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Special Feature
March 2002

Radiological Case of the Month

Arch Pediatr Adolesc Med. 2002;156(3):293. doi:10.1001/archpedi.156.3.293

A PREVIOUSLY healthy 16-year-old boy was brought to the emergency department with a 1-day history of fever, headache, and lethargy. On that day, he vomited several times, was disoriented, and was incontinent. The physical examination results were notable for confusion, meningismus, and anisocoria.

Results of a lumbar puncture showed an opening pressure of 55 cm H2O. The cerebrospinal fluid (CSF) was grossly purulent. Laboratory test results were white blood cell count, 17 × 103/µL (59% segmented neutrophils, 37% band forms); glucose, 20 mg/dL (1.11 mmol/L); and protein, 5.83 g/dL. A gram stain of the CSF showed intracellular gram-negative diplococci. Treatment was started with ceftriaxone, 75 mg/kg and mannitol, 0.5 g/kg. A computed tomogram of the brain was normal and showed unremarkable cisterns and ventricles. On arrival after transfer to a tertiary hospital, his blood pressure was 168/100 mm Hg and his heart rate was 80 beats per minute. The physical examination results showed minimally responsive pupils, petechiae of the face, hands, and feet, and decerebrate posturing in response to painful stimuli. The left side was less responsive than the right. Because of clinical evidence of increased intracranial pressure (ICP), an intraparenchymal catheter was placed in the right frontal lobe and the initial ICP was greater than 80 mm Hg. He was immediately treated with intravenous mannitol, sodium pentothal, fetanyl, and midazolam, and an external ventricular CSF drain was placed. After drainage of approximately 10 to 20 mL of CSF, the ICP was 10 to 14 mm Hg. A xenon-enhanced computed tomographic (CT) scan was obtained (Figure 1). Therapy consisted of dopamine to maintain a mean arterial pressure greater than 80 mm Hg, with a goal of a cerebral perfusion pressure of greater than 70 mm Hg, sedation with fentanyl and midazolam, muscle relaxation with pancuronium, mannitol for ICP greater than 20 cm H2O, mild hyperventilation to maintain arterial PCO2 of 35 to 40 mm Hg, and continuation of antibiotics. The CSF cultures grew Neisseria meningiditis. On the fifth hospital day, he had improved and was following commands. The ventriculostomy and the endotracheal tube were removed. A detailed neurologic examination performed after extubation revealed no focal deficits, and his mental status continued to improve. At the time of discharge on the 10th hospital day, the patient had normal neurologic examination results.

Accepted for publication June 15, 1999.

Corresponding author: Laura M. Ibsen, MD, Oregon Health Sciences University, Division of Pediatric Critical Care Medicine, Department of Pediatrics, 3181 SW Sam Jackson Park Rd, Portland, OR 97201-3098.