A 14-month-old male patient was admitted to hospital on 19 May 2021 for multiple burns all over his body. The burn area was 25% (superficial second-degree and deep second-degree) of the total body surface area (TBSA). His burns were located on the head, face, neck, chest, abdomen, back, and upper extremities. Deep second-degree burns (5% TBSA) were mainly located on the face, chest, and abdomen. Most of the burns in the remaining areas were superficial second-degree (11% TBSA). The child was healthy in the past and had no history of food and drug allergies.
After admission, the patient was treated with fluid rehydration, blood transfusion, antibiotics to prevent infection, tracheal intubation-assisted ventilation, and regular dressing changes on the wound areas (Table 1). From the second to seventh day of hospitalization, the patient had persistent fever; the antibiotics were changed according to drug sensitivity test results to better treat the infection. On the eighth day of hospitalization, tracheal intubation was removed, but the child still had persistent fever, occasional convulsions, eyes staring to the right, and high-pitched cry. Computed tomography (CT, day 8) showed that the intracranial brain parenchyma was scattered with patchy low-density foci, and patchy high-density shadows were seen in both lungs with blurred edges; mild cerebral oedema and pneumonia were considered in the initial diagnosis (Figure 1). On day 10, lumbar puncture and cerebrospinal fluid examination showed that the intracranial pressure was 228 mmH2O (reference range: 40-100 mm H2O), and the routine and biochemical abnormalities of cerebrospinal fluid were normal. Magnetic resonance imaging (MRI) on day 10 showed that bilateral fronto-parietal-temporal-occipital white matter and corpus callosum had symmetrical abnormal signals. The diagnosis is PRES (Figure 2). After pulse therapy with methylprednisolone (the dose was gradually reduced to oral prednisone), oxcarbazepine for anti-epileptics, and multiple other drugs and physical measures to treat fever, his limb activity, mental response, and eye gaze gradually improved. The episodes of convulsions also reduced. The burn wound healed on day 18 of admission. Intracranial pressure on lumbar puncture was 232 mmH2O on day 13 and 150 mmH2O on day 21; no other obvious abnormality was found in the cerebrospinal fluid test. Contrast-enhanced MRI performed on day 26 showed that there were multiple abnormal signals in the bilateral frontal, parietal, and occipital lobes, and the lesion range was smaller than that seen on the day 10 MRI. At this stage, PRES complicated with subacute late cerebral haemorrhage was considered. From day 27, the child had no fever, no right gaze, and no more convulsions, and his limb activities and mental reactions continued to improve further. Contrast-enhanced MRI on day 33 confirmed PRES combined with subacute late intracerebral haemorrhage; the haematoma was absorbed more than that seen in the previous MRI scan. We continued treatment with levetiracetam and piracetam for neuroprotection, oxcarbazepine for anti-epileptics, and oral prednisone to reduce cerebral oedema. On day 45 of hospitalization, the patient had no fever, convulsions, and right-eyed gaze; the fine movements of his hands improved; and he was discharged from the hospital.
After discharge, oral prednisone (within 45 days after discharge) and oxcarbazepine (within 1 year after discharge) were continued to prevent epilepsy (Table 1). MRI performed 17 days after discharge showed that the multiple abnormal signals in the original bilateral frontal, parietal, and occipital lobes were significantly absorbed and reduced, and there were still softening foci in the bilateral frontal lobes, and most of the original bilateral frontal lobe and right occipital lobe haematoma had been absorbed. The right frontal lobe still had patchy chronic phase bleeding changes (Figure 3). CT performed 4 months after discharge showed bilateral frontal lobe softening foci (predominant on the right). The vital signs of the child were stable, and the limb movement and fine movements of the hands gradually improved. One year after discharge from the hospital, the child's limbs and fine movements were normal; he could walk, run, and jump normally; and he could speak in short and simple sentences.