Authors: Lepage P, Dan B.
Bacterial meningitis (BM) remains a major global challenge. Globally, Hib, S. pneumoniae, and N. meningitidis cause about 90% of cases of BM beyond the neonatal period. After colonization of the upper respiratory tract by one of these pathogens, invasion occurs across the epithelium. Following entry into the bloodstream, bacteria survive through evasion of the complement system. Once into the CSF, bacteria multiply very actively. The clinical features of BM depend on the age of the patient, duration of illness, the pathogen involved, and host response to infection. Major neurological findings include meningeal signs, altered consciousness, increased intracranial pressure, seizures, and focal findings. Complications such as prolonged fever, seizures, subdural effusions, subdural empyema, and brain abscesses occur with variable frequencies. History, physical examination, and lumbar puncture are essential steps to establish the diagnosis of BM and should be performed before the initiation of antimicrobial therapy. Blood tests and CSF examination are essential for the diagnosis of BM. Various clinical scores have been recently developed to predict the risk of BM. Children with BM should be monitored for anticipated complications. Prompt initiation of therapy with appropriate antimicrobial agents given at correct dosage is essential in the management of these patients.
Authors: Kuczynski A, Crawford S, Bodell L, Dewey D, Barlow KM.
AIM: Post-traumatic headaches (PTHs) following mild traumatic brain injury (mTBI) are common; however, few studies have examined the characteristics of PTHs or their response to treatment. The aims of this study were (1) to describe the clinical characteristics of PTH in a prospective cohort of children presenting to a paediatric emergency department with mTBI, and (2) to evaluate the response of PTH to treatment.
OBJECTIVE: To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury. DESIGN: Retrospective analysis of a prospective observational study. SETTING: Pediatric emergency department (ED) in a children's hospital. PARTICIPANTS: Four hundred six children and adolescents aged 5 to 18 years. MAIN EXPOSURE: Closed head trauma. MAIN OUTCOME MEASURES: The Rivermead Post Concussion Symptoms Questionnaire administered 3 months after the injury. RESULTS: Of the patients presenting to the ED with mild traumatic brain injury, 29.3% developed PCS. The most frequent PCS symptom was headache. Predictors of PCS, while controlling for other factors, were being of adolescent age, headache on presentation to the ED, and admission to the hospital. Patients who developed PCS missed a mean (SD) of 7.4 (13.9) days of school. CONCLUSIONS: Adolescents who have headache on ED presentation and require hospital admission at the ED encounter are at elevated risk for PCS after mild traumatic brain injury. Interventions to identify this population and begin early treatment may improve outcomes and reduce the burden of disease.
Authors: Pulitanò S, Mancino A, Pietrini D, Piastra M, De Rosa S, Tosi F, De Luca D, Conti G.
BACKGROUND:: Positive end expiratory pressure (PEEP) improves oxygenation by optimizing alveolar recruitment and reducing intrapulmonary shunt. Unfortunately, PEEP can interfere with intracranial pressure (ICP) by increasing intrathoracic pressure. We hypothesized that the use of different PEEP levels could have an effect on intracranial and cerebral perfusion pressure (CPP), gas exchange, respiratory system mechanics, and hemodynamics in pediatric patients undergoing major neurosurgical procedures.
Authors: Ravish ME, Krowchuk DP, Zapadka M, Shetty AK.
BACKGROUND: Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes.
OBJECTIVE: Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF.
METHODS: We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection.
CONCLUSIONS: We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.
Authors: Viuff AC, Hansen JK, Møller HU.
Idiopathic intracranial hypertension is often believed to be an illness exclusively occurring in obese women in their twenties and thirties. This case describes a four-year-old boy presenting with headache, vomiting photophobia and double vision for six days. He did not have a fever; and all exams and tests, including a magnetic resonance imaging of the brain showed normal values. During the eye examination, he was found to have bilateral papilloedema and when undergoing lumbar puncture an elevated pressure of 230 mm water was discovered. The patient was diagnosed with idiopathic intracranial hypertension and treated with azetazolamide. Within few days, his symptoms disappeared.