A 6-year-old child with vacant episodes and unilateral convulsions

Abstract

A previously well 6-year-old girl was admitted to hospital in May, 1998, after having a vacant episode followed by right-sided upper and lower limb clonic movements lasting 30 s. She was feverish (38·6°C), neurological examination was normal, and she had no meningism. There was a leucocytosis (22·7 × 109/L, 70% neutrophils) and she had an Escherchia coli urinary-tract infection. She was given trimethoprim and discharged home the next day, to be readmitted 12 h later with further fits. She had no fever and physical examination and white-cell count were normal. She had several complex partial seizures. An electroencephalogram showed left frontotemporal sharp waves. Carbamazepine stopped her fits. 10 days after she became ill, a magnetic resonance imaging (MRI) scan showed a left frontal-lobe lesion of uncertain aetiology (figure A). She remained afebrile, well, and lively. Her white-cell count was 12·109L, ESR 30 mm/h, and C-reactive protein 20 mg/mL. Cerebrospinal fluid (CSF) showed no cells, and normal protein (0·08 g/L) and glucose (3·4 mmol/L; serum glucose 5·0 mmol/L). Intravenous acyclovir and ceftriaxone were started. There was no known contact with tuberculosis and no immunodeficiency. 48 h after starting acyclovir and ceftriaxone she deteriorated, with vomiting and drowsiness. A repeat MRI scan showed extension of the lesion with oedema and midline shift (figure B). CSF was sterile and PCR for herpes simplex virus (HSV), varicella zoster virus, and enterovirus were negative. Metronidazole was added. A brain biopsy showed a diffuse mononuclear leptomeningeal and perivascular infiltrate and was bacteriologically sterile.