Philippine Children's Medical Center 26 th 3-in-1 Postgraduate Course

1. Philippine Children's Medical Center26th 3-in-1 Postgraduate Course CHILD NEUROLOGY, CRITICAL CARE AND INFECTIOUS DISEASES: THE INTERSECTION A multidisciplinary Approach to CNS Infection July 10, 2014

2. Objective • To present a case of CNS infection and discuss the multidisciplinary approach in the management of CNS infection and its complications.

3. Specific objectives: • 1. To recognize, diagnose and manage status epilepticus which is a usual co-morbidity of CNS infection. • 2. To discuss CNS infections and its differential diagnoses. • 3. To emphasize the different diagnostic modalities necessary in the approach of CNS infections. • 4. To provide the current management of CNS infections and its complications. • 5. To design a framework for the long term care of post-infectious cases with CNS complications by a multidisciplinary team.

4. Case Protocol • ID: JBU,4/M from Bulacan admitted for the first time • CC: depressed sensorium • HPI: • 2-week history of fever (T max: 39.6 C) relieved with Paracetamol • No other associated S/S • Fever persisted until 3 days PTA, there was decreased appetite and increased sleeping time • Admitted in a local hospital. Imp: Kawasaki disease • Patient then developed GTC seizures. Diazepam was given at 0.3mg/kg/dose. • Transfer to PCMC

5. Past Medical History: unremarkable • Family History: (-) PTB • Social History: youngest of 5 siblings (only boy); enrolled in Nursery class prior to illness • Birth/Maternal History: non-contributory • Developmental History: at par for age • Feeding: eats regular table food • Immunization: completed EPI • During transfer, patient continued to have brief generalized tonic-clonic seizures without regaining consciousness. Travel time was approximately 30 minutes.

6. Case Protocol • At the ER: • PE: BP 125/80 CR- 128 RR-16 Temp- 38.1 C • No dermatosis; Pinkish palpebral conjunctiva, anictericsclerae, no CLN palpated, clear breath sounds, distinct heart sounds, no murmur; no hepatosplenomegaly; full and equal pulses, no cyanosis. • NE • Stuporous • No eye opening, minimal withdrawal to pain • Pupils 2-3mm EBRTL, normal fundoscopy • (+) corneals, (+) Doll’s • (+) withdrawal to pain bilaterally • (+) Babinski bilateral • (+) nuchal rigidity • At the ER, patient developed another GTC seizure. Another diazepam (0.3mg/kg/dose was given.

7. Objectives To recognize, diagnose and manage status epilepticus.

8. Moderator • How would you manage the patient? • Neurology (7-10 min) • Define status epilepticus (convulsive/non-convulsive) • Discuss the algorithm for the management of SE (based on the PCMC CNS algorithm) 1st line: benzodiazepines 2nd line: long-acting AEDs (Pb, Phy, VA, LEV) 3rd line: Refractory SE (ICU) (MDZ drip, Pentobarbital, Thiopental, Propofol) • Define subclinical status and the role of EEG • ICU (2 min) • ICU admission • ABCs in the mgt of SE • Open forum (3-5min)

9. Case Protocol • After diazepam, patient continued to have seizures lasting for more than 5 minutes. He was loaded with Phenobarbital with a loading dose of 20 mg/kg/dose, then maintained at 5 mg/kg/day. • Patient’s sensorium continued to deteriorate. Patient still has no eye opening with extension of the right extremities on pain stimulation. Pupils were 2 mm SRTL, with no corneals and no Doll’s. He was intubated using a 4.5 tube at level 15 and was hooked to the mechanical ventilator.

10. Objectives 2. To discuss CNS infections and its differential diagnoses.

11. Moderator • What is your impression of the case? • Neurology (10 min) • Diagnosis based on the neuro evaluation • Anatomic: • Etiologic: • Open forum (3min)

12. Objectives 3. To emphasize the different diagnostic modalities in CNS infections.

13. Moderator • What diagnostic tests would you request to confirm your diagnosis? • Neurology (5 min) • CSF studies • Neuroimaging • Neuroradiology (5 min) • What neuroimaging would be appropriate in this case? • criteria • based on stability, need for contrast, etc • Infectious (5 min) • What specific CSF exam would you request for? • Other ancillary tests: CRP, ESR • TB work-up, work-up family • Open Forum ( 3 min)

14. Objective 4. To provide the current management of CNS infections, and the approach of a multidisciplinary team in handling the complications of CNS infections.

15. Case Protocol • Upon admission to ICU: • VS, NVS, I/O were monitored • NPO; venoclysis was started • The following labs were done.

17. CXR: Bilateral pneumonia with consolidation, left; hyperaeration and lymphadenopathies

18. Initial CT scan (Nov. 26, 2013)call on the neurorad

20. Moderator • Neuroradiologist to give his comments and impression with differential diagnoses. (5 mins.) • CT scan of the head • Ill-defined hypodensity is seen in the left basal ganglia with mass effect on the ipsilateral ventricle. • Ventricles are dilated. • Meningeal enhancement is noted, particularly in the basal cisterns.

21. Moderator: A. Management of increased ICP • Neurology (5min) • Based on the CT, give your impression. • Recognizing signs of increased ICP • How would you manage the elevated OP? • Pharmacologic: decompressants, steroids • ICU (3 min) • Other pharmacologic agents: Totilac, hypertonic saline • Non-pharmacologic: correction of blood gas, elevate head, fluids, hyperventilation • Open forum (3 mins.)

22. CSF studies

23. Moderator: B. Management of TBM • Neurology(3-5 mins.) • give basis for diagnosis • Infectious (5 min) • Current WHO recommendations • (Tabulate recommendations of WHO, PPS, PIDSP, CNSP) • Can you rule out bacterial meningitis based on the CSF findings? • Steroids • Open forum (3-5min)

24. Case Protocol • On the 16th day of the hospital stay, patient developed on and off low to moderate grade fever, desaturations, apneic episodes. Septic work-up was done.

25. Rpt CXR: consolidation of the right lower lung. • Blood culture: negative • Patient was shifted to Piperacillin-tazobactam, and diflucan.

26. Moderator:C. Health-care associated infections • Discussants: ICU, Infx (5 mins.)

27. There was difficulty weaning the patient inspite of improving clinical and radiologic findings of the lungs. Patient remained vegetative with minimal eye opening, no regard, with roving eye movements. He also became quadrispastic.

28. ModeratorD. Complications of TB meningitis • What are the possible complications of TB meningitis? ( 3 mins. Each) • Neurology • Infectious disease • ICU

29. MRI of the brain (Jan. 3, 2014)

30. Moderator: • Neuroradiology (5 mins.) • Comments on the CT with extensive vasculitis, hydrocephalus, abscesses (?) • Patient was then referred to Neurosurgery for the progressive hydrocephalus and development of abscesses(?) • Neurosurgery • Neurology • Infectious disease • (3 mins. Each) • Open forum (5 mins.)

31. Case Protocol • Patient was referred to Rehabilitation medicine for PT and OT. • Medical management was continued. Patient was eventually weaned off and extubated. • He was discharged improved with the ff. PE and NE: • Awake, occasional smiling and crying • Decreased spasticity on all extremities, but no purposeful movement • (+) Withdrawal to pain • Bilateral Babinski

32. Objectives 5. To design a framework for the long term management of post-CNS infectious cases with sequelae by the different members of the multidisciplinary team.

33. Plans of the different services (15min) • Neurology- AEDs • Infectious- anti-koch’s • Rehabilitation med • Pediatric Palliative care OPEN FORUM

34. Summary • Diagnosis • Treatment • Complications • Long term care

35. Update • After a month, MRI was repeated which showed resolution of the abscesses. Ventriculomegaly persisted. • On follow-up, patient has no regard, with roving eye movement, smiles occasionally, sits with support in his wheelchair (with contraptions), fed per orem. He undergoes PT 3x a week, and OT 2x a week.

36. The End