1. Case presentation

2. Patient’s History 15 mo old saudi boy DOA 06/05/12 Presented with fever vomiting loose motion for 5days

3. Patient’s History no skin rash no contact with sick pt, or travelling history systemic review unremarkable no previous medical or surgical problems normal neonatal history developmental and vaccination history up to age has other two-sablings –normal, unconsanguineous parents

4. Question..?? D. Diagnosis…

5. Patient’s History Patient was seen 3 days back in ER same complain lower back discharge

6. Examination On 03/05…… stable. Dehydrated, v/s- T-38.2 Meningeal signs -? Redness over lower back Yellowish to green discharge Sacral dimble –dray Wbc 20.4, Neut. 73% Hb 10.5 PLT 473 blood c/s –no growth Urine – n Treatement….

7. Any idea…….

8. Examination on 06/05…… lethargic, sick, dehydrated v/s- T- 39 CNS..neck stiffness, increase reflexes in U., L. limb CT-brain and spine CSF STUDY : On 6 / 5 L.P. ---- PUS cells G.stain – G+ve cocci Culture – TF CBC … 15.8 -- Neu. 79% PLT 186 Ceftriaxon + vancomycin picu

9. For I.D. Consultation……

10. Consultation Seen by I.D. team on 07/05.. pt was clinically stable, afebrile, conscious, active on room air nick stiffness, increase reflexes, dimble dray no discharge impression – possible collection with tract connection. - meningitis advice- continue same medication - MRI- brain, spine seen by neurosurgery on call 6/5 advice for MRI brain /spine

11. Radiology CT-brain and spine without contrast on admission: bilat.decrease cerebral white matter with prominent ventricular system goes with hypoxic ischemic insult - no evidence of increase ICP or HGE Or mass lesion Spine-preserved disc spaces – spina bifida at sacrum.

12. Coarse in hospital Remain stable, afebrile, room air, till early morning of 08/05 at 3am pt spike 38.5, HR 150-210b/min BP 125/80 ….so kept NPO, paracetamol given HR 130, BP 110/70, T 37 So antibiotics changed by picu to tazocin and vanco Again at 5.30 am, HR 210, T 39.3 BP 145/75 with motlling skin poor perfusion weak pulses irregular breathing so pt intubated connect to M.V. given 3 boluses of R.L. Inotropic agents.

13. For I.D. Follow up….. For I.D. Follow up…..

14. Lab Report On 8 / 5 ………

15. B. Fragalis + S. millarae + Staph epid.

16. I.D. F/U on 8 /5 seen by I.D. team as f/u… Immpresion: polymicrobial meningitis with possibility of local collection at lower spine with tract connection need further study. Advice: 1- Repeat CSF study from ant. fontanelle 2-stop tazo 3-start meropenem + vancomycin + metronidazol 4-MRI spine

17. ECHO – N CSF on 8/5 – from Anterior fontanelle : clear WBC 15, RBC 20, polymorph 30%, lymphocyte 70%, G.S. – NOS, culture – no growth. CSF on 10/5 - L.P. : Bloody sample WBC 10, RBC 1280, lympho 100%, G.S. - NOS, culture – no growth.

18. coarse Pt continue deteriorating since early morning of 8/5 with deteriorate of GCS According to MRI finding on 9/5 pt taken to OR on 12/ 5 for abscess drinage and sacral sinus excision = laminectomy of L 3, 4, 5 Done after dropping of GCS from 7/15 to 3/15 Pt received from OR showing 2hr later sign of increase ICP HTN, bradycardia,. Pt on same day arrested 2 times, on the 2nd time at 23.06pm of 12/5 he did not response to resuscitation.

19. Radiology 1-CT- brain without contrast and spine on admission 6/5 ….. bilat.decrease cerebral white matter with prominent ventricular system goes with hypoxic ischemic insult - no evidence of increase ICP or HGE Or mass lesion Spine-preserved disc spaces – spina bifida at sacrum. 2- CT – brain and spine on 8/5 : Spine- track extending from skin in the sacral region to the spinal canal, need MRI for further evaluation. Brain- hemorrhage in Lt lateral ventricule with increase density along the right side of the falx suggest subdural hemorrhage.

20. Radiology MRI-brain / spine on 9/5 : spine- finding goes with intraspinal mass lesion (dermoid) with dermal sinus complicated by abscess formation in the lower spinal canal and meningitis (spinal,brain). brain- evidance of small subdural and intraventricular hemorrhage. Also images of lower spine shows subcutaneous soft tissue swelling with sinus tract extending from the subcutaneous tissue to the spinal canal at the level of the sacral vertebrae S3 associated with spina bifida. MRV- no evidence of dural sinus thrombosis.

21. Radiology CT- brain on 12/5 : generalized brain edema with hemorrhage in Lt lat. Ventricule and subdural hemorrhage and mild subarachnoid hemorrhage in right frontal lobe.

22. Lab finding NEUT.PLTHBWBCDATE 79%1861015.87/5 631968.218.58/5 77177818.69/5 transfusion752217.517.210/5 9221815.142.211/5 7426014.22412/5

23. LAB SugarAlbCLKNaCreat.UreaDate 8.4211004.5137413.68/5 24130433.110/5 14.2221433.1173482.811/5 41171442.7184893.312/5

24. Coagulation profile : 9/5 --- PT 13.7 - PTT 40.8 D-Dimer 3.45 12/5 --- PT 21.1 - PTT 35 Ratio 1.8 D-Dimer >20 BLOOD CULTURE : 6/5 and 8/5 -- Negative Urine c/s -- negative S. Ammonia - 25

25. Final diagnosis polymicrobial meningitis with infected dermoid cyst + severe cerebral edema and global brain ischemia + severe brain injury.