Case by Christina Rojas MD, Children’s National PEM Fellow

A 4-year-old male with a history of ITP presents with vomiting and increased sleepiness. His mother reports that he had three days of nasal congestion, and then today had 4 episodes of NBNB emesis. This morning, he seemed more sleepy than usual, however was still responding normally. However, towards the afternoon began to not say words in response to her (making noises, moaning), prompting her to bring him to the ED. Has had poor intake today. No fevers, diarrhea, rashes, cough, trouble breathing. No history of head trauma. Mom reports no concern for ingestions. Up to date on immunizations

• Medical history: ITP, previously on IVIG infusions, now managed with etrombopag (a bone marrow stimulant)
• No surgical history
• No allergies

VS: T 36.7, HR 108, RR 20, BP 105/71, SpO2 100%
General: Well-nourished. Not appropriately responsive to examiner or mother – moaning in response to questions
Skin: No rashes
Head: Normocephalic, atraumatic
Eye: PERRL, no eye deviation
ENT: TMs clear bilaterally, oral mucosa moist, no pharyngeal erythema or oral lesions
Neck: Full passive range of motion, unable to engage patient in active range of motion
CV: Regular rate and rhythm, no murmur. Normal peripheral perfusion
Resp: Clear lungs bilaterally, no increased work of breathing
Abdomen: Soft, non-tender, non-distended
GU: Normal external genitalia without any swelling or erythema, full wet diaper
Neuro:

• GCS: Eyes open in response to pain (2), verbal sounds (2), localizes painful stimuli (5) = 9
• Mental status: A&O x 0
• Cranial nerves: PERRL, extraocular movements appear intact, facial muscles symmetric, symmetric elevation of palate and uvula, symmetric tongue protrusion. Unable to assess facial sensation, hearing, shoulder shrug
• Reflexes: 2+ patellar
• Sensation: Unable to assess, though appears to feel examiner on all extremities
• Motor: Normal gross movement of all extremities, symmetric; unable to assess strength
• Cerebellar/gait: Unable to assess

Labs, an EKG, and a head CT are obtained. A 20cc/kg normal saline bolus is given. Results are noted below:

Labs

• VBG: pH 7.35, pCO2 28, bicarb 17, BE -7.9, lactate 8.4, glucose 93
• CBC: WBC 8.3, hemoglobin 9.5, platelets 177
• CMP: Sodium 139, potassium 3.8, chloride 101, CO2 17, BUN 19, creatinine 0.3, glucose 98, calcium 9.5, bilirubin 3.4, AST 191, ALT 79
• CRP 0.1
• Salicylate, acetaminophen, ethanol levels and UDS negative
• UA: 2+ ketones, otherwise negative
• RVP: positive for rhino-enterovirus
• UCx and BCx in process

EKG: normal
Head CT: normal

The patient’s mental status is unchanged. His updated VS are: T 36.9, HR 115, RR 20, BP 105/70, SpO2 100%. You give a second 20cc/kg normal saline bolus given the elevated lactate and ketones in the urine and start the patient on maintenance IV fluids.

You order an ultrasound for intussusception that is negative. You send an ammonia which returns elevated at 120. You discuss with metabolism who indicates they do not think this is a primary metabolic disorder and do not recommend any therapies at this time. You discuss with neurology who is not convinced this is a seizure, but they agree to put the patient on EEG. The patient is the same: he is intermittently making unintelligible noises, opening his eyes briefly in response to painful stimuli, and moving all extremities equally in response to touch. His vital signs are unchanged.