A seven-year-old girl who came to the emergency room in spring due to an episode of complex generalized crisis with disconnection of the middle and fall of the lip floor while recovering spontaneously, sialorrhea and movements.
The previous days the child had presented with myalgias, headache and fever of up to 39 °C, but she had already suffered from arthritis for 24 hours.
The patient was a girl with no relevant physiological history: pregnancy, delivery and perinatal period without interest. She also had no relevant pathological history and, as a family history, only maternal lithium treatment for bipolar disorder of years of evolution.
The patient, upon arrival to the emergency department, had a post-critical condition with a Glasgow score of 10, but the rest of the examination, both neurological and systems, was normal.
Blood tests revealed the following:
• Biochemistry:
— Glutamic-oxalacetic transaminase (GOT): 93 IU/l.
— Glutamic-pyruvic transaminase (GPT): 44 IU/l.
— C-reactive protein (CRP): 2 mg/l.
• Blood count:
— Activated leukocytes: 6000 (N: 30% L: 66% M: 4%).
— Platelets 125 000.
— Normal red series.
The patient was admitted to the emergency department with seizure disorder.
Two hours after admission, the patient developed a new seizure and monitoring with intravenous midazolam 0.15 mg/kg, but suffered respiratory arrest requiring T-piece ventilation, so the admission was decided.
Upon arrival to the intensive care unit, the patient presented post-critical condition, with Glasgow score of 7 and the rest of normal parameters except for an axillary temperature of 38 °C. Neurological examination revealed marked hyperreflexia in the lower limbs.
Urgent cranial computed tomography (CT), lumbar puncture, toxic urine and blood tests (due to maternal history) were performed, with normal results.
Urgent electroencephalogram (EEG) was performed and the activity compatible with meningoencephalitis was reported as global slowing.
Cerebrospinal fluid (CSF) serology was performed for enterovirus and herpes virus, both of which were negative.
Serology is also obtained for multiple agents such as toxoplasma, rubella, lees, herpes simplex 1 and 2, varicella-zoster virus, Mycoplasma, adenovirus, parotiditis, Cox parvovirus,
In the following hours after admission, the patient presents agitation episodes with drowsiness and again presents two generalized convulsive episodes, so maintenance levetiracetam was initiated despite 40 mg/kg/day of prior prophylactic treatment with 20 mg/kg/day.
Emergency brain magnetic resonance imaging (MRI) was performed with normal results and no bleeding or hyperdensity lesions were observed.
fever of the previous days and poor recovery of neurological symptoms, it was decided to determine influenza A antigens in the nasal exudate, resulting positive, so treatment with ostamidine was initiated.
Progressively, the patient improved, but suffered a new seizure episode and it was decided to extend serology to cytomegalovirus (CMV), Ebstein's virus remains normal (EBV), herpes and influenza negative.
Oligoclonal bands that are negative are requested in CSF and autoimmunity study with anti-DNA, anti-Ro, anti-La, anti-histoplasma, anti-Sm, anti-neutrophils.
Valproic acid is associated with doses of 40 mg/kg/day, with complete remission of seizures.
The patient had five seizures and at discharge an EEG improvement was observed, although not completely normal.
Treatment was continued with valproic 40 mg/kg/day and levetiracepam 60 mg/kg/day.
Currently, the patient follows controls in Neurology outpatient clinics, without anticonvulsant medication and remains asymptomatic, with normal EEG findings in the last visit.
