Hot Seat #17 Denouement: Sore throat and Headache

by Erin Augustine with Eiman AbdulRahman on the Hot Seat

The Case
This a case of a 4 year-old girl with headache, sore throat, and fever. During her stay in the ER, she was noted to have difficulty with coordination. For the full case presentation, click here.

Thank you to Dave, Dewesh, Rasha, and Jamil for their comments. Please click here to read their approaches to this case (scroll up). [Sonny's editorial comment: Highly recommend reading the commentary if you don't do it regularly, as they are filled with clinical pearls you can't readily get anywhere else. This is true both in cases of agreement and disagreement]

Here's how you answered our questions:
1. Would you perform repeat neck imaging at this time?

The patient is then observed having difficulty eating a Popsicle. When she attempts to bring it to her mouth, she repeatedly hits her nose instead. She also has a brief period of dysconjugate gaze and unilateral facial twitching. Her exam is otherwise unchanged. Given these new findings, a head CT is performed (click for CT).

2. Given the neurological findings and CT above, would you perform an LP?

3. If you perform an LP, would you start any anti-microbials while the results are pending?

Hot Seat Response
by Eiman AbdulRahman

I actually saw this patient on one of my overnights so I will describe her presentation when I saw her and my thoughts at the time. I guess I will forgo this opportunity to be on the hot seat.

When the resident presented the case of the patient with fever, sore throat, drooling, decreased po and decreased urine output, I was thinking more of an infectious etiology from an upper airway obstruction - RPA, bacterial tracheitis vs epiglottitis. In RPA, the abscess occurs in the anterior border of the cervical vertebrae and posterior wall of the esophagus - the deep, soft tissue space of the neck. All the children I have seen with RPA, similar to children with epiglottitis described in textbooks, are toxic appearing with high fever with neck pain - especially with movement of the neck. This patient was not drooling, nor posturing, had supple neck with only shotty LAD, no trismus or discomfort with neck movements. She was clingy to her father, sitting up on his lap, didn’t speak much and was not cooperative with neuro exam: symmetric face, no ptosis, no focality noted when squeezing my hands.

The description of her behaviour and speech changes was worrisome but it wasn’t clear if her speech was slurred or if she had changes in her speech because she wasn’t feeling well. My overall impression was of a developmentally delayed child with a febrile illness. Yet, her father assured me that this was not her baseline she previously was able to speak well with normal developmental milestones. I didn’t know what to make of “urinating on her father”. Her parents were more concerned with her weakness and briefly mentioned that she may be having headaches. I repeated another lateral x-ray, to rule out the possibility of early RPA (especially given the sore throat and drooling) and ordered labs and fluids to see if she would “perk” up after a bolus.

Re-exam after fluids, she remained sleepy/clingy but it was 3 or 4 AM, so what I usually do is get the patient to take a walk in the department to get a popsicle in order to get a sense of their overall health/mood. A neurologist once told me that the general impression of the child, their interaction with others and their surroundings is a great neurologic exam. In the middle of the night, getting the patient outside of their room into a new environment (with better lighting) within the department and giving them stickers/ popsicles to see their reaction can be very helpful. In this case, the patient with some prodding walked with normal gait, had improved energy, took the popsicle and attempted to lick it, missing her mouth a few times and touching her nose with the popsicle instead. At this point she also had twitching in the face, her speech was unintelligible vs some slurring - I couldn’t differentiate between aphasia or dysarthia. However, at this point, a neurological etiology was more likely and her presentation became very concerning for encephalitis. Her repeat lateral neck film was negative and with low suspicion for RPA so a CT neck was not ordered.

Neuro was consulted to see if they agreed with our plan to CT then LP prior admission for MRI. I will stop here before jumping ahead of the denouement.

The Denouement
by Erin Augustine

In the ED, initial tests demonstrated a normal CBC, BMP, and repeat neck x-ray. A head CT and LP were subsequently performed. The patient became progressively hypotensive with blood pressures of 70s/40s and a capillary refill of 3-4 seconds. She was given multiple fluid boluses and started on a dopamine drip. She received a Fosphenytoin load, Ceftriaxone, and Acyclovir. Her mental status remained unchanged and she was admitted to the PICU.

The patient’s head CT demonstrated ill-defined regions of hypodensity and loss of gray-white differentiation involving the bilateral posterior perisylvian frontal lobes. There was associated small amount of acute parenchymal and subarachnoid hemorrhage. These findings were consistent with encephalitis, and the presence of hemorrhage was suggestive of HSV. Her CSF was significant for RBCs 2000, WBCs 98, glucose 59, protein 41, and eventually, a positive HSV PCR.

The patient was diagnosed with HSV encephalitis and required dopamine for about 24 hours. She has nearly completed a 21-day course of Acyclovir, and continues to have dysphagia (receiving NG feeds), weakness, and poor coordination. The current plan is to discharge her to a rehab facility.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.