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vivaan.pptx
- 1. Presented by DrGururaja R MD,DNB Pediatrician
- 2. Vivaan, 42days old male infant first child of non consanguineous marriage Brought with h/o fever of 3 days duration And abnormal body movements of one day duration
- 4. Fever lowgrade, intermittent Abnormal body movements in the form of tonic movement of right hand and right leg with deviation of face and eyes to right side Baby had four episodes such abnormal body movements during fever
- 5. SEIZURE? CONVULSION? EPILEPSY?
- 6. SEIZURE – abnormal,involuntary, paroxysmal Motor/sensory/autonomic activity Due to abnormal electrical discharges from brain CONVULSION – Motor manifestation of seizure EPILEPSY – two or more UNPROVOKED seizures more than 24 hour apart
- 7. Is it seizureor seizure like activity? Alteration in motor activity Alteration in level of consciousness
- 8. Is itFebrile seizure? Simple/Complex Febrile seizures are common in 6 months to 5 yrs of age Generalized seizures during fever Single episode Lasts < 15 minutes
- 9. Parents deniedany history of trauma to head Antenatal period – uneventful Term delivery, LSCS done for non progression of labour AGA;B Wt- 3kg Cried immediately after birth No NICU admission Exclusively breastfed and he was feeding well Immunisation – up to date
- 10. 42 daysold male infant only child of non consanguineous marriage brought with history of fever of 3 days duration and multiple episodes of right sided focal seizures Antenatal, perinatal and neonatal period- normal
- 11. An infantwith fever of short duration and seizures What are the possibilities? Infection-CNS/Sepsis Structural abnormalities in CNS Hypoglycemia Hypocalcemia Hypomagnesemia Hypo/hypernatremia Inborn errors of metabolism
- 12. Focal corticaldysplasias Lissencephaly Polymicrogyria Sturge-weber syndrome Tuberous sclerosis
- 13. Pyridoxine deficiency Biotinidase deficiency Neuronal ceroid lipofusinosis Mitochondrial disorders Gangliosidosis GM2
- 14. Fever withseizure CNS infection is MOST IMPORTANT CAUSE However metabolic and dyselectrolytemias should be ruled out Infant of this age may not show typical signs of meningitis as his CNS is immature
- 15. Clinical examinationin between seizures was normal Baby was hemodynamically stable Head circumference – 41cms(>3SD) No facial dysmorphism No skin rash AF – normal No signs of meningial irritation No focal neurological deficits Other systemic examination – UNREMARKABLE
- 16. Only significantfinding noticed during examination was macrocephaly
- 17. Defnition –head circumference >2SD Growth charts used to know normal range for age
- 18. Familial Hydrocephalus Subarachnoid cyst Subdural effusion Dandy Walker cyst
- 19. Hydrocephalus Subduraleffusion
- 20. 42 daysold male infant only child of non consanguineous marriage brought with history of fever of 3 days duration and multiple episodes of right sided focal seizures Antenatal, perinatal and neonatal period- normal Macrocephaly
- 21. Bacterial meningitiswith subdural effusion CNS TB with hydrocephalus Congenital intrauterine infections with hydrocephalus
- 22. CBC –normal MP-negative Blood sugar- normal Electrolytes – normal CRP – Negative RFT/LFT – NAD Urine RE – NAD Blood C/S- NAD Urine C/S- NAD
- 23. Lumbar puncture Neuroimaging EEG
- 24. Lumbar punctureor Neuroimaging? In raised ICT – Lumbar puncture carries the risk of brain stem herniation Either fundoscopy or neuroimaging- first done Followed by lumbar puncture
- 25. CT orMRI? Which one to choose? MRI --- better anatomical delineation Grey-white distinction Myelination status Vascular anomailes better identified Midline, posterior fossa lesions better appreciated Special sequences like. DWI, MRA,MR Spectroscopy NO RISK OF RADIATION BUT REQUIRES SEDATION SOMETIMES GEN ANAESTHESIA
- 26. MRI brainshows dilated supraventricular system suggestive of non communicating hydrocephalus Multiple ring enhancing lesions of sub centromere size b/l supratentorial cerebral parenchyma suggestive of multiple granulomas
- 30. MRI showinghydrocephalus and multiple ring enhancing lesions What is its relevance in the present case? WHAT ARE WE DEALING WITH?
- 31. Tubrculoma Neurocysticercosis CNS Neoplasms – Glioma,CNS Lymphoma Metastsis to CNS Post radiation changes Toxoplamosis involving CNS cryptococcosis
- 34. CSF- clear– proteins -459mg% Sugar – 45mg% (blood sugar 64mg%) Total cells – 20 (LYMPHOCYTES) CSF ADA – 17 mg% (increased)
- 37. CSF- clear– proteins -459mg% Sugar – 45mg% (blood sugar 64mg%) Total cells – 20 (LYMPHOCYTES) CSF ADA – 17 mg% (increased)
- 38. PROTEINS –increased SUGAR - normal Cells – 20 – LYMPHOCYTES CNS TB INTRAUTERINE INFECTIONS VIRAL
- 40. ARE WEDEALING WITH CNS TUBERCULOSIS?
- 43. Sleep EEGshowed interictal spike and wave discharges localised to left frontocentral region
- 45. It distinguishesseizure from nonseizure states Helps in diagnosis of epilepsy and epilepsy syndromes
- 46. 2% normalpopulation have abnormal EEG EEG is normal in interictal period in patients with actual epilepsy
- 47. 42 dayold male infant Fever with seizures Macrocephaly CSF protein-rasied;20 lymphocytes CSF ADA – raised MRI BRAIN –non communicating hydrocephalus with multiple ring enhancing lesions both cerebral parenchyma
- 48. Congenital toxoplasmosis CNS – TB
- 49. Further childhad generised tonic clonic seizures requiring phenytoin loading dose followed by maintenance AED Child remained afebrile However drowsiness was present through out No other symptoms noticed
- 50. Airway –position,clear secretions Oxygen Iv access – iv midazolam,lorazepam(0.1mg/kg) Iv access difficulty – midazolam (0.3 mg/kg) – IM,Buccal,nasal Rectal Diazepam – 0.5mg/kg No control in 5 minutes---PHENYTOIN LOADING – 20mg/kg in NORMAL SALINE Slow iv infusion – 1 mg/kg/min Check sugar,electrolytes Control temperature Shift to ICU PRACTICALLY ANY SEIZURE > 5 MINUTES IS STATUS EPILEPTICUS Seizure must be controlled to protect BRAIN DAMAGE
- 53. Started onATT Empirical antibiotics also started Due to rarity of CNS TB at this age further evaluation continued
- 54. TB PCRof CSF ---negative Retrospectively, no contact h/o TB TB Screening of family members negative Mantoux test - negative
- 55. In viewof fever, seizure , congenital hydrocephalus----- possibility of congenital toxoplasmosis considered TORCH titer sent
- 56. Toxoplasma antibodypanel IgM 18.7(increased) Toxoplasma IgG 86.7(increased) CT brain intracerebral calcification which revealed generalized cerebral atrophy with periventricular, basal ganglia and sub cortical calcifications
- 58. In viewperiventricular calcification, CMV PCR --- not detected Diagnosed CONGENITAL TOXOPLASMOSIS Started on pyrimethamine @1mg/kg/day Sulfadiazine @ 100mg/kg/day Folinic acid @ 1 mg/kg /day
- 59. AED ---phenytoincontinued ATT stopped Ophthalmology evaluation --- Normal
- 60. Delayed milestones No social smile Head lag Not reaching for objects at 4 months
- 61. Detailed ophthalmologicevaluation revealed moderate to severe visual impairment Opinion of pediatric ophthalmologist taken Advised conservative management
- 62. Child developedabnormal body movements in the form of spasms In clusters – 15 to 20 per day
- 65. Sleep EEGshowed interictal spike and wave discharges on chaotic/asymmetrical background, representing hypsarrythmia INFANTILE SPASMS Started on ACTH 40 IU/day
- 66. 42 dayold male infant Fever with seizures Macrocephaly CSF protein-rasied;20 lymphocytes CSF ADA – raised MRI BRAIN –non communicating hydrocephalus with multiple ring enhancing lesions both cerebral parenchyma CT BRAIN – Perivetricular calcifications Positive toxoplasma serology Infantile spasms Blindness
- 67. CONGENITAL TOXOPLASMOSISWITH INFANTILE SPASMS
- 68. Toxoplasma gondii Protozoa,intracellular Transmitted by cat,oocysts Congenital inf ---through placenta Incidence---20/10,000 to 1 /10,000
- 69. Involve multipleorgans including brain Risk of transmission highest if inf in third trimester Severity highest if infected in first trimester Mainly involves CNS and EYE
- 70. Clinical features--- chorioretinitis,seizures,CNS calcifications,hydrocephalus,microcephaly,he patosplenomegaly,jaundice,skin rash,anemia,deafness,visualimpairment Varies from mild to severe Wide variety of severity May present later in infancy also
- 71. Diagnose withneonatal IgM antibodies against toxoplasma CSF findings Neuroimaging Ophthalmology evaluation
- 72. Treatment Sulphadiazine---50 mg/kg---daily—BD 12months Pyrimethamine---1mg/kg---daily BD---6 Months----thrice weekly---next six months Folinic acid
- 73.