Nervous System and Special Senses 1 out of 626
A 7-year-old boy is brought to the emergency department because of high-grade fever and lethargy for 4 days. He has had a severe headache for 3 days and 2 episodes of non-bilious vomiting. He has sickle cell disease. His only medication is hydroxyurea. His mother has refused vaccinations and antibiotics in the past because of their possible side effects. He appears ill. His temperature is 40.1°C (104.2°F), pulse is 131/min, and blood pressure is 92/50 mm Hg. Examination shows nuchal rigidity. Kernig and Brudzinski signs are present. A lumbar puncture is performed. Analysis of the cerebrospinal fluid shows a decreased glucose concentration, increased protein concentration, and numerous segmented neutrophils; a Gram stain shows gram-negative coccobacilli. This patient is at greatest risk for which of the following complications?
Communicating hydrocephalusPostinfectious communicating hydrocephalus resulting from impaired reabsorption of CSF in the basal cisterns (due to obstruction of subarachnoid villi) is most often seen in patients with tuberculous (TB) meningitis. Although patients with TB meningitis may present with clinical features similar to those seen in patients with meningitis due to H. influenzae, TB meningitis typically has a subacute or chronic course, not an acute course. In addition, a Gram stain would not show gram-negative coccobacilli. While postinfectious hydrocephalus (communicating or noncommunicating) can also occur as a long-term sequela of other types of bacterial meningitis, including H. influenzae, it is a rare complication. Adrenal insufficiency
Adrenal insufficiency due to Waterhouse-Friderichsen syndrome is a dangerous complication of meningococcal meningitis and is due to a coagulopathy triggered by endotoxins, which may lead to hemorrhagic necrosis of the adrenal glands. Although this patient's age and functional asplenia are risk factors for patients affected with meningococcal meningitis, Gram staining of CSF would have shown gram-negative diplococci. Cerebral palsy
Cerebral palsy (CP) is a possible complication of pediatric meningitis but usually occurs in meningitis affecting children younger than 3 years of age because CP is a result of insult to the developing brain. CP is unlikely to develop in a 7-year-old child. Brain abscessSecondary brain abscess is a very rare complication of meningitis that is seen mainly in newborns. It is typically associated with infection by Listeria monocytogenes (a gram-positive bacillus) or certain enteric gram-negative bacteria (e.g., Cronobacter, Citrobacter). Hearing lossTransient or permanent sensorineural hearing loss, which is an important complication of bacterial meningitis, may occur as early as 48 hours after the onset of symptoms as a result of the spread of infection from the meninges to the cochlea via the cochlear aqueduct. In patients with sickle cell disease (SCD), multiple episodes of splenic infarction cause atrophy and fibrosis of the spleen, and by the age of 3 years most patients would have functional asplenia which increases the risk of infection with encapsulated bacteria such as H. influenzae and S. pneumoniae. The risk is further increased by the fact that the child has not received the Hib vaccine. Other common long-term neurological complications of bacterial meningitis include cognitive impairment, focal motor deficit (spasticity/paresis), and seizure disorders. Dexamethasone is recommended for children above 6 months of age with Hib meningitis because it has been shown to decrease the risk of hearing loss.
SCD is also an independent risk factor for mild sensorineural hearing loss because it can cause vaso-occlusive crisis in the narrow labyrinthine artery and/or its branches.
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