Case Index

CASE STUDIES IN NEUROLOGY
Case 6 March 1, 11:00 a.m.

HPI

A six-year-old girl is hospitalized for evaluation of fever, weight loss and lethargy of 10 days duration. Her household includes her parents, six siblings, and her paternal grandparents. Her grandfather was recently treated for pneumonia.

PE
  • General Exam: Her examination is significant for cough, mild dehydration, somnolence, a temperature of 39C, and nuchal rigidity.
NEURO
  • MS: Irritable and sleepy, becomes transiently more alert with noxious stimuli. Follows directions inconsistently.
  • CN: Normal
  • MOTOR: Strong and symmetric movements when resisting examiner, slightly increased reflexes.


Study Questions:
  1. Discuss the significance of the physical findings and neurological signs.
  2. Discuss the importance of family history.
  3. What diagnostic studies would you request and why?
  4. How soon do the tests need to be done?



Some tests are done including a lumbar puncture. The cerebrospinal fluid reveals 50 white blood cells per cubic millimeter (43% neutrophils, 57% mononuclear cells), protein of 192 mg/dl, and glucose of 25 mg/dl (serum glucose of 95 mg/dl).

While waiting for the results of microbiologic cultures, the child is placed on broad spectrum antibiotics.

Three days later, she develops increased somnolence and projectile vomiting. When she is aroused, she complains of headache.

Examination reveals a temperature of 39.__C, nuchal rigidity, bilateral papilledema, and decreased upgaze. There is a mild increase in tone in the lower extremities; increased knee jerk and ankle jerk reflexes, and bilateral Babinski signs.

Study Questions:
  1. Discuss the significance of CSF results.
  2. What do you think has occurred?
  3. What if temperature was reported to be 37 o C?