Case 1: The importance of a complete history

Abstract

A 10-month-old Cree boy from northern Quebec presented to his family doctor with a three-day history of rhinorrhea, cough and fever. He had presented to the clinic with these symptoms on each of the two previous days and was sent home with a diagnosis of viral upper respiratory tract infection. His appetite had decreased, he was described as “cranky” and he had vomited once. There were no ill contacts. He had been a healthy child apart from some gastroesophageal reflux, for which he was taking domperidone and ranitidine. On physical examination, he had a low-grade fever (38.2°C), a pulse of 150 beats/min and a respiratory rate of 40 breaths/min, with an oxygen saturation of 94% in room air. He looked unwell and was irritable, but his physical examination was nonspecific apart from mild intercostal retractions. On investigation, his white blood cell count was 13.3×109/L (normal range 6×109/L to 17.5×109/L), with 34% neutrophils, and his chest x-ray was suggestive of a mild left lower lobe pneumonia. He was admitted and treated with intravenous antibiotics. He initially seemed to improve with the intravenous fluids and antibiotics. On the second day of his admission, his grandparents, who spoke better English than his mother, provided some additional information. They had witnessed his “eyes rolling back” or “wandering” over the past few weeks and thought that he had decreased activity and shown some vague behavioural changes over the past month. Around this time, his eyes were noted to intermittently roll back in his head, with some tremors and stiffness of his lower extremities. On the third day of his hospitalization, he deteriorated rapidly, becoming very spastic and poorly responsive, with a tonic-clonic convulsion. He was given phenobarbital and phenytoin and intubated for transport to a tertiary care centre. At the tertiary care centre, the patient remained intubated and sedated, and continued on his antibiotics and anticonvulsants. A further test was performed, which revealed the diagnosis.