3 thoughts on “Hot Seat #78: 5yo F with fever and AMS”

1. 
   

   Hello everyone….August vacations have left this blank….

   Let me try my hand at this….

   What’s going on with this kid? Well, that’s a little unexciting as most of us are in the same ballpark with the choices of dispo and therapies: meningitis, encephalitis or some combination thereof.

   Then this really becomes a discussion of where do I fall on the risk tolerance/aversion spectrum and clearly there’s a distribution here. To me, risk tolerance is a funny thing, informed by experience, anecdotes, other’s anecdotes and some attending’s comments in residency and/or fellowship.

   As I was recently sharing with the first years, residency training comes over with a “this is THE way to manage X” and not until you get out and/or do fellowship can you realize that there are options. Even as a resident, when we were told different things, we often wrote it off (or were told to write it off) to “that” attending just does it differently….no why, no to limited analysis at best. To me, it’s interesting as I discuss cases with residents how the perception still sticks of “that’s THE way to treat X” despite many of us thinking that we are open and willing practitioners acknowledging the different practice patterns. To me, that comes down to the busy-ness of the ED and limited opportunity to engage in those discussions, so the resident still takes away “THE” only way to treat X.

   Anyhow, it’s those comments/thoughts that start to inform our risk tolerance: Don’t send a kid home with THAT….THAT can always go home and be managed outpatient…We like to think there are black and white rules about it but we know there aren’t. Recall the pediatricians’ study where neonates with fever (<28 days) had a decent percentage (20-some %, I believe) being discharged home (with close follow-up likely).

   As long as we actively think about what risks are we tolerating, what are we not accepting and where does that leave us in the big picture of healthcare resources, balanced against this particular patient and family's situation, we'll find a judgment that sits well with us and lets us fall asleep after that shift (hopefully)….

   I'll let others chime in on this or other topics….

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2. 
   

   In this child with meningitis, the decision is how to approach treatment and whether to hospitalize. The Bacterial Meningitis Score is a prediction rule to define pediatric patients with pleocytosis who are at low risk for having bacterial meningitis. Low-risk features include: negative CSF Gram stain, CSF ANC <1000 cells/μl, CSF protein <80 mg/dl, peripheral blood ANC <10 000 cells/μl and no seizure at or prior to initial presentation. This retrospectively-derived rule has subsequently been found to be accurate in identifying the low-risk children. In this case, the patient meets low risk criteria for bacterial meningitis- as long as her CBC look ok.
   If I say that this is probably viral meningitis, then I know the most common cause is one of the enteroviruses, such as coxsackie. The next question is whether there is risk for HSV. Clinical parameters to increase my level of concern include altered mental status and seizures, while elevated protein on the CSF is a lab parameter that would make me consider HSV (and other causes). If her mental status is sufficiently altered, then there are the less common causes of meningoencephalitis to consider, such as the arboviruses (mosquito-borne viruses), such as Eastern Equine, Lacrosse, and others– these tend to be region-specific.
   To return to Pavan's point, the treatment plan depends on risk tolerance. Some clinicians would give ceftriaxone in the face of the pleocytosis, while some would be reassured by the low risk features of the CSF. Further, some would tolerate the sleepiness with normalization of vital signs while others would want to hospitalize and treat with antivirals and antimicrobials.

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3. 
   

   This patient has fever, AMS and clinical features concerning for an infectious process involving the brain +/- meninges. She has AMS, which is more consistent with meningoencephalitis.

   The CSF findings suggest a viral rather than bacterial infection with normal glucose and protein and 60% mononuclear cells.

   Characteristic clinical features of viral infection at specific sites of the CNS can be blurred:
    Meningitis – Fever, headache, nausea, vomiting, photophobia, and stiff neck
    Encephalitis – Altered mental status (decreased level of consciousness, lethargy, personality change), seizures and focal neurologic signs, fever, headache, nausea, vomiting
    Rhombencephalitis (brain stem encephalitis) – Myoclonic jerks, tremor, ataxia, cranial nerve involvement, respiratory distress, shock, and coma
    Myelitis – Muscle weakness, bladder dysfunction, flaccid paralysis, and reduced or absent reflexes
    Radiculitis – Muscle weakness, shooting pain, dysesthesia, and diminished reflexes

   This patient presents in July and I would consider enteroviral disease since this is more prevalent during summer and fall months. A wide variety of viruses can cause encephalitis (see table 1) and you should look for clinical features that may help in isolating the cause e.g. herpangina may suggest HSV infection, travel to areas with arboviruses eg West Nile virus, etc. Despite intensive testing, many viral causes remain unidentified.

   Other causes of encephalitis to consider include post-infectious or acute disseminated encephalomyelitis, ADEM, which would typically not present with fever as in this case. Also autoimmune encephalitis is increasingly being recognized in older children. Toxins and metabolic disorders as well as intracranial masses should be considered but in this case the fever and CSF results indicate an infectious process. Neuroimaging was also negative, and was rightly obtained prior to the LP.

   As Pavan discusses, disposition depends on your risk tolerance. If the patient seemed to dramatically improve with the IVF bolus and after the LP (some patients with viral meningitis improve after an LP), and I suspected the AMS was more related to dehydration from poor feeding/headache and she is not encephalopathic, I might consider sending home with close follow up. If however she remained altered or not quite back to baseline, I would admit for observation and to ensure she improves rather than deteriorates. Complications of acute viral encephalitis may include status epilepticus, cerebral edema, SIADH, and cardiorespiratory failure. Patients with encephalitis and disseminated HSV may have DIC.
   Indications for hospitalization may include:
    Ill-appearance or signs of encephalitis
    Need for empiric antimicrobial therapy
    Need for intravenous hydration or aggressive pain control
    Immunocompromised host
    Age < 1 year

   The decision to treat children with suspected viral meningitis with empiric antibiotics while awaiting bacterial cultures should be on a case by case basis and based upon epidemiology and clinical factors, such as season, age and clinical status of the child, exposure history, and findings of the initial evaluation. Because of the serious consequences of delayed treatment for bacterial meningitis, the threshold to initiate empiric antibiotic therapy should be low.

   Because of the initial presentation with AMS, I myself would admit this patient and cover empirically with ceftriaxone and acyclovir while awaiting bacterial culture results. I would send additional CSF tests for HSV, west nile virus, arboviruses, and enteroviruses.

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