case scenario based

1. CASE PRESENTATION
Presented by : Dr Kumar Gaurav
Moderator : Lt Col S.Badal

2. History
• 13 year old ( DOB: 20/07/2007) female
child
• 1st born of non-consaguineous marriage
• Resident of Khadakwasla, Pune
• Admitted on 15 June 2020 at CH (SC)

3. Chief Complaints
• Poor Scholastic performance since 3-4 year
• Abnormal jerky movements since 2-3 year

4. HOPI
• Poor scholastic performance was sub-acute in onset
• Patient complains of poor performance in exams since 6th std
• Earlier she used to score > 60% marks but now she barely pass
• Complaints from teachers regarding her studies has increased apart
from PT meetings
• Usual complaints include- 1. Slow in handwriting
• 2. Homework/syallabus not completed
• 3. constantly looking outside the window
• 4. Slow in calculating maths problem
• 5. Not able to concentrate
• 6. Both recent and past memory problems
• Presently she is in 8th std with poor scores

5. HOPI (CONTD)
• H/o abnormal jerky movements since last 2-3 year
• This condition had an sub-acute onset which is associated with constant
stare
• Brief episodes of behavior arrests which followed by rhythmic movements
of shoulder, proximal upper limbs and neck lasting for around 2-3 minutes
which were self aborted
• Initially these episodes were 1-2 in a month but for last 3-4 months the
frequency has increased to 6-8 per month
• Now the semiology has changed from last 1-2 months to paroxymal events
which started occuring after scolding from parent/teacher or under stress,
always occur in presence of family members, not occuring during sleep,
child used to fall but without any injury marks
• These events lasted for 5-10 minutes, self aborted and occuring in
frequency of 5-6/month
• The frequency of these paroxymal events has increased to 5-6 episodes
daily since last month after the demise of her mother on 10th May 2020

6. HOPI (CONTD)
• There was no episode of -
• 1. Prolonged tonic-clonic movements with uprolling of eye-balls
• 2. Neck/eye deviation with focality
• 3. Precipitation with flash of light
• 4. Precipitation with fever
• 5. Myoclonus

7. NEURAXIS HISTORY
• 1. H/o unconsciousness with interest in surroundings
• 2. No h/o speech delay
• 3. Sleep pattern is normal
• 4. No behaviour issues except emotional disturbances
• 5. No h/o loss of smell, not recognising the strangers
• 6. No h/o squint, diplopia, drooping of eye lid
• 7. No h/o loss of sensation over face, diffucilty in chewing
• 8. No h/o drooling of saliva, deviation of angle of mouth
• 9. No h/o vertigo, loss of hearing
• 10. No h/o loss of taste, dysphagia, nasal regurgitation, change of
voice
• 11. No h/o drooping of shoulder, alteration of speech

8. NEURAXIS HISTORY (CONTD)
• No h/o problem in combing of hairs and dressing/buttoning of clothes
• No h/o problem in getting up from sitting position, slipping of chappals
• No h/o thinning of muscles
• No h/o loss of perception of sensation
• Bowel and bladder control attained

9. ETIOLOGICAL HISTORY
• No h/o fever with rash
• No h/o jaundice, abnormal behaviour
• No h/o vaccination induced seizures
• No h/o encephalopathy with waxing/waning course
• No h/o headache, dementia, trauma
• No h/o other neurological disorder

10. TREATMENT HISTORY
• Child was admitted in civil hospital for the same and started with
antidepressant medications
• Psychiatry opinion was taken and they referred to us for
neurological consultation

11. ANTENATAL/POSTNATAL HISTORY
• Antenatal History was uneventful
• Born at 40 weeks POG
• NVD
• Birth wt- 2.8 kg
• Roomed in with mother after birth and started on DBF on d-1
• No h/o NNJ, NNS, NNH
• Post natal tranisition was uneventfull and discharged on d-3 of life on
DBF
•

12. DEVELOPMENT HISTORY
• Child has attained all the milestones as per age

13. IMMUNISATION HISTORY
• Immunisation status not clear
• Father admits missing of doses
• Last vaccination was given at 5 year of age
• BCG scar present
• No h/o convulsions after DPT vaccination

14. NUTRITIONAL HISTORY
• Child consumes mix diet
• Total calories intake is around 2200kcal/day
• Total protein intake is around 24gms/day

15. FAMILY HISTORY
• She has two younger siblings 11 year old sister and 09 year old
brother
• Both are developmentally normal with fair scholastic performance

16. SUMMARY
• 13 year old female child with h/o poor scholastic performance
and seizures of multiple seimiology possibility
• 1. Chronic slow CNS viral infection
• 2. Neurodegenerative disorders
• 3. SOL ( Unlikely)
• 4. Primary psychiatric illness

17. GENERAL EXAMINATION
• Child is conscious
• Well nourished
• Ambulatory
• HR- 90/min
• RR- 18/min
• Spo2- 98% on room air
• CFT<3 secs
• BP- 112/72 mmHg in right arm supine position
• No clubbing, cyanosis, pallor, edema, lymphadenopathy
• No dysmorphic features
• No neurocutaneous markers

18. ANTHROPOMETRY
• Height for age - 154cm ( 0 to -1)
• Weight for age - 50 kg ( 0 to -1)
• OFC – 52 cm ( 0 to -1)
• Child is well nourshied as per age

19. SYSTEMIC EXAMINATION
• Child is examined while sitting on chair and in lying down
position on examination couch
• Child is oriented to time, place and person
• HMF - MMSE was done with score of 30/30
• Cranial Nerve examination: Normal
• 1. Appreciate smell with each nostril
• 2. Recognises parents/ objects with visual acuity and pupillary
reflex was normal
• 3. Follows objects, no diplopia/squint
• 4. 4th/5th CN – normal
• 5. Sensation over face intact
• 6. No deviation of angle of mouth/drooling of saliva

20. SYSTEMIC EXAMINATION (CONTD)
• 7. Hearing intact
• 8. Uvula in midline with gag reflex +
• 9. No drooping of shoulder
• 10. No tongue fasciculation or wasting

21. MMSE EXAMINATION

22. SPINOMOTOR EXAMINATION
• Bulk : bilateral symetrical and equal
• Tone : normal in all four limbs
• Power : 5/5 in all limbs
• Reflexes : Superficial- 1. corneal and conjunctival both present
• 2. abdominal reflex present
• 3. piantar – flexor
• Deep reflexes- 1. biceps/triceps/supinator/knee -
normal
• Sensory system - Superficial- pain, touch, temperature +
• Deep- vibration, muscle, position, joint sense +
• Gait was normal
• No cerebellar signs
• No involuntary movements
• No signs of meningeal irritation

23. SYSTEMIC EXAMINATION (CONTD)
• CVS- S1 S2 normal, no murmur appreciated
• RS- air entry bilateral equal , no added sounds
• P/A- soft, bowel sounds +, no organomegaly

24. PROVISIONAL DIAGNOSIS
• 13 year old female child with h/o poor scholastic performance and
seizures of multiple semiology with MMSE score 30/30 and other
CNS examination
• High possibility of chronic CNS viral infection

25. THANK YOU