Sushmita, an 8 month old girl, presented with no neck control and abnormal movement since infancy. Her birth history included prolonged labor, meconium aspiration, and respiratory distress requiring hospitalization. On examination, she had dystonic posture, microcephaly, reduced muscle power, and developmental delays. Investigations showed evidence of past congenital CMV infection. She was diagnosed with dystonic cerebral palsy due to congenital CMV infection, and a multidisciplinary treatment approach was recommended focusing on nutrition, therapy, and antiviral medication.

1. Dr. KANTA HALDER
Resident (MD;Phase A)
BICH

2. Particulars of the patient
 Name: Sushmita.
 Age: 8 months.
 Sex: Female.
 Address: Najirpur, Barisal.
 Date of Admission: 16.01.2016.
 Date of Examination: 17.01.2016.

3. Chief Complaints
 No neck control till date.
 Abnormal posture & movement since
early infancy.

4. History of present illness
According to the statement of mother, her
child –
• No neck control yet.
• Abnornal posture & movement since early
infancy.
• No H/O seizure.
• No H/O trauma or CNS infection.

5. Birth History
Antenatal :
• Planned pregnancy.
• Regular ANC.
• Non-diabetic, normotensive.
• No H/O fever with rash.
• No H/O offending drugs.
• No H/O APH, less foetal movement or
trauma.

6. Birth History
Natal :
• H/O Prolong labour.
• Failed home trial.
• LUCS at term.
• Average birth weight.

7. Birth History (cont..)
Postnatal :
• Delayed cry after birth.
• H/O ingestion of meconium in utero.
• Developed respiratory distress.
• Hospitalization for 7 days.
• No H/O jaundice or seizure.

8. Feeding History
• Exclusive breast feeding: Up to 7 months.
• From 7 months: Suji with formula milk,
Breast feeding.
Immunization History
• EPI schedule.

9. Family History
• 1st issue.
• Non consanguineous parents.
Socio-economic History
• Poor socio-economic background.

10. Treatment History
• Treated by local traditional healer.
Developmental Milestone
• No neck control yet.
• Social smile: 3 months.
• Vocalization: 3 months.

11. General Examination
Appearance: Has apparently small head,
interested to surroundings, having social smile
with dystonic posture.
Mildly pale.
Jaundice:
Cyanosis:
Clubbing: Absent.
Oedema:
Dehydration:

13. Cont..
Skin: BCG mark present, no neurocutaneous
stigmata.
Lymphnode: Not palpable.
Signs of meningeal irritation: Absent.
Ear:
Nose: Normal.
Throat:

14. Cont..
Vital Signs:
Pulse: 112/min
Respiratory Rate: 38/min
Temperature: 99°F
Blood Pressure: 70/50 mmHg

15. Cont..
Anthropometry:
OFC: 38 cm (-5.4 SD).
Weight: 6.3 kg.
Height: 64 cm.
HAZ: -1.63 SD (normal).
WHZ: - 1.40 SD (normal).

16. Nervous System Examination
 Higher psychic Function :
Conscious, oriented to surroundings.
 Cranial nerves examination :
No facial asymmetry.
Pupillary size and shape was normal, light
reflex was present.
No squint, eye balls moved in all direction.
Drooling was present, no swallowing
difficulty.

17. Cont..
 Motor function :
Muscle bulk : Normal in all 4 limbs.
Muscle tone : Variable in all 4 limbs.
Muscle power : 3/5 in all 4 limbs.
Jerks : Exaggerated in all 4 limbs.
Clonus : Absent.
Planter response : Bilaterally extensor.
Dystonia present.
 Sensory function : Can not be evaluated.
 Fundoscopy : Normal.

18. Developmental Assessment
 Gross motor :
Writhing movement of 4 limbs present.
Pull to sitting - Head lags behind the body
line.
Ventral suspension – lifts head above body
level.
Lifts chin up on prone lying.
Can not go side lying position.
Persistance of Assymetric Tonic Neck Reflex.

19. Cont..
 Fine motor :
No midline activity.
Does not reach or hold object.
Holds object tightly when placed in hand, but
difficulty in releasing.
 Cognition :
Recognizes family members.
Social smile present.

20. Cont..
 Vision :
Fixes and follows smartie.
 Hearing :
Turns head to rattle, clapper bell & voice.
 Speech :
Vocalization present.
Other systemic examination including
Abdominal examination revealed normal
findings.

21. Salient feature
Sushmita, 8 months old girl, 1st issue of her
non-consanguineous parents, presented with
no neck control till date, abnormal posture &
movement since early infancy. She had history
of perinatal asphyxia with meconium
ingestion, but no history of neonatal jaundice
or seizure.

22. Cont..
She was mildly pale having microcephaly, no
neurocuteneous stigmata or organomegaly.
Dystonic posture was present. Vitals were
within normal limit. Her cranial nerves were
intact, muscle power was reduced with
variable tone in all 4 limbs, jerks were
exaggerated with bilateral planter extensor.
Motor, cognition & speech delay was present.

23. Provisional Diagnosis
Dystonic cerebral palsy with microcephaly
with motor, cognition & speech delay.

24. Differential Diagnosis
TORCH infection with microcephaly with
motor, cognition & speech delay.

25. Investigations
Complete Blood Count :
• Hb%: 11.2 gm/dl
• WBC: Total count: 11,400/cumm
Differential count:
o Neutrophil: 34%
o Lymphocyte: 60%
o Monocyte: 04%
o Eosinophil: 02%
o Basophil: 00%

26. Cont..
o RBC:Normocytic normochromic
o WBC:Mature with above
distribution
o Platelet: Adequate
• Platelet : 478,000/cumm
• PBF:

27. Cont..
RBS : 5.9 mmol/L.
S. Electrolytes : Na⁺ - 141.9 mmol/L.
K⁺ - 5.0 mmol/L.
Cl⁻ - 105.7 mmol/L.
S. Calcium : 2.64 mmol/L.
SGPT : 47 U/L.
USG of brain : Cortical atrophy.

30. Cont..
CT Scan of Brain : Suggestive of sequel of
TORCH infection with feature of mild hypoxic
encephalopathy.
EEG : Epileptiform discharge around midline
and right centro-parieto-occipital area.

31. Cont..
Torch Panel :
Toxoplasma : IgG - <5 IU/ml.
IgM - <100 U/ml.
Rubella : IgG - <5 IU/ml.
IgM - <2 U/ml.
CMV : IgG - 147.3 U/ml.
IgM - <5 IU/ml.
HSV type 1 : IgG - <10 U/ml.
IgM - <10 U/ml.
HSV type 2 : IgG - <10 U/ml.
IgM - <10 U/ml.

32. Final Diagnosis
Dystonic cerebral palsy with microcephaly
with motor, cognition & speech delay with
congenital CMV infection.

33. Management
Multidisciplinary team approach :
• Paeditritian.
• Developmental therapist.
• Psychologist.
• Opthamologist.
• ENT specialist.

34. Cont..
 Counseling.
 Nutritional management :
Complementary feeding including khichuri
along with breast feeding.
Feeding position.
 Management of spasticity :
Tab Nitrazepum.
Physiotherapy.

35. Cont..
 For Congenital CMV infection :
Inj. Gancyclovir – 3 weeks.
Neuro-developmental therapy and
stimulation.
 Follow up

36. Thank You