BEYOND BOUNDARIES

Dr. Shareen K. Lakibul

Second Year Pediatric Resident

Objectives:

To present a case presenting squinting To discuss the actual management of the case To present a patient-centered case discussion arriving to an appropriate diagnosis

Arabani, Sabrina 4 years old/female Sta. Catalina

History of Present illness

3 days PTA, noted to have intermittent eye squinting and weakness of extremities associated with headache, generalized, on and off, occurring at any time of the day paracetamol Vomiting was present Low grade fever, No cough, seizure, history of trauma

Consulted private MD, requested CT scan but did not comply. Persistence of symptoms prompted consult Serum Potassium was requested which revealed hypokalemia admitted

Past medical history

Known patient with Hypokalemic periodic paralysis Had several admissions for potassium correction Last admission was March 2012 No known allergies exposure to person with PTB

Family History

No known heredofamilial disease

Personal and Social History

Home delivered assisted by hilot, (+) PNCU, (+) Multivitamins, (+) TT injections Complete immuizations 4th among 4 siblings Mother is 45yo, housewife Father-deceased

Physical Examination:
Gen. Appearance Awake, not in respiratory distress & Vital signs T-36.3 C HR-11o wt 12.5 kg Skin HEENT Chest/Lungs: CVS Abdomen Extremities (-) pallor, (-)jaundice, good turgor PPC, AS, (-) Sunken eyeballs , (+) eye squinting

RR- 25

ECE, (-) ICR, clear breath sounds

AP, normal rate, regular rhythm (-) murmur Flat, hypoactive BS, soft, (-) organomegaly (-) gross deformities, good pulses

Neuro

Awake, cooperative Pupils equally reactive to light No preferential gaze Reflexes ++ + Motor ++ + 5/5 4/5 No meningeal signs Cranial nerves VI palsy 5/5 4/5

ADMITTING IMPRESSION:

Hypokalemic Periodic Paralysis t/c Ophthalmoplegic Migraine

COURSE IN THE WARD

S
On Admissi on

A
HPP

P
Please admit Secure consent DAT Start IVF with D5LR + 3.5 meqs/kg/day KCL at FM rate Do fast KCL correction at 0.3 meqs KCL/kg plus 20cc PNSS to run in 1 hour Labs - CBC, platelet, bld typing - Na, K Meds - Paracetamol 10mg/kg/dose IVT for headache VS and O2 sat monitoring q2 I and O q shift For close watch

r/o ophthalmoplegi c migraine

Serum Na 137 mmol/L Serum K- 2.2 mmol/L

S 2nd HS

O (+) still with headache (+) squinting episodes Awake Afebrile HR- 110 T- 36.8 C RR- 30 BP-90/60 ECE, (-) CI, CBS AP, NR, RR Flat, NABS, soft Good pulses

A HPP

P maintain IVF For repeat Serum K For possible Cranial CT scan with contrast For BUN, Crea

CBC Hgb- 106 Hct-0.34 WBC- 22.5 Segm-85 Lympho-12 Plt-302

S
3rd HS

O (+) still with headache (+) squinting Awake Afebrile HR- 110 T- 36.8 C RR- 30 BP-90/60 ECE, (-) CI, CBS AP, NR, RR Flat, NABS, soft Good pulses

P Change IVF to D5IMB at fm rate Give Paracetamol 10mg/kg/dose IVTT PRN for headcahe Still for Cranial CT scan with contrast

K 4.1 mmol/L

S
5th HS

O (+) still with headache (+)decreasing squinting episodes Awake Afebrile HR- 110 T- 36.8 C RR- 30 BP-90/60 ECE, (-) CI, CBS AP, NR, RR Flat, NABS, soft Good pulses

A Hypokalemia, resolved

Mother signed for DAMA Home meds 1. For follow up with Cranial CT Scan t/c official reading Ophthalmoplegic PPD Migraine TBM

On follow up

5 days post discharge

2 weeks after the first follow up

Case discussion

Case discussion
Hypokalemic Periodic Paralysis
Squinting

Hypokalemia

Ophthalmoplegic migraine

This rare form of migraine characterized by a severe, unilateral headache with prolonged oculomotor palsies involving the third, fourth, or sixth cranial nerves. May precede, accompany, or follow the headache

Migraine
The incidence of migraine peaks earlier in boys and girls. The mean age of onset is 7 years old for boys and 11 years for girls; the gender ratio also shifts during the adolescent years.

Case discussion
Hypokalemic Periodic Paralysis
Squinting

Hypokalemia

Ophthalmoplegic migraine
TB Meningitis

Squinting

Anti TB meds
PPD positive

Improvement of Squinting

CT Scan

Basal enhancement

TB meningitis

Symptoms evolve less rapidly compared to bacterial meningitis Because of inherent chronicity, signs of cranial nerve involvement (usually ocular palsies, less often facial palsies or deafness) and papilledema may be present at the time of examination

Nelsons Textbook of Pediatrics; 18th edition

Stages of TB meningitis
STAGE 1 1-2 weeks Non specific symptoms Focal neurologic signs are absent begin more abruptly Focal neurologic signs are present: lethargy, nuchal rigidity, seizures, meningeal signs, hypertonia, vomiting, cranial nerve palsies Development of hydrocephalus, increased ICP, and vasculitis coma, hemiplegia or paraplegia, hypertension, decerebrate posturing, deterioration of vital signs and eventually death

STAGE 2

STAGE 3

Nelsons Textbook of Pediatrics; 18th edition

Sometimes irregular movements of the eyes are observed and a squint is frequently developed ;

Majority presented with fever, headache, vomiting, neck stiffness and altered conscious level. Different complications were seen in the patients; hydrocephalus was seen in 60% and cranial nerve palsies in 50% cases.

BAI JERBAI WADIA HOSPITAL

FOR CHILDREN PEDIATRIC CLINICSFOR POST GRADUATES

Chest Radiograph 2050% of children have a normal chest radiograph

The tuberculin skin test nonreactive in up to 50% of cases examination and culture of the lumbar CSF
acid fast stain of the CSF sediment is positive in up to 30% of cases culture positive in 50-70% of cases

CT Scan
normal during early stages of the disease basilar enhancement and communicating hydrocephalus with signs of cerebral edema or early focal ischemia Nelsons Textbook of Pediatrics; 18th edition

Hypokalemia Age Fever Headache Focal Neurologic deficits Cranial Nerve deficits Cranial CT scan findings normal Any age __ __

Migraine common __ + + + normal

TB meningitis common + + + + +

SUMMARY:
CONFIMATORY FINAL DIAGNOSIS Therapeutic Trial

PARACLINICALS
Therapeutic Trial Other CONSIDERATTIO N EXISTING PROBLEM OF THE PATIENT

LITERATURE REVIEW

Lessons Learned:

Persuasion shall not only happen within hospital Importance of patient-physician communication even beyond hospital premises Importance of pushing through with the appropriate diagnosis even after discharge Doing all these even beyond boundaries!!!