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1. COMPREHENSIVE CLINICAL
CLASS:
A case of child presenting with fever and altered
sensorium
Mentor: Prof. Y K Amdekar,
Medical Director,
Wadia Hospital,
Mumbai.
Presenter: Dr.Ashray S Patel,
2nd year MD Pediatrics,
VVH, BMCRI, Bengaluru.
2. General Information:
• Name: XYZ
• Age: 14 years
• Sex: Girl
• Second born to 2nd degree consanguineous parents
• Address: Tumkur
• Religion: Hindu
• Informant: Mother(Reliable)
• Date of Admission: 2.09.21
• Date of Examination: 2.09.21
3. Chief Complaints:
• Fever from 6 days
• Vomiting from 1 day
• Altered sensorium from 1 day
• 1 episode of paroxysmal movements in the morning
4. History of Presenting Illness:
• Patient was apparently normal 6 days ago, when she developed fever.
• Fever during the initial two days was low grade, intermittent, responding to
medication(Paracetamol 500mg), inter-febrile period she used to feel
better and used to recur every 5-6 hrs.
• From the third day of illness, fever progressed to being high grade,
intermittent type, though the temperature used to come down with
medication, she continued to feel sick, fever used to recur every 5-6 hrs.
There was also associated headache from second of illness, frontal and
occipital region, used to partially resolve on medication. No chills and
rigours present.
• From fourth day of illness, she complains of feeling very tired, unable to do
her daily activity, most of the time lying down on the bed.
5. • Child then had vomiting on fifth day of illness, sudden onset, 2
episodes, non-projectile, containing food particles, non bilious, not
blood tinged.
• From fifth day of illness, there has been progressive decrease in the
level of consciousness, she was confused initially, not being oriented,
then slowly became drowsy further progressed to awakening only on
waking her up.
• The morning of the day of presenting to hospital (sixth day) she had
one episode of paroxysmal movements, lasting for 1-2 minutes,
involving all 4 limbs, tonic clonic type. The event occurred when she
woke up in the morning and post the episode there was loss of
consciousness for around 10 minutes and after that she has remained
drowsy. No urinary or fecal incontinence and tongue bite.
6. • History of exposure to pets present in the house.
• No history of travel.
• No history of any head trauma, ear discharge.
• No history of abdominal pain, bleeding manifestations, passing black
coloured stools, swelling of abdomen, reduced urine output.
8. Treatment History:
• The child was taken to a local clinic on the first day and was given
Paracetomol 500mg to be taken thrice a day.
• Due to deterioration in general condition she was again taken to the
same clinic and was given antibiotic and asked to continue
Paracetamol.
• On the morning of presenting to our hospital she was taken to
Tumkur GH, she was put on IV Fluids, given one dose of
CEFTRIAXONE, gave one loading dose of MIDAZOLAM and then
referred to our hospital for further management.
9. Antenatal History:
The child is of 2nd order born of second degree consanguineous marriage.
No significant Antenatal, Natal and Postnatal history.
1st trimester:
• No h/o of fever, rash.
• Dating scan was done
• Folic acid was taken
• No other drug intake or radiation exposure.
• No alcohol/tobacco/substance abuse.
10. 2nd Trimester:
• Quickening felt at 18 weeks.
• 2 doses of Tetanus toxoid taken 1 month apart.
• Iron, frolic acid & calcium taken.
• Anomaly scan done and no abnormality noted.
• No h/o Headache, swelling of feet, blurring of vision, pedal edema,
documented hypertension.
• No h/o of Polyuria, Polydipsia & OGTT was done and was normal.
11. 3rd Trimester:
• Appreciated fetal movements well.
• No h/o maternal fever, diarrhoea, UTI.
• No bleeding per vaginum, leaking per vaginum, foul smelling liquor,
premature rupture of membranes.
12. Birth History:
• Place: Vani Villas Hospital
• Mode: Normal Vaginal Delivery
• Period of gestation: 39 weeks of gestation
• Baby cried immediately after birth.
13. Postnatal History:
• Birth weight: 2.9kg.
• Full term
• Cried immediately after birth
• Breastfeeding started 30 mins after delivery.
• Breast feeding was done adequately on demand at day and night, no
feeding problems was noticed.
• No respiratory difficulty, jaundice, cyanosis or seizures.
14. Birth History:
• Place: Vani Villas Hospital
• Mode: Normal Vaginal Delivery
• Period of gestation: 39 weeks of gestation
• Baby cried immediately after birth.
15. Developmental history:
• Development of the child was appropriate for age, presently studying
in 8th standard, with average scholastic performance.
19. Family history:
• Type: Extended family
• Members: 6(Grand parents, Parents & 2 kids)
• Sibling: 18 years old girl child, healthy.
• No history of tuberculosis contact.
20. Socioeconomic Status:
• House: 2 room Pucca house, with a kitchen, separate bathroom and
toilet, with adequate sanitary measures & clean water supply.
• Father occupation: auto driver(15000 per month) education till
Middle school.
• Mother occupation: tailor(5000 per month), no schooling.
• Kuppuswamy scale: Class 2
21. Summary:
• 14 year old girl child was brought to our casualty with history of fever
from 6 days, vomiting and altered sensorium from one day and one
episode of abnormal movements in the morning.
• With would like to consider that the child is suffering from acute
onset, meningoencephalitis, probably of infectious etiology.
22. General Examination:
Child was bought to our hospital in a stretcher, she was actively convulsing.
A: Child actively
convulsing, GTCS type,
involving all four limbs.
B: irregular breathing
efforts
C: cyanosis+, bleeding in
the oral cavity+ due to
tongue bite.
23. A: pooling of secretions+,
maintained by simple
measures.
B: RR:30cpm, SpO2: 85% under
room air, irregular, B/L air entry
equal, drooling of saliva with
gurgling sounds, conducted
sounds+.
C: PR:100bpm, Good Volume, all
peripheral and central pulses well
felt, BP:100/60mmHg, appeared
cyanosed, altered sensorium, UO: on
catheterization adequate urine
output+
D: decreased level of consciousness,
generalized tonic clonic seizures of
all 4 limbs.
GCS: 8/15
AVPU: response to painful
stimulation.
E: T: 98.6 degree, active
bleeding from oral cavity
due to tongue bite.
24. • The child was initially stabilised, Airway, Breathing and Circulation taken care
off. The seizure was aborted with Midazolam followed by single loading dose of
Levitiracetam.
Examination: child was sick looking, lying on the bed, not oriented to time,
place and person.
Vital Signs:
•Temperature: 100 degree Farenheit
•PR: 102bpm, good volume, all peripheral pulses felt
•RR: 26cpm
•BP: 104/76mmHg
•SpO2: 99% with 2L O2
•GRBS: 138mg/dL
25. HEAD TO TOE EXAMINATION:
Icterus+
No pallor, cyanosis, clubbing, lymphadenopathy, edema.
Rest of the examination was normal.
28. CRANIAL NERVE RIGHT LEFT
I Could not be tested Could not be tested
II Pupil : Round, Regular & Reactive
Fundus Evaluation: Normal
Pupil : Round, Regular & Reactive
Fundus Evaluation: Normal
III,IV,VI Pupillary reflexes: present
EOM could not be assesed
Pupillary reflexes: present
EOM full could not be assesed
V Sensory: Intact
Motor: Intact
Corneal reflex: could not elicit
Sensory: Intact
Motor: Intact
Corneal reflex: could not elicit
29. CRANIAL NERVE LEFT RIGHT
VII Facial expressions present Facial expressions present
VIII Hearing intact
Doll’s eye reflex: present
Hearing intact
Doll’s eye reflex: present
IX,X,XI Could not be assesed Could not be assesed
XII Could not be assesed Could not be assesed
35. OTHER SYSTEM EXAMINATION:
Cardiovascular Examination :
S1S2 heard in all areas.
No added sounds /murmurs.
Respiratory Examination:
Chest movements equal bilaterally
Normal vesicular breath sounds in all areas
No added sounds
Per abdomen examination:
Soft non tender abdomen
No palpable organomegaly
36. DIAGNOSIS:
A case of Acute Encephalitis Syndrome, secondary to:
•Ricketsial
•Leptospiral
•Dengue
•Cerebral Malaria
•Viral Meningoencephalitis
39. • CSF Study done fifth day of admission: Normal
• CSF serology: Normal
• Blood Culture: Sterile
• Urinalysis: Normal
• Serology: IgM positive for Ricketsia(Scrub typhus) and Chikungunya
• Dengue NS1 Ag & IgM: Negative
• Rapid Ag test and PS for Malaria Negative.
41. • Patchy area of restricted diffusion in the right parieto-occipital region.
• No evidence of meningeal lento meningeal enhancement.
• Infective Etiology to be ruled out.
42. Course:
• Due to further deterioration in level of consciousness, child had to be
intubated.
• Empirically she was started on CEFTRIAXONE, ACYCLOVIR, DOXYCYCLINE,
ARTESUNATE. But later only continued DOXYCYCLINE for ten days.
• Anti-edema measures were taken, LEVITIRACETAM maintainance dose
continued.
• There was gradual improvement in sensorium from day 2 of admission and
she was extubated on third day of admission.
• There was no fever spikes from third day of admission.
• General condition of the child gradually improved and she was discharged
on day 10 of admission with maintainance dose of LEVITIRACETAM to be
continued and asked to get EEG done in the next visit.
