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