Girl with fever vomiting and head ache

11 year old girl child was bought with complaints of

• Head ache and vomiting    4 days
• Fever                                  2 days
• Seizures today while on transport to our hospital

She was normal child going to school.No past history of significant illness.

At the time of admission in PICU

• Airway was normal,shallow respiration
• Pulse was good volume,regular 58/mt
• Blood Pressure above 95th centile 
• EMV score  8
• Temperature 100/mt.

After stabilizing measures detailed history was taken

• No history of skin rashes, or bleeds.
•  No history of fall/trauma,
• No history of ear discharge.
• No history of contact with tuberculosis , 
• No history of cough,
• fever or recent weight loss 
• History of travel outside state from school . History of taking bath in swimming pool

Discussion

Previously normal child 11 years presenting with fever altered sensorium possibility of 'encephalitic syndromes' was considered. This is s vague diagnosis which includes many entities. 

Altered sensorium situation in a child may be divided for convenience in to two broad categories 

• with fever
• without fever

Group with fever  

• Infection of CNS 
• Connective tissue disorder involving brain
• Malignancies 
• Rare possibility of fever triggering a metabolic problem.

Out of this 90 percent are due to infections. May be bacterial,viral,protozoal,fungal ,rare organisms especially if subject is immuno- compromised.

With these possibility in mind we searched for diagnostic clues in the General examination 

• No rash, bleed
• No lymph node
• No significant pallor
• No jaundice

Cranial nerves ( possible way in a drowsy child) . 

Position of eyes normal.No deviation to any side,upward or downward deviation

Fundus papillodema.Mac evans sign was negative

Pupils norml size equal and reacting normal on both sides 

Other cranial nerves normal

Long tract signs

Tone was higher both sides , more in lower limbs than upper. 

DTR exaggerated knee,ankle biceps and triceps 

Plantar upgoing

Doubtful neck stiffness.

Other systems 

Within normal limits

Discussion 

Even though possibility of CNS infection is most likely one finding which is atypical here. 

Papillodema 

High blood pressure and bradycardia, may occur in meningitis/ encepahlits due to cerebral edema but papillodema is very rare in a case of meningitis or encephalitis of whatever etiology during the acute stage

May be during follow up papillodema may occur due to one of the complications like abscess formation, venous sinus obstruction.

In this context another possibility thought of was ,

A mass lesion where the fever is caused due to a a mechanism other than infection. One possibility causing such a situation is a lesion somehow interfering with hypothalamic temperature control mechanism 

So we did nt do Lumbar puncture,

She was put on Ceftriaxone,Acyclovir ,mannitol, anticonvulsants and other supportive measures 

Possibility of unusual situations like cerebral malaria, primary amoebic meningitis also considered.

• But absence of pallor and hepatosplenomegaly were against cerebral malaria. 
• Remote possibility of unusual organism we considered in view of taking bath in a swimming pool the details of the location we did nt know 

CT was taken 

Both lateral ventricles were dilated
Cerebellum,fourth ventricles brain stem normal
There was a mass in the third ventricle

See the mass is not originating from within parenchyma. There is a clear gap between the anterior part of midbrain. It is compressing backwards on the midbrain.

Possibility considered at this stage was 

• Colloid cyst
• Astrocytoma
• Craniopharyngioma 

MRI followed to confirm

MRI confirmed possibility of Collod cyst ,but one interesting finding which we missed in the CT 

In the MRI there was diffusion restriction in the area supplied by posterior cerebral artery on the left side 

When we go back to the CT film, after seing this MRI , there is hypodensity in the corresponding area in CT. In fact we have  noticed this finding in the CT  , but took it as CSF seeping due to high pressure in the lateral ventricle 

How to explain the infarct in the PCA territory/

Must be due to the posterior compression by the mass at the top of basilar on the left PCA 

What we did? 

Patient was taken up by neurosurgeons. Initially extraventricular drainage done followed by open surgery. 

Patient is now recovering, but some sequele is likely .

Past experiences

One of my junior batch students in Calicut medical college was diagnosed as Colloid cyst in early eightees. Surgery done, uneventful recovery. At that time No MRI dont remember the details 

We lost one boy with coning three years back.

Now most of the cases diagnosed early outcome is excellent. I think in this case the ischemia ,bit late intervention made the outcome not so good

(My post graduate students Dr.Keerthi, Dr.Divya and Dr.Sameeha Helped me in treating the case and preparing this note.
Thanks to the Neurosurgery team MCH Thrissur for the surgical support)