Tuesday, December 4, 2012

A Case Of Brain abscess in an 8 yr old child

An 8 year Male from a Remote region , who has history of Recurrent Ear discharge since 2 years of age, came with complains of :-
1. Earche/ Ear discharge for 2 weeks
2. Fever for 12 days
3. Altered Sensorium for 3 days

He was apparently well 2 weeks back, when he started complaining of ear ache on both sides, more severe on right side. It was followed by gush of fluid discharge from right ear, profuse amount, whitish-clear, foul smelling, without blood stains, intermittent discharge occurred amounting to around 300ml in 2 weeks.
It was followed by fever 2 days later, which was high grade, measured upto 103 F, on/off, without specific pattern or timing, was associated with chills and rigors and profuse sweating.
It was associated with headache, localized to front and back area. Vomiting occurred 2-3 episodes total, non-projectile and content was food.
Child had progressive weakness due to poor intake of food and was bed ridden due to illness for last 7-8 days.

The fever and ear discharge persisted despite of local Antibiotic eardrops.
He was taken to Hospital where he was given Intravenous antibiotics for 3 days.
As the child started to develop altered sensorium with fluctuating level of consciousness, parents decided to bring him to our Centre. The child used to obey commands and recognize parents at times but other times used to shout meaningless but comprehensible words. He was irritable and used to toss in bed.
He had good control of bowel and bladder before but since 3 days he is bed wetting and passing stool in bed.
Intake has been poor and parents were concerned about significant weight loss.

The course was progressive and the status of child was deteriorating.

There was no history of Loss of consciousnesses, abnormal body movements.
No history of head injury, any preceding viral infections, any drug intake or immunization.
There was no joint pain or swelling, rashes over the body, oral ulcers or photo-sensitivity.
No history of bleeding from any site, bluish patches over the body.
No h/o weakness of any part of body, difficulty breathing or swallowing.
No h/o cough cold, throat-ache, purulent nasal discharge or caries tooth.
No h.o travel to Endemic Terai region, forest areas or swimming in ponds.
No h/o recurrent rashes, skin lesions, recurrent or chronic diarrhea, chest infection in the past.

Past history revealed history of  ear discharge starting at 2 yrs age and was treated with topical ear drops. but at 5 yrs age he had abscess at back of ear which needed surgical drainage. He also had hearing deficit since 3 years back. He also had fleshy outgrowth from right ear that needed removal 2 yrs back.

He was a developmentally normal child with normal birth and neonatal history. Was immunized as per EPI schedule and his nutritional status before illness was satisfactory.

On Examination-
G C - Child was disoriented, shouting irrelevant words and was lying supine in bed. Had foley's catheter and IV cannula in situ.
There was no obvious respiratory distress.

BP- 100/70 Normal for age
Pulse was 78/min, regular and normal volumes
RR- 28/min
CRT was below 3 sec
Temp was 100 F
JVP was normal.

There was no pallor, icterus, edema, dehydration, cyanosis and clubbing.

No dysmorphism.
There was Ear discharge from Right ear. wax was present bilaterally and typmanic membrane could not be visualized.

CNS Examination-
Disoriented. No focal neurological or cranial nerve deficits.
Motor system examination revealed, hypertonia in lower limbs with brisk reflexes.
Sensory system was intact.
No cerebellar signs
Kernig, Brudzinski and Neck rigidity were well demonstrated.

Respiratory Normal findings
CVS- Normal findings
Per Abdomen- Normal
Musculoskeletal- grossly Normal.
No petechial/purpuric rashes.

Provisional Diagnosis -
Chronic Suppurative Otitis Media with Meningitis probably Bacterial with Raised Intracranial Pressure

Differential Diagnosis -
CSOM with Brain Abscess
CSOM with Lateral Sinus thrombophlebitis

Investigations were sent-
CBC-
Hb- 10 g%
WBC- 14600 with 86%N
plateletes- 179000
Blood Culture was sent

Fundus examination revealed no papilledema.

CSF examination was done
Color was frank turbid.
Ejection pressure was increased.
Cells- 32000 with 80% Polymorph, 20 Monomorph
RBC- 200
Protein - 168 mg/dl
Sugar- 10mg/dl

CSF for culture was sent.

CT Scan Head was done including Contrast-
Revealed Brain Abscess in the Right temporal Area.

Diagnosis- CSOM with Brain Abscess with Acute Bacterial Meningitis.

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