8 month old male presented with vomiting for 5 days Case discussion 8 month old male presented with vomiting for 5 days Intern: 林伯昱

Identifying Information 陳O睿, 8-month-8-day-old male Birth history: G1P1, term, AGA, C.S (mother spinal cord injury) Growth and development: BH: 73cm(75%~85%), 8.3kg(25~50%) No developmental delay Past medical history: Convulsive episode at 1 week old, no diagnosis after survey Falling from bed two times in the past Seborrheic dermatitis History of carbuncle and furuncle NKDA Chart Number： 16731650

History of present illness (2 versions) 8 days prior to admission (5 days) Fall from bed: 80 cm high, head on floor Crying, no LOC, no seizure, no limb weakness 6 days prior to admission (3 day) Decreased oral intake: congee + 150ml QID  120ml QID Vomiting every day after oral feeding, esp. morning feeding 2 days prior to admission (1 day) Vomiting persisted Fever up to 38 degree Celsius, wax and wane Dry cough, no diarrhea, no sputum production, no skin rash Grand mother had dry cough also

Family history Dry cough for weeks

Physical examination T：38.6oC, P：156/min, R：32/min, BP：111/64mmHg General: fair spirit, loud crying, easily consoled HEENT: Fontanel not bulging, no scalp hematoma Pink conjunctiva, anicteric sclera, injected throat, no ulcer no pus Neck: freely movable, no palpable LAP Chest: clear breath sound, no crackle, no wheezing Heart: regular heart rhythm, grade II systolic murmur, esp. apex Abdomen: normoactive bowel sound, normal on palpation Limbs: warm, active peripheral pulses Skin: no petechiae, no ecchymosis, no rash

Neurologic examination Light reflex: normal Extraocular movement: normal Gag reflex: normal Normal muscle tone, no limb weakness

Lab data on admission

Impression Fever Head injury Dry cough, injected throat, contact history CBC no left shift, CRP: 16.7mg/L, U/A(-) Plan: throat swab viral test, supportive care Head injury Vomiting after eating every day, no scalp hematoma Discrepancy in history, previous head trauma Neurosonography: subdural, subarachnoid effusion Plan: Eye fundus, long bone X ray, brain MRI Consult social worker

Ophthalmoscope examination No retinal hemorrhage (OU)

Long bone X ray

MRI, GRE 10 days post injury

Consult social worker Good family support, enough care takers. No medical evidence of shaking baby syndrome Informed the family to reinforce child safety at home

CSF data Blood

Throat swab Stool Blood culture

5th day after admission Fever abruptly subsided Maculopapular rash appeared on trunk Roseola infantum The patient was discharged after 24 hr fever free.

Discussion: Evaluation of suspected shaking baby syndrome

History Retrospective case series, 163 cases 0-3 y/o, presented with acute traumatic intracranial injury History Reference: Pediatrics. 2003 Mar;111(3):602-7

History Reference: Pediatrics. 2003 Mar;111(3):602-7

History Prospective case series, 87 head injury patient, < 2y/o Reference: Pediatrics. 2004 Jul;114(1):165-8

PE Retinal hemorrhage: deep, peripheral, multiple Prospective case series, 104 cases 24 hours of admission to PICU, Royal Hospital for Sick Children Edinburgh PE Retinal hemorrhage: deep, peripheral, multiple Reference: Pediatrics. 2012 Nov;130(5):e1227-34.

PE: other Cutaneous bruising Rib fracture: esp. posterior Long bone fracture: esp. metaphyseal Reference: CMAJ. 2003 Jan 21;168(2):155-9

Lab CBC, coagulation profile CSF: xanthochromia, RBC, myelin basic protein(?)

CT in acute condition Subarachnoid: equal Epidural: not likely Systemic review, 1970-2010, <11 y/o patient, most < 3 y/o CT in acute condition Subarachnoid: equal Epidural: not likely Reference: Arch Dis Child. 2011 Dec;96(12):1103-12.

CT in acute condition Multiple SDH over the convexity, posterior fossa Systemic review, 1970-2010, <11 y/o patient, most < 3 y/o CT in acute condition Multiple SDH over the convexity, posterior fossa Interhemispheric hemorrhage Hypoxic-ischaemic injury Cerebral edema Reference: Arch Dis Child. 2011 Dec;96(12):1103-12.

MRI For evaluation of actual damage amount

An additional case in brief

A patient with similar history 4 m/o, previously healthy HPI: Fall from bed when changing diaper Presented with vomiting, decrease oral intake On examination: No scalp hematoma Neurosonography: subdural and subarachnoid effusion

Diagnosis Shaking baby syndrome

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