Clinical Reasoning: An 8-year-old girl with multifocal brain lesions and cerebral edema

Abstract

An 8-year-old right-handed girl with a history of declining school performance presented to the emergency center with acute onset altered mental status. For 3 weeks, the former straight A student had been failing classes, but her family noted no changes in her personality or ability to perform activities of daily living. On the night of presentation, the patient was found minimally responsive, lying in vomitus. She aroused briefly with stimulation but was limp. Her past medical history was significant for a full-term birth without complications, normal acquisition of developmental milestones, and no chronic medical conditions. She took no medications. She had no unusual food or animal exposures and had not traveled overseas. Her family had no history of seizures, strokes, blood clots, cancer, rheumatologic disorders, or recurrent miscarriages. On examination, she was afebrile with normal vital signs. Her examination was significant only for lethargy and bilateral papilledema. Initial workup revealed a normal complete blood count, electrolytes, and blood glucose. ### Question for consideration: 1. What is the most appropriate next diagnostic study? GO TO SECTION 2 An emergent CT of the …