This document provides a case history for a 2.5 year old female child named Shreya who presented with an enlarged head, vision loss, and seizures. Her developmental history revealed global developmental delay. On examination, she had macrocephaly, hypertonia, and upgoing plantars. Investigations showed communicating hydrocephalus. She has been diagnosed with hydrocephalus, for which the treatment is either medical management to temporarily relieve symptoms or surgical intervention like ventriculo-peritoneal shunt placement.

1. General case
Juhi Dhanawat
Pratik Kumar
Ashar Lodi
Ridhima Sakhuja
Richa Singh

2. history
• Name: Shreya
• Age : 2.5yrs , sex: female
• From: Shimoga
• Informant: mother, Reliability : good
• Came to RAPCC 15days back with
• Chief complaints:
• enlarged head , loss of vision , seizure since
2yrs4months

3. History of presenting illness
• Child was apparently normal 2yrs4months back when she
developed fever for which the mother gave paracetamol
tablet. Fever decreased but spiked up again on the 8th day
with one episode of seizure. There was no frothing of saliva
or biting of tongue. The hands and legs became stiff which
normalized within 2-3 minutes. Baby was admitted in the
ICU at a local hospital ,treated and was discharged on
medications for seizure, a tablet and syrup.
• Every time the mother gives the child head bath, she
develops seizure.
• History of loss of vision since 2yrs 4 months.
• The child does not recognize the mother and no social
smile present.

4. • No other episodes of fever. No history of vomiting.
• No history of difficulty in feeding .
• When the child did not improve, mother took her to
manipal hospital 2months back where scans were done
and mother was told an operation would be required.
She was referred to RAPCC.
• No history of difficulty in chewing.
• No history of lateral gaze palsy.
• No history of hearing deficit, drooling of saliva, nasal
regurgitation .
• History of difficulty in wearing napkins.

5. Birth history
• Antenatal history: primigravida
Ist trmester:Concieved spontaneously.
No history of fever with rash, burning
micturition.
No history of exposure to radiation or intake of
drugs.
Ultrasound scan not done.

6. 2nd trimester: quickening felt at 6th month.
No history of fever with rash.
No history of GDM, PIH.
One USG scan done-nnormal
3rd trimester:
No history of GDM, PIH.
USG scan done-normal.

7. • Full term delivery.
• Elective caesarian section due to decrease in
fetal movements.
• Baby cried immediately after birth.
• Birth weight:2.75 kg
• Meconium and urine passed within 24hrs.
• Breast feeding initiated after 4hrs of delivery.
• No postoperative complications.

8. Developmental history
• Gross motor- head control not achieved
• baby cannot sit with support
• Fine motor- grasp reflex present.
• Language and communication: bysyllables
(amma) only word spoken.
• Social: no social smile
• does not recognise the mother
• Inference: global deveopmental delay

9. Immunization history
• Immunized for age
• Last vaccine taken: 1.5 yrs- DPT booster and
OPV.
• Dietary history:
• Exclusive breast feeding till the age of
5months.
• Weaning : 5th month, cerelac given.
• Presently eats from the family pot.

10. calories protiens
8am 5buiscuits+ I cup 100+ 130= 230 0+7=7
milk(200ml)
10am ½ dosa 60 1.5
1pm 1 cup rice+I cup 175+50=225 4+ 2=6
curry
3pm 1 fruit 50 0.5
5pm 5buicuits +1cup 100+130=230 0+7=7
milk
7pm I cup rice+ 1 cup 175+50=225 4+2=6
curry
9pm 1cup milk 130 7
total 1150 35
required 1150 19.5
Inference: no deficit

11. Family history
• Child born out of consanguinous marriage

12. Socio economic history
• 5 members in the family
• 3rooms, no over crowding
• income rs 4000/month
• Belongs to lower middle class family according
to Modified Kuppuswamy scale.

13. Examination

14. General Condition
• A well nourished, conscious and confortable child
• Decreased alertness to surrounding
• VITALS
- Afebrile
- Pulse rate – 96/min
- Respiratory Rate – 16/min
- Blood Pressure- 110/ 80 mm hg

15. Anthropometry
• Weight
– Actual- 12.5 kg
– Expected- 13 kg
– Inference – 96 % Normal (IAP)
• Height
– Actual - 83 cm
– Expected - 93 cm
– Inference - 89 % Grade II stunting (Waterlow)

16. • BMI – 18 Kg/m2
• Mid Arm Circumference
– Actual 18 cm
– Expected >13.5 cm
• Head Circumference
– Actual – 55 cm
– Expected 48 cm
– Inference Macrocephaly

17. Head to toe examination
• Pallor present (palpebral conjunctiva)
• No icterus
Clubbing
Cyanosis
Lymphadenopathy
Edema

18. • Head Circumference of 55 cm (macrocephaly)
• Prominent forhead
• No dilated scalp veins
• Anterior Fontanelle – Open, non pulsatile, in
level, 4x4 cm
• Normal hair distribution and growth
• Eyes- Setting sun sign present
- Unresponsive to light

20. • Normal facial feature
• Limbs- Increased tone
• Chest – normal
• Spine – normal
• Abdomen – normal
• Genitals – normal
• No skin abnormalities

21. Developmental Assesment
• Expected for age (2.5 yr)
Gross Motor
- Runs well, Climb stairs
Fine Motor
- Turns Pages, Dress her/himself
Social
- Dry by day, listen to stories
Language
- 3 word simple sentences, refer to self as “I”

22. Developmental
assessment(obsereved)
• Gross Motor
– No head control
– Cant sit with support
– DQ- 14%
• Fine motor
– Grasps finger
– Can hold objects in one hand
DQ- 17 %

23. • Social
– No social smile
– Day time bed wetting present
– DQ- 14%
• Language
– Monosyllables
– DQ- 30 %
– Global Developmental Delay

24. Systemic Examination
Central Nervous system examination
- Conscious, disinterested in surrounding
- Spastic response to sudden loud sound
- Skull and Spine- no deformity

25. Cranial nerve examination
I. Not done
II. Pupils reactive
Menace reflex- Absent
III, IV, VI. Could not be assessed
V. Normal B/L
VII. No facial palsy
VIII. Could not be assessed
IX, X, XI, XII. Not assessed

26. Motor System Examination
Right Left
Upper/Lower Upper/Lower
Nutrition Normal/ Normal Normal/Normal
Tone Increased/Increase Increased/Increase
d d
Power Grade 3/ Grade 3 ? Grade 3/ Grade 3 ?

27. Sensory system
• Could not be assessed
• Reflexes
Superficial Right Left
• Corneal Normal Normal
• Abdominal Normal Normal
• Plantar Upgoing Upgoing

28. Deep refelexes
Right Left
• Triceps Grade 2 Grade 2
• Biceps Grade 2 Grade 2
• Knee Grade 3 Grade 3
• Ankle Grade 3 Grade 3
Visceral- No bladder control
Gait- could not be assessed, scissoring of lower
limbs present.

29. • Respiratory System
- Trachea central, B/L symmetrical chest
movements
- Normal vesicular breath sound heard
- No added sounds

30. • Cardiovascular system examination
– PR- 90/min
– Apex beat- 5th ICS medial to mid clavicular line
– S1 S2 heard
– No murmur

31. • Per abdomen
Abdomen- soft, non tender
no organomegaly

32. Summary
• Decreased alertness to surrounding
• Grade II Stunting
• Macrocephaly with open ant fontanelle
• Setting sun sign, loss of vision, Pallor
• Hypertonia
• Severe Global developmental delay
• Grade 3 lower limb reflexes

33. DIFFERENTIAL DIAGNOSIS OF
LARGE HEAD

34. • MEGALENCEPHALY :
- No signs of increased intracranial pressure.
- Ventricles are not large, nor under increased
pressure
Causes :
1. Hurler’s syndrome
2. Metachromatic leukodystrophy
3. Tay Sach’s disease

35. • Chronic Subdural hematoma :
- Causes large head,mostly located in the parietal
region without prominent scalp veins or sunset
sign.
• Others :
1. Hydranencephaly
2. Rickets
3. Achondroplasia
4. Hemolytic anemias
5. Familial macrocephalies

36. INVESTIGATIONS

37. Haematological investigations
• Haemoglobin
• Total count and differential count
• ESR
• Platelets

38. In our patient
• Haemoglobin- 12.2g%
• Total count-11,800/cc
• Differential count
N-32% L-59% M-6% E-3%
• Platelets-2.3 lakh/cumm

39. Biochemical investigations
• Electrolytes
• Serum urea and creatinine
• Liver function tests

40. In our patient
• Electrolytes
Na⁺ 143meq/L (136-149meq/L)
K⁺ 4.4meq/L (3.5-5.3meq/L)
Cl⁻ 107.3meq/L (98-111meq/L)
HCO₃⁻ 23.3meq/L (23-27meq/L)
• Serum urea-26mg/dl (5-18mg/dl)
INCREASED
• Serum creatinine-0.4mg/dl (0.3-0.7mg/dl)
• Liver function tests
total bilirubin-0.1mg/dl (0.2-1.2mg/dl)
direct bilirubin-0.0mg/dl (upto 0.3mg/dl)

41. Radiological investigations
• CT scan of brain
• Ultrasound
• MRI

42. In our patient
• CT scan brain
grossly distended lateral,3rd ,4th ventricles
communicating hydrocephalus

43. Other investigations
• CSF analysis
• Urine screening tests
• Visual assessment
• Hearing assessment
• EEG
• EMG
• Metabolic work-up

44. In our patient
• Hearing assessment
 BERA
 OAE
 Intermittance
Impression-bilateral adequate hearing for
speech and language development

45. TREATMENT

46. TREATMENTMENT OF
HYDROCEPHALUS
MEDICAL TREATMENT
-It provides temporary relief & includes the use
of drugs which act either by decreasing CSF
secretion by choroid plexus (Acetazolamide &
loop diuretics ) , or by increasing CSF
resorption (isosorbide).

47. • Since, the increase in head size is associated with
progressive symptoms, therefore it is necessary to
intervene surgically.
1. VENTRICULO-PERITONEAL SHUNT
-CSF directly drained into circulation or peritoneal
cavity.
-Advantage- shunt need not be lengthened as the child
grows.
2. VENTRICULO ATRIAL SHUNT ( VASCULAR SHUNT )
3. VENTRICULOSTOMY
-by endoscopic approach.