Quadriplegia and cortical blindness in Hemophilus influenzae meningitis

Abstract

A 3-year-old white female with fever, headache, and vomiting of 12 hours' duration became increasingly lethargic, developed seizures, and was taken to a local hospital. Lumbar puncture revealed cloudy cerebrospinal fluid which contained 4,400 white blood ceIIs/mm 3, 100% of which were poiymorphonuclear leukocytes. The concentration of glucose in the CSF was 6 mg/dl and of protein, 123 mg/dl. Gram-negative pleomorphic bacilli were seen on smear and were later identified as IL ba, fluenzae type B. Therapy was begun with chloramphenicol (100 mg/kg/24 hour) and ampicillin (400 mg/kg/24 hour) intravenously, and she was transferred to the James Whitcomb Riley ttospital for Children. On admission she was unresponsive and flaccid, tler pupils were mi0iic but reacted to light. The optic fundi were normal and reflex extraocular movements were full. Corneal reflexes were present. Shortly after admission she became apneic and was placed on mechanical ventilation. The CSF became sterile after 24 hours of treatment. She remained unresponsive for three days and then .became able to open her eyes and mouth on command. Spontaneous respiratory effort and movement of extremities were not observed during thi s time. After one week she continued to move the facial muscles purposefully but remained flaccid and had no respiratory effort. One week later she began to show reflex withdrawal of her extremities but made no effort to breathe. A spinal tap after eight days of treatment revealed 20 white blood cells with 5% polymorphonuclear leukocytes and 95% lymphocytes; CSF glucose and protein concentrations were normal. She was treated for a total of 15 days with chloramphenicol intravenously. Spinal taps done subsequently revealed nornfal CSF. An electromyogram at one month showed a denervation pattern in the left lower extremity with normal conduction velocity in the peroneal ne~'e. A repeat EMG one month later