A 6-month-old boy complained of fever and no other symptoms. Four days later, the fever persisted, then the patient had 1 episode of watery stool and 1 episode of generalized tonic-clonic seizure which lasted for 10 minutes. The patient was awake after the seizure ceased, and he was admitted to a district hospital later. On the first day of hospitalization, the patient experienced seizures 6 times and decreased level of consciousness with a pediatric coma scale (PCS) of 5. Physical examination revealed that the patient had fever of 38.5 C, stiff neck, and anisocoria; he was transferred to the Pediatric Intensive Care Unit (PICU) of the same hospital subsequently. Head computed tomography (CT) scan demonstrated signs of meningoencephalitis. Patient was eventually referred to the PICU of our hospital because of status epilepticus.
Upon arrival to the PICU, the patient was still in a coma with PCS of 5; the physical findings were persistent fever, anisocoria, sluggish pupillary light reflex, positive Babinski reflex, positive clonus, and positive Brudzinski sign. The initial hemogram was: Hb 11.1 g/dL; leukocyte count 8620/muL (69.8% neutrophils; 27.0% lymphocytes; 3.1% monocytes); platelet count 125 000/mm3. There was an increase in C-reactive protein (CRP) of 139 mg/L. A cerebrospinal fluid (CSF) analysis revealed: red and turbid in appearance, proteins 1.59 g/dL; glucose 1 mg/dL (serum glucose 117 mg/dL); blood cells 1120/muL (64% polymorphonuclear and 36% mononuclear); erythrocytes 7300/muL; lactate dehydrogenase (LDH) 2659 U/L; positive Nonne and Pandy tests; which was typical for bacterial meningitis. The patient was administered 100 mg/kgBW/day of ceftriaxone, paracetamol, mannitol, dexamethasone, and maintenance dose of phenytoin.
On the fifth day of hospitalization, the patient experienced Cushing triad. An evaluation head CT scan demonstrated signs of obstructive hydrocephalus and diffuse cerebral edema, a neurosurgery consult was made and ventricular tapping were performed. Interferon gamma release assay (IGRA) blood test of CSF was performed for any Tuberculosis suspicious, and result test was intermediate. Considering the clinical deterioration and the indeterminate IGRA test result, the tuberculous meningoencephalitis regimen protocol was then initiated.
CSF culture showed moderate number of gram-positive cocci in chains, consistent with S. pneumoniae. The isolate was susceptible to the following 10 antibiotics: ampicillin, penicillin G, clindamycin, ampicillin-sulbactam, ciprofloxacin, ertapenem, imipenem, meropenem, vancomycin, moxifloxacin; ceftriaxone was not tested due to lack of reagent. The bacteria were resistant to: azithromycin, oxacillin, amikacin, cefoxitin, doxycycline, tetracycline, trimethoprim/sulfamethoxazole, chloramphenicol. After 7 days of ceftriaxone administration, the antibiotic regimen was switched into 400 mg ampicillin/kgBW/day IV devided q6h of ampicillin-sulbactam according to the antibiogram. Three days following the administration of ampicillin-sulbactam, the fever significantly increased, then antibiotic was escalating to 40 mg/kgBW IV q8h. The patient experienced recurrent seizures and decerebration. Unfortunately, the patient died due to cardiorespiratory failure on day 17th of hospitalization (Table 1).