Index of Suspicion

Abstract

* ADEM: : acute disseminated encephalomyelitis CSF: : cerebrospinal fluid CMV: : cytomegalovirus CT: : computed tomography EBV: : Epstein-Barr virus ED: : emergency department HSV: : herpes simplex virus IV: : intravenous PMNS: : postmalaria neurologic syndrome A 45-day-old girl presents to the emergency department (ED) with a 1-day history of slow breathing and decreased feeding. She was well the previous day, breastfeeding 5 to 6 times per day for 15 minutes during each feeding. She wets 6 to 8 diapers daily. She has been constipated since birth, passing 1 stool every 5 days, and, at the time of presentation, she had not had a bowel movement in 8 days. She was a term infant born via spontaneous vaginal delivery with Apgar scores of 9 at 1 and at 5 minutes. The delivery was complicated by her mother requiring a large episiotomy. Physical examination reveals a temperature of 98.4°F, heart rate of 154 beats/minute, respiratory rate of 20 breaths/minute, blood pressure of 71/52 mm Hg in the right upper extremity, and oxygen saturation of 69% on room air. Her length, weight, and head circumference are in the 50th percentile. She appears toxic, with sluggish movements and labored breathing. Femoral pulses are palpable with capillary refill of 2 seconds. Respiratory examination reveals slow, shallow, and irregular breathing, without wheezing or retractions. Her pupils are small, but reactive. The remainder of the physical examination, including cardiac assessment, is normal. Her complete blood cell count and serum electrolyte levels are within normal limits. Initial blood glucose level is 144 mg/dL, and a capillary blood gas shows a pH of 7.27, partial pressure of carbon dioxide of 54 mm Hg, and partial pressure of oxygen of 50 mm Hg. The results of a portable chest radiograph are normal. Additional history and laboratory findings reveal the diagnosis. A 7-year-old boy presents to the busy ED in India with a 1-day history of abnormal behavior, generalized seizures, and altered sensorium. Two weeks ago he was successfully treated for Plasmodium falciparum cerebral malaria and …