Clinical Assessment of Children with Suspected Central Nervous System Infections

Clinical Assessment of Children with Suspected Central Nervous System Infections Brain Infections GroupUniversity of Liverpool, United Kingdom

Using this presentation Introduction Checking the sick child History taking General questions JE-related questions Neurological disease Seizures or abnormal movements Completion of patient history Example of a history proforma Examination Neurological examination 1.0 Observation 2.0 Assessment of mental state or conscious level 2.1 Assessing mental state 2.2 Assessing conscious level 3.0 Examination of the central nervous system 3.1 Cranial nerves Neurological examination continued: 3.2 Cerebellar tests 3.3 Brainstem 3.4 Special tests 3.5 Clinical significance of findings 4.0 Examination of the peripheral nervous system 4.1 Tone 4.2 Power 4.3 Reflexes 4.4 Sensation 4.5 Gait Examination General Example of examination proforma Example cases 1-4 Additional Resources Acknowledgments Contents

Using this presentation (1) • This presentation can be viewed by: • Clicking through each slide consecutively. • Clicking on the arrows on the bottom right and left of each screen. • Clicking on items on the contents slide to go to that slide. • To return to a slide after clicking a link, click • To get back to the contents page from any slide click on the house image. • To exit press the arrow and line image.

Using this presentation (2) • This presentation contains still images linked by an arrow button. • There are notes below many of the slides to assist presenters.

Introduction (1) • This presentation has been developed for use by doctors and health care workers in areas where Japanese encephalitis (JE) is endemic. • It is designed to identify key aspects of the clinical assessment and neurological examination which are of particular importance in encephalitis patients, with particular emphasis given to JE. • There are examples of normal and abnormal cases illustrated using photos and video clips of normal children and children with Japanese encephalitis or who presented with an acute encephalitis syndrome. Additional case examples at the end of the presentation may be used for small group discussion.

Introduction (2) • At the end of the presentation participants will • Be better able to take a history with specific questions for encephalitis patients. • Be better able to examine a patient with encephalitis. • Be aware of what neurological problems to look for and how to examine them. • It is not meant to give exhaustive instruction in clinical examination as there are many excellent textbooks available for this. Some are listed at the end of this presentation. • The tool is freely available, but when using it, please acknowledge the University of Liverpool, UK, and PATH.

Checking the sick child Check the ABC’s: • Airway • Breathing • Circulation

Patient history: general questions (1) • Presenting history • What brought them to hospital, details, length of time complaint has been present, triggers (if any) • Fever, history of fever • Note that even if a child is not febrile at this time, a history of fever is important • Cough, cold symptoms, redness of the eyes • Assess current hydration/nutritional state • Diarrhoea, vomiting, recent food and fluid intake and urine output • Immunization history

Patient history: general questions (2) • Social history • Economic circumstances • Childcare/schooling • Medication/Treatment • Ask about recent and current medications • Ask specifically about traditional medicines • Check for any known allergies • Family history (e.g., history of tuberculosis, epilepsy, diabetes, or asthma)

Patient history: JE-related questions (1) Is this an area where JE occurs? Is this the JE season? In much of the tropics the season begins soon after the rainy season However in many areas there is low level transmission even out of season Have other children had a similar illness? Does the child live in a rural area, where JE is more likely? Note that JE also occurs on the edges of some cities in Asia

Patient history: JE-related questions (2) Are there epidemiological features to suggest that this is NOT JE? Are animals sick? The virus does not cause disease in birds or swine (though it may cause abortions in pregnant swine). Are many adults affected? JE causes less disease in adults than children (or no disease in adults at all) because most individuals have been exposed to the virus and developed immunity during childhood. Does it appear to be transmitted by a different route (e.g., direct contact, faecal-oral route, or aerosol) ? There are many viruses, bacteria, and parasites which could be included in the differential diagnosis. Malaria, dengue, and typhoid are just a few important ones to consider.

Patient history: neurological disease (1) Ask about: • Stiff neck • Photophobia (avoidance of light) • Phonophobia (avoidance of noise) • Confusion/irritability/restlessness • Altered behaviour • Sometimes mistakenly attributed to psychiatric illness

Patient history: neurological disease (2) Ask about: • Altered cry • High pitch cry is a late sign of raised intracranial pressure (ICP) • Limb weakness • Has the child stopped walking, or stopped using one hand? • Does he/she normally use the right or left hand, and are there any changes in this since illness?

Patient history: seizures or abnormal movements (1) • Ask about abnormal movements of eyes, face, limbs. • Distinguishing convulsions from spasms, tremors and rigors is difficult. • It is often easier to ask the parent to mimic the movements the child made rather than describing them. They are more likely to do this if the health care worker sets an example. • The distinction is important because • Seizures may need anticonvulsant drugs. • Characteristic spasms and tremors are seen in some types of viral encephalitis (e.g., JE) and so may point toward the diagnosis.

Examples of seizures or abnormal movements • Ask parent to mimic seizure / abnormal movements………………………………. • Seizure……………………………………. • Subtle seizure……………………………. • Orofacial movements……………………. • Go to slide 20: Seizures and abnormal movements (2)……………………………

Asking parent to mimic child’s seizure or abnormal movements Return to examples

Seizure activity in JE patient Return to examples In this patient, the left arm was shaking slightly (subtle partial seizure)

Subtle seizure activity Return to examples

Orofacial movements are characteristic of patients with JE Return to examples

Patient history: seizures or abnormal movements (2) • If seizures are reported, ask about frequency and duration. • Changes in frequency and duration of seizures are used to monitor treatment effectiveness. • Ask if any seizure has been followed by unconsciousness for >30 minutes. • Status epilepticus (seizure lasting >30 minutes) is important to look for. • It is a poor prognostic indicator. • The seizures of status epilepticus may be subtle partial seizures.

Completion of patient history • Growth chart • Height for age and weight or mid upper arm circumference. • Family tree and birth history • Previous illnesses • Systems review • Respiratory system: coughs/colds/asthma • Cardiovascular system: palpitations, arrhythmias, rheumatic heart disease, murmurs • Gastrointestinal: diarrhoea and vomiting, hepatitis, bladder and bowel function • Central Nervous System: headaches, vision problems.

Example of a history proforma

Neurological examination Neurological examination includes: • Observation • Assessment of mental state or conscious level • Examination of the central nervous system (CNS) • Cranial nerves I-XII • Cerebellar function • Brainstem tests • Special tests • Examination of the peripheral nervous system (PNS) • Muscle tone • Limb muscle power • Reflexes • Sensation in limbs • Gait

Observation • Simple observation is vital • A huge amount of information can be gained for the examination by observation alone. • A full formal neurological examination is time consuming and will not be tolerated by small children. • Observe as much as you can before disturbing the child, then begin to examine with minimal disturbance. Look for: • Any obvious abnormalities or asymmetry • Bulging fontanelle in young infants and children • Reduced spontaneous movements of one or more limbs • Abnormal posture • Abnormal movements, subtle seizures

2.1 Assessing mental state • Assessing mental state can be difficult, particularly in young children. • Surrogate questions can be used, asking parents or carers about: • Behavioural changes • Mood swings and temper tantrums • Concentration levels • School work • Ability to help with tasks around the house

2.2 Assessing conscious level The Glasgow Coma Score is the most widely used score A modified Glasgow Coma Score exists for children <5 years old A simple AVPU score (Alert/Voice/Pain/ Unconscious) allows a very rapid initial assessment, and is better than nothing An example of the sternal rub is provided, used with the Glasgow coma scale

Glasgow Coma Score and the James Modification for children <5 years Return to examples AVPU

AVPU rapid assessment of consciousness level • A ALERT • V responds to VOICE • P responds to PAIN • U UNRESPONSIVE Return to examples GCS

Glasgow Coma Score: Sternal rub - patient localises to pain

3.1: Cranial nerves I-VII • This examination can be done in older children and adults. • I Olfactory • Is the sense of smell normal? • II Optic • Is visual acuity normal? • Do the pupils react to light and to accommodation? • Are the visual fields normal to confrontation? • Are the optic fundi normal? • III, lV, Vl Oculomotor, Trochlear, Abducens • Are the eye movements normal? • Is one pupil dilated (IIIrd nerve lesion)? • V Trigeminal • Is sensation normal on the face (and cornea), and is jaw power normal? • VII Facial • Is there facial weakness?

3.1(cont.): Cranial nerves Vlll-XII • VIII Vestibulocochlear • Is hearing reduced? • IX Glossopharyngeal • Is sensation in the pharynx normal (tested by eliciting the gag reflex)? • X Vagus • Do both sides of the palate move when the patient says “Agh”? (And during the gag reflex?) • XI Accessory • Do the shoulders lift? Is power of head turning normal? • XII Hypoglossal • Does the tongue look and protrude normally?

3.1 (cont.): Eye examination • Optic (II) • Visual acuity: Snellen chart or “E” card • Visual fields: confrontation test • Optic and oculomotor (II, III) • Light reflexes: direct and consensual • Oculomotor, Trochlear, Abducens (III, IV, VI) • Eye movements • Examine the optic discs • Doll’s eye reflex

Eye examination - examples Visual acuity charts………………...... Direct light reflex……………………… Eye movements…………………….... Right VIth nerve palsy:.……………… Bilateral VIth nerve palsy: video…..... Ophthalmoscopy right eye…………… Ophthalmoscopy left eye……………. Ophthalmoscopy young child……….. Go to slide 45: Cranial nerves V-Xll…

Visual acuity charts E Ш E Return to examples E Ш E Ш E Ш E Ш Ш EШ Ш Ш E Ш EШ E Ш E EШ EШ EE E Ш EШ Ш EШ E EШ Ш Ш E E Ш E EШ Ш Ш E E Ш E

Direct light reflex Return to examples Film credit: T Solomon

Eye movements: head still, instruction “follow my finger” Return to examples Photo credit: Tom Shulz

Right VIth nerve palsy–right eye is unable to abduct (move outwards) Trying to look this way Return to examples

Bilateral VIth nerve palsy–look carefully, neither eye abducts Return to examples

Ophthalmoscopy: examiner’s right eye to patient’s right eye Return to examples Photo credit: Tom Shulz

Ophthalmoscopy: examiner’s left eye to patient’s left eye Return to examples Photo credit: Tom Shulz

Opthalmoscopy: young child Return to examples Photo credit: Tom Shulz

Cranial nerves V-XII examples • V Trigeminal nerve examination..………………………. • V Trigeminal nerve: Jaw jerk normal……………………. • V Trigeminal nerve: Jaw jerk abnormal…...……………. • VII Facial nerve - “Screw your eyes up” ……………….. • V and VII nerves .………………………………………… • Hearing: Otitis externa/otitis media ……………………. • VIII nerve examination: Hearing ……………………….. • Vlll nerve: Profound hearing loss………………………. • XI nerve examination: Neck and shoulders…………... • XII nerve: “Stick out your tongue” ……………………… • XII nerve: Tongue movements………………………….. • Go to slide 57: Cerebellar tests………………………….

V Trigeminal nerve examination Return to examples Photo credit: Tom Solomon

V Trigeminal nerve: jaw jerk normal Return to examples Photo credit: Tom Solomon

V Trigeminal nerve: jaw jerk abnormal (brisk) Return to examples Photo credit: Tom Solomon

VII nerve examination: “Screw your eyes up” Return to examples

V and VII nerves: “Screw your eyes up,show me your teeth” Return to examples

Clinical Assessment of Children with Suspected Central Nervous System Infections