Question

Ch. 17-Nervous System Diseases The patient was a 13-month old child who, on the day of admission, seemed fine according to his mother except for a runny nose and a low-grade fever (which she treated with Tylenol). Later in the day, while riding in the car with his mother, he suddenly had a grand mal seizure with shaking of the arms and legs. The seizure lasted 2 minutes. She called an ambulance. The emergency medical technicians found him limp, unresponsive, and apparently post ictal (post seizure state). In the emergency room he had a second seizure. On physical examination, he had a temperature of 39.5° C, and a pulse of 160 BPM He was noted to be lethargic, but his neck was supple. Except for a runny nose, the rest of his physical examination was normal. Blood and urine cultures were obtained to rule out sepsis, and the child was begun on IV ceftriaxone (rocephin). His vaccination record is incomplete, but his mother insists that he is up to date on all vaccines. The patient's mental status did not improve overnight, and a lumbar puncture was performed and a CSF WBC count of 4,650 cells ut, wth 95% neutrophils, glucose of 48 mg/dl (normal, 50-75 mg/dl), and protein of 107 mgidl (normal, 15-45 mg/dl). Ovemight his WBC count had increased to 14,600 cells/yl. He was transferred to a university hospital, where he was found to be iritable and have a stiff neck. His admission blood culture was positive. Gram stains of the organism obtained from the blood culture is shown in figure 1. Growth of the organism is shown in figure 2 Figure 1: Organism under 1000x TM (Gram ) Figure 2: Organism grown on chocolate and 5% sheep's blood agar, respectively

Answer 1

1.  The child was irritable and had stiff neck which are symptoms of meningitis.

2.High WBC count, low glucose, high protein in cerebrospinal fluid shows that the infection is  bacterial meningitis. In viral meningitis the glucose in CSF will be normal .Figure 1& 2 shows that the organism is HAEMOPHILUS INFLUENZA B. This bacteria is gram negative, non motile, thread like organism and also very small . It has no flagella .

• On Blood Agar it appears translucent, low, convex or flat pin point colonies.
• On Chocolate Agar it appears grayish, transparent, smooth, low, convex or flat with a slightly splayed out, entire edge, mucoid , pale.

3. Haemophilus influenza b (Hib) is a major cause of childhood infectious disease. It is the causative organism of  meningitis, primary bacteremia, pneumonia in children .Peak incidence of this organism is at 10–12 months.

Haemophilus influenza is an encapsulated organism . Through sneezing via respiratory droplets or by direct contact this organism enters the host by penetrating the epithelium of nasopharynx. After penetrating , organism enters blood stream and crosses the blood brain barrier leading to inflammatory reaction in meninges. Infection develops leading to sepsis /bacteremia.

4.The child should have received BCG vaccine, three doses of DPT (diphteria, pertussis, tetanus)vaccine, three doses of HiB ( haemophilus influenza )vaccine, three doses of pnuemococcal vaccine. Child is due for booster dose of HiB vaccine.

According to the vaccination record provided by mother it was incomplete. So it is not known whether the child has received the vaccinations till date.