investigations show normal blood sugar, blood gases, serum ammonia, complete blood count and renal and liver function tests.

What is the diagnosis_?

Discussion :
This child has excessive sleepiness, lateral rectus palsy and a non-healing ulcer. Lateral rectus palsy suggests raised intracranial tension and sleepiness could be due to that. Since this child has no fever, meningeal signs or seizures, meningitis leading to raised ICT seems unlikely. It may be due to intracranial space occupying lesion {SOL}. An SOL with a skin ulcer makes one suspect tuberculosis or brain abscess. However brain abscess may be associated with fever of a longer duration and would be unlikely. In this child, MRI brain showed multiple ring enhancing T2 hypointense lesions in left posterior parietal, parieto occipital, left fronto-parietal and right perisylvian and left cerebellar region with hydrocephalus suggestive of tuberculosis. Skin lesions were also suggestive of gumma. CSF examination showed 26 cells with 100 percent lymphocytes. Child was treated with 4 drugs antituberculous therapy and steroids to which he responded.

E-published: May 2011 Vol 8 Issue 5 Art No. 34

Correct Answers :  yes 100%
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