1. Pediatric Infectious Diseases City-wide Round Dr. Daifallah Al Malki Fellow, Pediatric Infectious Diseases Department of Pediatrics College Of Medicine King Khalid University Hospital King Saud University Octobe 16, 2012

2. Patient’s History 15 month old Saudi boy admitted on 06/05/12 Presented with: Fever Vomiting Loose motion for 5 days

3. Patient’s History No skin rash No contact with sick patient or travelling history Systemic review unremarkable No previous medical or surgical problems

4. History Normal neonatal history Developmental and vaccination history up to age Has other two-siblings –normal, consanguineous parents

5. History Patient was seen 3 days prior to admission in ER with:  Same complaint  History of lower back discharge

6. Course In the ER The patient was seen again with the same symptoms highly febrile, sick-looking and his first visit investigations including blood culture and urine culture were negative. The ER team decided to do lumber puncture before starting antibiotics so CT brain and spine X-rays were done. Lumber puncture was done and pus was coming out, thus the patient was admitted to PICU and started on ceftriaxone and vancomycin.

7. Patient

8. Work Up In PICU CT-brain/spine done on admission…. CSF study on 6/5 : PUS cells ??? G.stain – G+ve cocci + G-ve rod Culture – TF

9. Consultation Seen by I.D. team on 07/05.. Patient was clinically stable, afebrile, conscious, active on room air Neck stiffness, increase reflexes, Dimple dry no discharge Impression -meningitis - possible collection with tract connection. Advice- -MRI- brain/spine -continue same antibiotics -neurosurgery consult

10. Course in hospital Remained stable, afebrile, room air, till early morning of 08/05 at 3AM patient spike 38.5,HR 150-210b/min BP 125/80 Again at 5.30 AM, HR 210, T 39.3 BP 145/75 with mottling Skin poor perfusion weak pulses irregular breathing so patient intubated connect to M.V. given 3 boluses of Ringer Lactate Inotropic agents. Antibiotics changed by picu to tazocin and vanco. And urgent CT brain/spine.

11. CT Spine showing dermal sinus tract communicating the skin to the thecal sac

12. CSF Culture:….. 1.) Bacteroides Fragilis 2.) Streptococcus milleri 3.) Staph.epidermidis.

13. BLOOD CULTURE : 6/5 and 8/5 -- Negative Urine c/s -- negative

14. I.D. F/U on 8 /5 seen by I.D. team as f/u… Impression: Polymicrobial meningitis with possibility of local collection at lower spine with tract connection need further study. Advice: 1- Repeat CSF study from ant. fontanelles 2- Stop tazo 3- Start meropenem + vancomycin + metronidazol 4-MRI brain/ spine

15. MRI lumbo-sacral spine Sagittal T2WI showing high signal intensity space occupying lesion in the conus medullaris and lumbar thecal sac (arrow) and the dermal sinus tract (double arrows)

16. MRI lumbo-sacral spine Sagittal T1WI pre (A) and post contrast (B) showing low signal intensity space occupying lesion in the conus medullaris and lumbar thecal sac which is peripherally enhanced in post contrast sequence MRI cervical / thoracic spine Sagittal T1WI post contrast (c) showing diffuse leptomeningeal enhancement surrounding the spinal cord A BC

17. MRI brain axial T1WI post contrast showing diffuse meningeal enhancement (arrow) as well as enhancement of 5 th cranial nerve (double arrows) indicate diffuse meningitis

18. Radiology Results: MRI-brain / spine Spine- finding goes with intraspinal mass lesion (dermoid) with dermal sinus complicated by abscess formation in the lower spinal canal and meningitis (spinal,brain).

19. Laboratory findings: NEUT.PLTHBWBCDATE 79%1861015.87/5 631968.218.58/5 77177818.69/5 transfusion752217.517.210/5 9221815.142.211/5 7426014.22412/5

20. LABORATORY FINDINGS: SugarAlbCLKNaCreat. UreaDate 8.4211004.5137413.68/5 24130433.110/5 14.2221433.1173482.811/5 41171442.7184893.312/5

21. 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.

22. Course Patient continue s to deteriorate since early morning of 8/5 with deterioration of GCS According to MRI finding on 9/5 Patient taken to OR on 12/ 5 Drainage of abscess formation in the lower spinal canal And sacral sinus excision = laminectomy of L 3, 4, 5 Patient received from OR showing 2hr later sign of increase ICP, HTN, bradycardia,. Patient on same day arrested 2 times, on the 2nd time at 23.06pm of 12/5 He did not respond to resuscitation.

23. Dermal sinus tract www.themegallery.comCompany Logo

24. DSTs In cases of tethering spinal cord: -Gait difficulty and bladder dysfunction,reccurent meningitis are common neurologic presentations. -The early diagnosis of DSTs mainly depends on a highly suspicion. -Skin stigmata, such as a sinus ostium, hypertrichosis, abnormal pigmentation, subcutaneous lipoma, local infection or induration, repeated meningitis of unknown origin -The gold standard of surgical interventions of DST includes complete resection and intradural exploration. -In case with active infected lesions: surgery is recommended 3-4 weeks after the infection has been controlled with antibiotics.

25. Infected Spinal Dermal Sinus Tract with Meningitis Yi-Min Wang, Ming-Jung Chuang, Min-Hsiung Cheng Acta Neurol Taiwan 2011;20:188-1911 Abstract Purpose: Congenital dermal sinus tract (DST), an uncommon entity of cranial or spinal dysraphism, occurs along the midline neuraxis that may arise from nasion and occiput down to the lumbar and sacral region. It is often diagnosed in infants and children for skin signs, neurological deficits, local infection, meningitis, or abscess. For spinal DST, there is a paucity of case or series report in Taiwan. Case Report: In this paper, we report a case in a 6-year-old girl. The girl presented with midline lumbar skin dimple, hypertrichosis, and history of bacterial meningitis. She was successful treated by surgical excision of the DST with local infection that ended within the subarachnoid space between L2-3 vertebrae. Conclusion: This case highlights the importance of a thorough examination of the midline craniospinal axis in children with meningitis or history of meningitis.

26. Lumbar region skin stigma: pinhole opening and focal hypertrichosis (arrow).

27. MRI of patient 2A showing a dermal sinus tract extended into the spinal canal (arrow). (2B): Contrast-enhanced T1 weighted sagittal lumbar MRI showing subcutaneous enhancement (arrowhead)at L2

28. Dermal sinus tract-review In 1990, a review of all published cases of congenital spinal dermal sinuses reported that: 1% occurred at the cervical level, 10% at the thoracic, 41% at the lumbar, 35% at the lumbosacral region More than 90% of DSTs terminate into subdural space; nearly 60% enter the subarachnoid space 27% are attached to the neural elements Associated anomalies of DST include: bifid lamina, tethered cord, inclusion tumors (epidermoid and dermoid cyst), split cord malformation, tight filum terminalis, Spinal dysraphism such as lipomyelomeningocele and myelomeningocele

29. Can J Infect Dis. 2004 Jan-Feb; 15(1): 53–54. Headache, fever and back pain in a 16-year-old boy Alireza Nateghian, MD, Vivek Mehta, MD, and John L Robinson, MD His neck was stiff and a positive Brudzinski sign was present Non contrast brain CT scan was normal cefotaxime and vancomycin were started. Staphylococcus aureus was isolated from the CSF culture in broth after 72 h but there was no growth on the primary agar plates MRI..revealed an intradural, extramedullary oval rim-enhancing collection in the posterior canal at the L4 level, sinus tract which went between the L5 and S1 discs down to the dura and led to an inflamed and ruptured epidermoid cyst partial L2 and complete L3 to L5 bilateral laminectomy were performed So the massege of this case…… All spinal dermoid and epidermoid cysts should be excised. Urgent surgical drainage followed by appropriate antibiotic therapy for polymicrobial organisms is the usual management of paraspinal abscesses. www.themegallery.comCompany Logo

30. Dermal sinus tracts of the spine-review of 23 cases SCOTT ELTON, M.D., AND W. JERRY OAKES, M.D. Departments of Neurosurgery and Pediatric Neurosurgery, Children’s Hospital, Birmingham 2001, Alabama. The authors review their experience with 23 dermal sinus tracts treated between 1981 - 2000 by the senior author. The clinical findings, radiographic appearance, treatment, and pathological findings of these lesions will be discussed. The authors will also provide a summary of the literature covering these lesions

31. Dermal sinus tracts of the spine-review of 23 cases We found a total of 23 patients treated for dermal sinus tracts of the spine. Thirteen were male, and 10 were female. The average age was 6.6 years (range 5 days–38 years). Six (26%) of 23 patients harbored intradural dermoid cysts: three were intramedullary, and three were intradural but not involving the spinal cord. Nine (39%) of 23 presented with other findings of occult spinal dysraphism. There were two children with lipomyelomeningoceles and three with diastematomyelias. In eight of 23 patients, the findings were consistent with a tethered spinal cord. All were surgically treated. There was no incidence of mortality in this series. There were no cases of surgery-related neurological worsening in those children who presented with neurological deficit. No patients suffered a neurological insult as a result of intervention. No other deficits were incurred. www.themegallery.comCompany Logo

32. Case review 2002 Mar-Apr;36(2):393-401. [Vertebral canal abscess as a complication of congenital sacral sinus in a two year old girl]. Gamza M, Mandera M, Jamroz E, Kluczewska E, Marszał E. Gamza MMandera MJamroz EKluczewska EMarszał E Source Kliniki Neurologii Wieku Rozwojowego Slaskiej Akademii Medycznej w Katowicach. Abstract Vertebral canal abscess is rather an uncommon disease. Since 1830, when the first report that spinal of abscess was published. Till to 2000, no more than 20 cases as a result of dermal sinus infection were reported. Dermal sinus results from an incomplete separation of the cutaneus ectoderm from the neural ectoderm between the 4 and 6 weeks of fetal development. Surgical excision of the sinus is the treatment of choice for prevention of infection. The authors describes a 2-year-old girl with that abscess secondary to dorsal dermal sinus in sacral region. The patient presented with fever, since two weeks, flaccid paraparesis mainly in the right lower extremity, urinary and bowel incontinence. The child was initially treated conservatively, and after limitation of inflammatory process the dermal sinus and dermoid cyst containing a large quantity of pus were excised. The authors reviewed the literature of spinal cord abscesses secondary to congenital dermal sinus.

33. Case review 1997 Dec;25(6):1462-4. Anaerobic meningitis due to Peptostreptococcus species: case report and review. Korman TM, Athan E, Spelman DW. Korman TMAthan ESpelman DW Source Department of Microbiology, Alfred Hospital, Prahran, Victoria, Australia. Abstract We describe a patient with postsurgical anaerobic meningitis due to Peptostreptococcus magnus. In cases of meningitis associated with Peptostreptococcus species reported in the literature, the most common predisposing factors are meningorectal fistulae and head- and-neck surgery. Most patients respond well to appropriate antimicrobial therapy. Surgical intervention may be required in some instances.

34. Review 1 Anaerobic meningitis after missed penetrating trauma in a 6-year old child Yael Shachor-Meyouhas a,*, Joseph N. Guilburd b, Gad Bar-Joseph c, Imad Kassis a 2010 Published by Elsevier Ltd www.themegallery.comCompany Logo

35. Review1 Anaerobic meningitis may occur alone, but is usually encountered as a complication of a brain abscess. In either case it is rare in a normal host. We present a 6-year old boy with anaerobic meningitis after missed penetrating trauma, stressing the need for a thorough investigation after head trauma. www.themegallery.comCompany Logo

36. CT scan demonstrating a depressed fracture and bubbles tract www.themegallery.comCompany Logo

37. CT scan demonstrating early formation of brain abscess and generalized gyral enhancement with contrast media. www.themegallery.comCompany Logo

38. CT scan 6 weeks after therapy with remnant evidence for brain abscess www.themegallery.comCompany Logo

39. Final diagnosis Polymicrobial meningitis with infected dermoid cyst + dermal sinus complicated by abscess formation in the lower spinal canal and meningitis (spinal, brain).