Recurrent decrease level of consciousness as first manifestation of high grade glioma

Abstract

Objective and method: Paroxysmal and recurrent alteration of the level of consciousness is a diagnostic given by multiple causes, being sometimes the first sign of a systemic or central nervous system disease. We report a case of a 9-year-old patient with a recurrent decrease in the level of consciousness. Results: He was admitted at PICU with acute fever, vomiting, headache and decreased of the level of consciousness. Analysis, urine toxics and CT, normals. CSF showed 10 cells without germ. Eeg slowed activity. Acute meningoencephalitis was suspected and treated with cefotaxime and acyclovir. Excellent improvement, recovery of the level of consciousness in the first 24 h and discharged at home at 7 day. That day reentered by similar episode with agitation psychomotor, aggressiveness requiring intubation. Another craneal CT normal and CFS showed 13 cells and hyperproteinorraquia. Two craneal NMR and another CT were normal. Autoimmune encephalitis was suspected and initiating Methylprednisolone. NMDA antibodies in CSF, oligoclonal bands, GADs, lactic, ammonium, and PCR herpes were negatives. Extubated on the 3rd day with normal level of consciousness, discharged at 11 days, persisting bradypsychia. Readmited to the 14 days by similar episode and convulsive crisis and papillary effacement. We measured the pressure of the CSF. We treated of HTC, with sharp decreases in the level of consciousness with response to SSH3%. ICP monitoring showed 60 cm H2O placing VDVP. Clinical improvement being discharged, restless legs and ataxia. Cranio-medullary MRI showed germinoma hypothalamic-pineal disease with leptomeningeal carcinomatosis. Moved to Childhood Oncology Unit, being death on a month Conclusions: A systematic and oriented study of recurrent alteration of the level of consciousness, without forgetting that the normality of tests not discard our suspicion. In our case the late syndrome of restless legs, was the key. The request for pathological anatomy in CSF could help before.