Chapter 6 Fever and encephalopathy Case II

1. Chapter 6Fever and encephalopathyCase II

2. Case study: Asha Asha, an 8 year old girl brought to hospital after 2 weeks of fever, not eating or drinking. On the day of referral she could not be woken up and had a seizure.

3. What are the stages in the management for any sick child?

4. Stages in the management of a sick child(Ref. Chart 1, p. xxii) • Triage • Emergency treatment • History and examination • Laboratory investigations, if required • Main diagnosis and other diagnoses • Treatment • Supportive care • Monitoring • Discharge planning • Follow-up

5. Have you noticed any emergency or priority signs? Temperature: 39.50C, pulse: 140/min, RR: 50/min, SpO2 92%, breathing noisy but regular, no cyanosis, intermittently shaking left arm and leg, unresponsive to voice, withdraws to pain

6. Triage Emergency signs (Ref. p. 2, 6) • Obstructed breathing • Severe respiratory distress • Central cyanosis • Signs of shock • Coma • Convulsions • Severe dehydration Priority signs (Ref. p. 6) • Tiny baby • Temperature • Trauma • Pallor • Poisoning • Pain (severe) • Respiratory distress • Restless, irritable • Referral • Malnutrition • Oedema of both feet • Burns

7. What emergency treatment does Asha need?

8. Emergency treatment • Airway? • Breathing? Oxygen? • Anticonvulsants? • Immediate investigations? □ Blood sugar <2 mmol/L

9. Emergency treatment - position the unconscious child to protect the airway (Ref. Chart 6, p. 12)

10. Place the prongs just inside the nostrils and secure with tape. Use an 8 F size tube Measure the distance from the side of the nostril to the inner eyebrow margin with the catheter Insert the catheter to this depth and secure it with tape Give oxygen (Ref. Chart 5, p. 11 p. 312-315) Start oxygen flow at 1-2 litres/minute

11. Emergency treatment (continued) □ How do you treat acute convulsions? • Give diazepam (or paraldehyde) rectally (Ref. Chart 9, p. 15) • Insert an IV drip • Load with phenobarbitone OR phenytoin if convulsions continue (Ref. Chart 9, p. 15) □ How do you treat hypoglycaemia (Blood glucose <2 mmol/l)?  Give IV glucose urgently (Ref. Chart 10, p. 16))

12. Emergency treatment Reassess: • Airway • Vital signs and oxygen • Convulsions ceased • Blood glucose normal (recheck) and give an ongoing source of glucose

13. Give emergency treatment until stable…then take a history and do full examination

14. History • Asha was well until two weeks ago when she developed high fever and was eating and drinking poorly. She was taken to the health centre, where she was given penicillin for three days, but the fever persisted and she became more lethargic. On the day of referral she could not be woken up and had a seizure. • Family history: Asha's aunt has tuberculosis, which was diagnosed recently. • Social history: she lives with an extended family including her parents, grandparents and her uncle's family in a three-room house.

15. Examination Asha was thin, pale looking. She was intermittently shaking her left arm and leg. Vital signs: temperature: 39.50C, pulse: 140/min, RR: 50/min Weight: 17 kg Height: 110cm □ Use (Ref. p. 391-392) forweight-for-length Neck: enlarged non-tender right-sided lymph nodes Chest: gurgling upper airway sounds. On chest auscultation only transmitted upper airway sounds Cardiovascular/Abdomen: normal Neurology: Asha was unconscious and withdrew only to pain (squeezing her earlobe) and only on the right side. Her neck was stiff and she grimaced when it was moved. Her pupils were unequal. Intermittent jerking of her left arm and leg, otherwise no movement of her left side.

16. Differential diagnoses • List possible causes of the illness • Main diagnosis • Secondary diagnoses • Use references to confirm (Ref. p. 24-25, p. 151)

17. Differential diagnoses (continued) • Bacterial meningitis • TB meningitis • Cerebral malaria • Viral encephalitis • Trauma / head injury • Poisoning / drug overdose • Brain haemorrhage • Hypoglycaemia • Shock □ Discuss which is most likely • Ref. Table 3 p. 24-25 • Ref. p. 151

18. Further examination based on differential diagnoses Assess first the depth of coma • AVPU (Ref. p. 18) • Aalert • V responds to voice or handling  P responds only to pain • Uunconscious Also check: • Pupil size and light reaction  Unequal pupils • Abnormal posturing (Ref. p. 167-168) • Tense or bulging fontanelle (only in infants)

19. Raised intracranial pressure (Ref. p. 168, p. 56)

20. Further examination based on differential diagnoses • Look for signs of the cause of coma and fever: • Neck stiffness (suggesting meningitis) • Other signs of tuberculosis (Ref. p. 115-118, p. 171) • Splenomegaly or pallor (suggesting malaria or anaemia) • Signs of trauma • Rash (e.g. purpuric rash of sepsis) (Ref. p. 168, p. 153)

21. Further examination based on differential diagnoses • Assess nutrition • Weight-for-age, weight-for length (Ref. 381, 385 & 401) • Look for wasting and oedema

22. What investigations would you do?

23. Investigations • Full Blood Examination • Blood film or RDT for malaria parasites • Chest x-ray • Mantoux test / GeneXpert test • Would you do Lumbar Puncture in this child?(Ref. p. 346-347)

24. Investigations (continued) Full blood examination: Haemoglobin: 82 g/l (115-140) Platelets: 780 x109/l (150 – 400) WCC: 30.6 x109/l (5.5 – 15.5) Neutrophils: 21.4 x109/l (1.5 – 8.5) Lymphocytes: 8.0 x109/l (2.0 – 8.0) Monocytes: 1.2 x109/l (0.1 – 1.0)

25. Investigations • Repeat blood sugar: 4.5 mmol/l after emergency treatment • Blood film: malaria parasites not seen in both samples, and RDT negative • Other tests that could be done: • Mantoux test (Tuberculin skin test: TST) • Gastric aspirate (Z-N stain, GenXpert, TB culture) □ Lumbar puncture was not done because Asha had unequal pupils and focal seizures (Ref. p. 346-347)

27. Diagnosis Summary of findings: • Examination: coma and focal seizures, cervical lymphadenopathy, positive contact history for tuberculosis; failure to improve after 3 days of antibiotic treatment • Chest x-ray: miliary pattern consistent with TB • Blood examination: anaemia, neutrophilia and thrombocytosis

28. Diagnosis (continued) • Suspected tuberculous meningitis and pulmonary TB

29. How would you treat Asha ?

30. Treatment  Clinical meningitis, likely TB meningitis and pulmonary TB, possibly bacterial meningitis TB treatment(Ref. p. 116-117)  First 2 months (initial phase): isoniazid and rifampicin and pyrazinamid and ethambutol daily,  Followed by next 8 months (continuation phase): izoniazid and rifampicin daily  Dexamethasone for tuberculous meningitis(Ref. p. 152)  Ceftriaxone for 10 days (Ref. p. 169) in case bacterial meningitis

31. What supportive care and monitoring are required?

32. Supportive Care (Ref. p. 172-174) • Maintain a clear airway • Positioning and turning • Fluid and nutritional management: • Early attention to nutrition is crucial to outcome • Nasogastric feeding early • Continue to monitor the blood sugar level • Fever control • Anticonvulsants, but avoid respiratory depression • Oxygen if convulsions, respiratory distress or apnoea • Physiotherapy • CT scan if possible

33. Monitoring • Nurses should monitor frequently the child's state of (Ref. p. 174): • Level of consciousness • Adequacy of breathing (airway, RR, oximetry) • Pupil size • Record and treat seizures • Use a Paediatric monitoring and response chart (Ref. p. 320, 413) • Medical review at least twice daily • Consider the complications

34. What complications might occur? • Aspiration • Convulsions (Ref. p.15, Chart 9) • Hypoglycaemia (Ref. p.16, Chart 10) • Fluid overload (Ref. p.173) • Hydrocephalus – acetazolamide (Diamox) • Skin pressure areas • Worsening malnutrition • Constipation • Urinary retention • Limb contractures • Hospital-acquired infection

35. What long term complications may occur? • Development problems • Hearing loss (Ref. p.174) • Motor • Visual • Learning difficulties • Epilepsy • Nutritional

36. Progress and Discharge planning • In 5 days after starting TB treatment Asha started to regain consciousness. • She still had a left-sided residual hemiparesis and her weight had decreased to 15.6 kg • She was fed more frequently (6 times a day) with nutritious foods (Ref. p. 298, 209) once she was conscious enough to swallow. The nasogastric milk was continued for several weeks to provide additional supplementation. • Physiotherapy was commenced for Asha’s hemiparesis and her mother was also taught some exercises • After three months her clinical condition has improved: she was alert, eating and sleeping normally, she had a mild left sided hemiparesis and walked with a limp • On discharge, Asha she was 20.5 kg

37. Follow-up On follow-up visit: • Assess neurological complications • Assess nutritional state • Screen for hearing loss (Ref. p. 173) • Continue physiotherapy, mobilisation (wheelchair, walking frame) • Follow-up family screening and TB contact tracing • Monitor frequently if antituberculous treatment is taken at home

38. Summary • A case of probable tuberculous meningitis • Think of tuberculous meningitis if • the febrile illness is prolonged • there are other signs of TB (e.g. lymphadenopathy, malnutrition, family history, chest x-ray) • Children in coma are at risk of many complications that need to be anticipated: aspiration, hypoxia, hypoglycaemia, malnutrition, constipation, urinary retention, pressure sores, joint contractures