Case by Seth Gerard MD, INOVA PEM Fellow

A 2-year-old previously healthy male presents to the ED with approximately 3 hours of altered mental status and twitching. Started with altered mental status at around 10:15, and was noted to also have significant jerking movements and intermittent agitation. Family adamantly denies any recreational drug use or possible exposure to ingestions; similarly they deny any recent illness, pertinent family history, or similar episodes in the past. On presentation, the patient is noted to vary between agitation and severe obtundation with additional periodic apnea causing significant desaturations requiring noxious stimulation (sternal rub, flicking soles, etc.). You start the patient on low-flow nasal cannula with some decrease in frequency of apneic episodes, however the patient continued to have periodic apneic spells requiring stimulation. Glucose was obtained on arrival was 72.

Vitals: T: 98.5°F (36.9°C), HR 163, RR 32, SpO2 93%, BP 101/62
General: Ill appearing, variably confused and agitated or obtunded.
HEENT: Normocephalic, atraumatic. Pupils 2mm bilaterally and sluggishly reactive to light. Noted intraoral (posterior) ulcerated lesions.
CV: Regular rate and rhythm, no noted murmurs. Cap refill and peripheral pulses reassuring.
Pulm: Lungs CTAB. No noted increased WOB. Periodic apnea.
Abd: Soft, non-distended.
MSK: No noted abnormalities, neck supple.
Skin: No noted rashes or lesions.
Neuro: Lethargic/somnolent, occasionally agitated (uncooperative and disoriented while agitated); moving all extremities symmetrically; having occasional total body jerking (seizure-like) movements.

You decide to obtain a CT head as well as labs including CBC, CMP, CK, CRP, Serum Tox panel, UDS, and VBG.

CBC, CMP, CK, CRP, and serum tox panels were reassuring.VBG showed pH 7.46, PCO2 33.4, PO2 62, HCO3 23.5. UDS is sent to the lab and is pending.

CT head showed no noted acute intracranial abnormalities.

After coming back from CT, the patient was noted to have an increasing frequency of apneic episodes, despite LFNC; you subsequently decide to place the patient on HNFC and prepare advanced airway equipment to take over the airway if necessary. Given her examination findings as well with what appears to be herpangina vs. HSV stomatitis, as well as agitation/somnolence and seizure-like movements, you have rising clinical concern for encephalitis and decide you need to obtain a CSF sample to further evaluate. Unfortunately, the patient once again continues to have an increasing frequency of apneic/hypoxic episodes, once again requiring frequent noxious stimuli.

You decide to place the patient on NIV (ram cannula) and plan to give a dose of versed to facilitate LP while standing at the ready to give induction dose ketamine and intubate if the patient has intractable apnea. The patient’s apneic episodes seemed to significantly lessen after being initiated on RAM cannula. After giving the versed, just prior to LP, the UDS comes back positive for cannabinoids.