The encephalopathic child is a paediatric emergency and presents a considerable challenge.
We present a 4 year old boy who was admitted with 3 week history of excessive fatigue and sleepiness, waking for only 4–5 hours a day. He had occasional episodes of vacant stares and “wanted to go home”, when was at home.
He had gastroenteritis after exposure to snails at nursery and was treated for otitis media by general practitioner. There was no history of fever or foreign travel.
He was sleepy with normal neurology and an apthous ulcer over lower lip. He was managed as encephalitis and treated with acyclovir, ceftriaxone and clarithromycin. He had neutrophilia with normal lumbar puncture and viral PCR’s.
After a week of admission, he deteriorated with generalized pain, bedwetting, ataxia and upper motor neuron signs. MRI scan showed asymmetric, bilateral white matter changes suggestive of acute demyelinating encephalomyelitis (ADEM) or other viral encephalitis.
Repeat lumbar puncture showed pleocytosis with neutophilia. Viral PCR’s were negative. ASOT was raised. MRI with contrast showed 4 mm high signal focus behind C2 body and C2–3 disk.
After completing a 10 day course of acyclovir, he was started on methyl prednisolone for ADEM and drastically improved. He was discharged after 3–4 days of the treatment with follow up.
This case initiated a lot of discussions- presence of fever to diagnose encephalitis? When to start and stop acyclovir in suspected encephalitis with negative viral PCR’s? To start steroids or not - why the delay?