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

2. 15- month old boy Saudi DOA – 05/06/12 HX. Fever, vomiting, diarrhea 5d No skin rash No contact with sick pt, or travelling hx Systemic review unremarkable No previous medical or surgical problems Normal neonatal hx Developmental and vaccination hx up to age Has other 2-siblings –n, unconsanguineous parent

3. Patient was seen 3days later in ER Same complaint Lower back skin discharge

4. On examination 03/05…… Stable. Dehydrated, v/s- T-38.2 Meningeal signs -? Redness over lower back Yellowish to green discharge Sacral dimble –dry Treatment

5. Examination on 06/05…… Lethargic, sick, dehydrated v/s- T- 39 Meningeal sign CT-brain and spine Full septic screening Antibiotics Picu

6. Seen by I.D. team on 07/05..pt was clinically stable, afebrile, conscious, active,room air playful baby Nick stiffness, increase reflexes, dimble dry no discharge Impression – possible collection with tract connection - meningitis Advice- continue same medication - MRI- brain, spine

7. Investigation on 03/05 WBC 20.4, neut. 73% / HB 10.5/ PLT 473 Blood c/s –no growth Urine – n

8. Lab on 06/05 CBC…. L.P. ---- PUS G.stain—G+VE cocci Culture-TF Blood c/s--- TF Urine c/s----TF

9. 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 No mass lesion Spine-preserved disc spaces – spina-bifida at sacrum.

10. Course 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 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. Then he was managed as a sceptic shock with fluids (3 boluses of R.L. and dopamine) which hold b/c SBP 160 then put on epinephrine, sedation on same day later seen by I.D. Advice to stop tazocin, start meropenem with vancomycin and flagyl after discussion with microbiology lab regarding CSF Finding of MRI spine.

11. Course Also pt seen by neurosurgery 6/5 advice for MRI brain /spine 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 after deterioration of GCS from 7/15 to 3/15 Pt received from OR showing 2hr later signs of increasing ICP - HTN, bradycardia,. Pt on same day arrested 2 times, on the 2nd time at 23.06pm of 12/5 he died.

12. Radiological finding- 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 evidance of increase ICP or HGE Or mass lession 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.

13. MRI-brain / spine on 9/5 : Spine- finding goes with intraspinal mass lesion (dermoid) with dermal sinus complicated by abcess 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 evidance of dural sinus thrombosis.

14. 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.

15. On 12/5 operation done – abcess drinage and Sacral sinus excision = laminetomy of L 3, 4,5

16. 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

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

18. CSF STUDY : On 6 / 5 L.P. ---- PUS cells G.stain – G+ve cocci Culture – TF On 8/5 call from lab that CSF c/s growing : Bacteroid fragalis + strep. Millariae + staph Epidermidis According to this result and deterioration of pt – tazocin stoped, and started by I.D. team on meropenem – vancomycin - metronidazole

19. On 3/5 --His investigation –n bld c/s -No growth 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. : Blood sample WBC 10, rbc 1280, Lympho 100%, G.S. - NOS, culture – no growth.

20. 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

21. Final diagnosis: Infected dermoid cyst + severe cerebral edema and global brain ischemia + severe brain injury.