“I Think My 17 Month Old Baby’s Drunk” Daniel P. Davis, MD UCSD Emergency Medicine.
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Transcript of “I Think My 17 Month Old Baby’s Drunk” Daniel P. Davis, MD UCSD Emergency Medicine.
““I Think My 17 Month Old I Think My 17 Month Old Baby’s Drunk”Baby’s Drunk”
Daniel P. Davis, MDUCSD Emergency Medicine
Daniel Davis, MD
Case PresentationCase Presentation
• 17-month-old healthy female brought to ED by parents for staggering gait.– First noted by grandmother that day– Gastrointestinal illness several days prior– No fever, head trauma or ingestions– Grandmother with BP meds and “back pills”
in house but doubts ingestion
Daniel Davis, MD
Case PresentationCase Presentation
• Exam–T 37.7 rectal, HR 144, RR 25, CR <2s
–Awake/alert, nontoxic, appropriate
–No external e/o trauma
–Cardiopulmonary normal
–Abdomen soft
Daniel Davis, MD
Case PresentationCase Presentation
• Exam– Normal, age-appropriate mental status– Normal head circumference and shape– Use of both extremities w/o ataxia– Symmetric strength and sensation– Normal EOMs and facial symmetry– Gait – persistent falling to right w/o pain
Daniel Davis, MD
Case PresentationCase Presentation
• Labs–WBC 17.4 with left shift, no bands
–Chemistries normal
–Hgb/Hct 12.2/36.8
–Urine tox screen negative
Daniel Davis, MD
Case PresentationCase Presentation
• Radiographs–Head CT negative
• Procedures–Traumatic LP• 1400 WBC• 240,000 RBC• Gram stain negative
Daniel Davis, MD
Case PresentationCase Presentation
• ED course–Remained afebrile
–Normal neurologic exam but persistent gait ataxia
–Neuro consultation
–Discharge home with no medications
Daniel Davis, MD
Acute Cerebellar AtaxiaAcute Cerebellar Ataxia
• Definition–Rapid onset of ataxia
–Usually <6 years of age
–Usually prodromal illness
–Usually benign and self-limited
Daniel Davis, MD
Acute Cerebellar AtaxiaAcute Cerebellar Ataxia
• Many names to describe• Post-infectious cerebellar ataxia• Acute disseminated encephalomyelitis• Meningoencephalitis• Cerebellar encephalitis• Viral cerebellar ataxia• Post-varicella ataxia• Encephalomyelitis• Transient cerebellar ataxia
Daniel Davis, MD
Why interesting?Why interesting?
• You will see at some point
• Historical perspective
• Pathophysiology
Daniel Davis, MD
Clinical ClassificationClinical Classification
• ACA– Gait ataxia– Usually complete resolution
• ADEM–Mixed sensory/motor and cerebellar– Patchy and bilateral
• ME– Sick patient
Daniel Davis, MD
Laboratory ClassificationLaboratory Classification
• ACA–Less inflammation on LP?
• ADEM–More inflammation on LP?
• ME–Lots of inflammation on LP?–Systemic illness
Daniel Davis, MD
Pathological ClassificationPathological Classification• ACA– Vascular inflammation without CSF penetration?
• ACA & ADEM– Anti-viral Ab and viral in serum– Often anti-viral Ab and virus in CSF– Autoantibodies
• ME– More direct viral invasion of brain tissue– More autopsy specimens available
Daniel Davis, MD
Radiographic ClassificationRadiographic Classification
• ACA– Normal– Limited to cerebellum
• ACA & ADEM– Diffuse white-matter lesions (periventricular,
cerebellar, basal ganglia, corpus callosum)– Identical to MS
• ME– Diffuse necrosis and edema
Daniel Davis, MD
ACA
ADEM ME
Systemic Viral Illness
Myeloradiculopathy
Immune response
Direct invasion
Daniel Davis, MD
Systemic Viral Illness
Mild Severe
ADEMADEM MEMEACAACA
ACUTE
CHRONIC
MULTIPLE SCLEROSIS?MULTIPLE SCLEROSIS?
Daniel Davis, MD
Why is this important?Why is this important?
• Classification scheme reflects our understanding of disease
• Therapeutic decision
• Useful to keep more severe diseases in mind when approaching these patients
Daniel Davis, MD
ED ApproachED Approach
• Work-up– CT/MRI to rule-out serious illness• Meningitis/ME• Intracranial mass lesion• Tumor
– Toxicology screen– Routine labs– LP
Daniel Davis, MD
ED ApproachED Approach
• Treatment–Prophylactic antibiotics• Anti-bacterial• Anti-viral
_ Acyclovir_ Pleconaril?
–Steroids?– IVIg?
Daniel Davis, MD
SummarySummary
• ACA and ADEM– Post-viral syndromes– ACA limited to cerebellum– ADEM diffuse CNS
• Auto-immune link to MS?– Steroids? IVIg?
• Viral invasion link to ME?– Anti-virals
Daniel Davis, MD
SummarySummary
• Work-up and treatment focus on other potential etiologies– Intracranial mass lesion
–Meningitis/ME
–Toxic ingestion
–Metabolic disturbance