Background

Rabies is a disease caused by Rabies lyssavirus, which is transmitted through the bites of infected animals. Transmission occurs when the infected animal’s saliva enters a person’s wound. Cases of people being bitten by rabid animals exist in the Republic of Belarus. However, there is reliable rabies prevention, which prevents the development of the disease and the incidence of rabies in children in the Republic of Belarus over the past decade is not known, except as presented in this case report.

Objectives

The report considers the case of infection of a 5.5 year old healthy child with a rabies virus after a dog bite. Initiated prevention of the disease with rabies was not effective due to a violation of the anti-rabies prophylaxis scheme. The disease developed with manifestations not similar to rabies (paralytic form), which made it difficult to diagnose specific encephalitis. The therapy carried out could not be effective due to the lack of the existence of drugs that can cure rabies. The child died 2 months after infection of rabies.

Methods

Case study

Results

The use of existing antirabies action plays a key role in preventing the development of rabies.

Conclusion

1. Obligatory success in preventing the development of rabies is the strict adherence to preventive schemes that depend on the category of damage.

2. Patients with a developed of encephalitis should have clear data on the anamnesis morbi, especially in areas endemic to rabies.

Background

Enteroviruses (EV) are human viruses associated with various clinical syndromes, from minor febrile illness to severe. Viral testing does not appear in the algorithms for the evaluation of neonatal infections. It may be easy to miss these viruses. We report a male neonatal EV meningitis.

Objectives

Aim of our report was to awareness of neonatal enteroviral infections.

Methods

Case presentation: A 35-year-old woman delivers a term male infant weighing 3,310 g through cesarean delivery due to previous cesarean section. Her prenatal screening tests were unremarkable. He developed respiratory distress soon after birth. An empiric treatment with intravenous ampicillin and gentamycin were initiated. His condition was a gradual improvement until day of life 9, he had fever and tachycardia. CBC was unremarkable and CRP was 4.7 mg/L.The cerebrospinal fluid (CSF) showed a white blood cell count of 200 cells/µL , with 24% neutrophils, 40% monocytes and 36% macrophage. The CSF glucose was 48.3 mg/dL with a serum glucose level 77 mg/dL and a CSF protein of 74 mg/dL. The intravenous antibiotics were changes to ceftazidime, cloxacillin and acyclovir. CSF virology a polymerase chain reaction (PCR) test was positive for Enterovirus and negative for herpes viruses. All bacterial cultures were negative.

Results

He was discharged from hospital in a good clinical condition fourteen days later.

Conclusion

Neonates who appear septic without bacterial etiology may have EV meningitis. We suggest that neonatal sepsis ought to be identified by a PCR testing not only HSV but also EV.This could help reduce the administration of antibiotics and antiviral medications.

Background

Elizabethkingia meningoseptica is a gram negative bacillus colonizing various hospital sites. It can rarely cause serious neonatal infections and outbreaks.

Objectives

Treatment is challenging since the organism is resistant to commonly used antimicrobials. We present the outcome of a neonate with ventriculitis.

Methods

A 6-day old term male neonate presented to a referral centre with complaints of fever, vomiting and irritability since 1 day. He had been exclusively breast-fed and discharged on day 4. Initial sepsis screen was negative and empiric intravenous cefotaxime and amikacin was initiated. By day 13, the baby presented to our centre in refractory status epilepticus requiring invasive ventilation and muliple antiepileptics. A repeat septic screen was positive and CSF analysis was suggestive of bacterial meningitis. MRI Brain showed signs of meningitis, ventriculitis and hydrocephalus. Two separate CSF samples grew Elizabethkingia meningoseptica as identified by VITEK 2 and MALDI-TOF MS. The isolate was sensitive to ciprofloxacin, tigecycline and rifampicin and treatment was tailored accordingly. The vancomycin MIC by E strip was 16 (susceptibility breakpoint 4) and in view of suitability of administration, intraventricular vancomycin was given for 4 weeks via External Ventricular Drain (EVD). In view of worsening obstructive hydrocephalus, a Ventricularoperitoneal (VP) shunt was inserted. Systemic and oral antibiotics were continued for a total of 12 weeks.

Results

At eighteen months, baby is neurodevelopmentally normal.

Conclusion

This case highlights the need for correct identification and susceptibility testing as well as applying the basic principles of drug pharmacokinetics/ pharmacodynamics especially when therapeutic options are limited in case of rare infections.

Background

Methicillin-Resistant Staphylococcus aureus (MRSA) is commonly a hospital-acquired infection. The incidence of community acquired MRSA is relatively uncommon, and yet serious infections may occur.

Objectives

To emphasize greater suspicion, aggressive approach to diagnosis, and early initiation of treatment for community-acquired MRSA infections to prevent long term morbidity and mortality.

Methods

A 1-year-old female child was referred after initial empirical therapy with Piperacillin-Tazobactam and Amikacin for complaints of fever of 2 weeks, a transient cough and cold, and a neck swelling of 5 days. Malaria, enteric fever, dengue and urinary tract infection were ruled out. Investigations revealed leukocytosis, progressively increasing platelet counts, elevated C-Reactive Protein and Erythrocyte Sedimentation rates. A computed tomography (CT) scan of the neck and chest revealed retropharyngeal abscess with extension in upper, anterior and posterior mediastinal compartments. Treatment was initiated with Ceftriaxone and Vancomycin, and Fine Needle Aspiration Cytology (FNAC) was performed from the neck swelling. The FNAC sample was negative for tuberculosis. Thoracoscopic abscess drainage was performed, and culture from the drained pus showed growth of MRSA. The child was treated with intravenous Vancomycin for 14 days followed by oral Linezolid for the following 4 weeks.

Results

The child was afebrile by the 7^th day of intravenous antibiotic therapy. A repeat CT Scan after 4 weeks showed no residue or recurrence of the abscess. The child made a complete and uneventful recovery.

Conclusion

Though MRSA is commonly considered a hospital-acquired pathogen, community-acquired infections with serious manifestations are reported. Early suspicion and appropriate radiological and microbiological diagnosis aid therapy and recovery.

Background

Sepsis is a syndrome caused by a dysregulated host response to infection. Our knowledge of the pathophysiology of sepsis suggests that some patients present with hyper inflammation leading to different clinical phenotypes like Macrophage Activation Syndrome (MAS). The hallmark finding in the diagnosis of MAS is fever and high levels of ferritin.

Objectives

To present a case of secondary MAS due to sepsis and favorable outcome.

Methods

We would like to report a septic episode, involving MAS, in a 9 months old female infant with sort bowel syndrome. At the age of 4 months she developed sepsis and multiorgan dysfunction syndrome (MODS). She was hemodynamically unstable, with acute renal injury, hepatobillary dysfunction and DIC. Although her organs were supported we failed to stabilize her homeostasis, especially her hematologic parameters (pancytopenia). Her ferritin was 3200 ng/mL and she fulfilled the criteria for MAS.

Results

She has treated with methylprendisolone (2 mg/Kg) and IVIG (1g/Kg) with rapid resolution of her septic episode and normalization of her laboratory findings (pancytopenia, hepatobillary dysfunction, DIC). At the age of 8 months she had a second infection. She has feverish but hemodynamically stable without MODS. Her ferritin was 2800 ng/ml and we added in her treatment methylprensidolone and IVIG with quick resolution of her symptoms.

Conclusion

Although MAS secondary to sepsis has a high mortality rate we suggest that intermediate phenotypes exist in this process. Patient with high ferritin and sepsis may benefit from immune therapy at an earlier clinical stage.

Background

Epstein-Barr Virus (EBV) infection is often asymptomatic but it may exhibit various life threatening and atypical presentations. Acute liver failure (ALF) as a complication of EBV is very rare . We are presenting a case of an infant admitted with Acute gastroentertitis followed by septic shock and multiorgan dysfunction who went into ALF secondary to EBV infection in the recovery phase .

Objectives

To study clinical profile of a case of Acute Liver Failure secondary to EBV

Methods

A 10 month old child was referred to our centre with 1 week history of loose stools followed by respiratory failure and septic shock. On admission he was intubated and started on mechanical ventilation and ionotropes. Broad spectrum antibiotics were initiated empirically. He had multiorgan dysfunction with derranged LFTs, coagulation profile, encephalopathy and bicytopenia. Due to multisystem involvement Mycoplasma IgM was sent which came positive and Azithromycin was started. He was extubated on day 3 and was shiffted to ward. Around day 10, he was noticed to have jaundice with clay coloured stools. LFT showed direct hyperbilirubinemia, raised liver enzymes and INR. Etiological work up for liver failure showed elevated EBV viral load. New Born Screening Test was normal. Supportive measures for cholestatic jaundice were instituted after which, he started improving gradually and was discharged

Results

EBV reactivation causing acute liver failure is rare in infancy. Timely instituted supportive measures can reduce morbidity and moratliy

Conclusion

There should be a high index of suspicion of EBV infection in ALF cases in infancy though a rare occurence.

Background

Enteroviruses (EV) are a common cause of infection around the world. Most cases are usually asymptomatic however in newborns can lead to severe sepsis with multiorgan failure. Despite their potential high morbidity and mortality rates, there are no data available regarding the maternal- fetal transmision rate and no recommendations on viral testing appear in the algorithms for the screening or diagnosis of neonatal infections. Neonates with clinical suspicious of enterovirus infection usually have mothers or other contacts with recent symptoms consistent with a viral illness

Objectives

We described a case of a term newborn of EV meningitis

Methods

Description of a clinical case through review of the clinical history

Results

A female neonate who on five day of life presented lethargy with poor feeding and isolated temperature of 37,7ºC. Mother had started with a cold 24 hours previous labour. The hemogram and the phase acute reactants were normal. The initial study of cerebrospinal fluid (CSF) did not present any alteration although the Polymerase Chain Reaction for enterovirus resulted positive. Brain ultrasound performed was normal. The level of alertness improved. No antiviral treatment was required. The newborn was discharged from the hospital after one week of stay with no adverse outcome

Conclusion

The neonatal EV infection is probably underdiagnosed. Its potential fatal outcome requires high index of suspicioun specially in pregnant women with symptoms of viral infection

Background

Sepsis is the leading causes of morbidity and mortality in critical patients in many intensive care units. There were numerous parameter and biomarkers available to confirm the presence of sepsis.

Objectives

The aim of this study was to determine which one the parameter or biomarkers (white blood cell, CRP,procalcitonin and TNF-α) has a role as an outcome predictor in pediatric sepsis patient.

Methods

This prospective cohort study was conducted in Pediatric Intensive Care Unit Wahidin Sudirohusodo hospital from December 2015 until May 2017. A total of 108 sepsis patients were included. Plasma specimens were collected at admission, then the patients were being followed up for survived or non-survived. The diagnosis of sepsis is using the International Pediatric Sepsis Consensus 2005 criteria. Serum CRP, Procalcitonin TNF-α were measured using Enzyme Linked Immunosorbent Assay technique.

Results

The initial serum procalcitonin level and TNF-α in non-survived children with septic were very significantly higher than those in the survived groups with p=0.000 with OR 2,46 CI(0,905-6,697) in procalcitonin and p=0.000 with OR 44,69 CI(5,749-347,36) in TNF-α. There were no significant in WBC and CRP between survived and non-survived group

Conclusion

: The initial serum level of PCT and TNF-α can be used as a predictor outcome of sepsis patient in children

Background

Background: C - reactive protein (CRP) detection is a nonspecific response to neonatal sepsis, but along with clinical symptoms is helpful, it is an early inflammatory marker, and readily available, less costly makes it an easy test to screen for neonatal sepsis especially in developing countries.

Objectives

Objective: The purpose of this study is to evaluate the early detection of CRP and its correlation to blood culture to diagnose neonatal sepsis.

Methods

Methods: The study was conducted in the special care baby unit at the University Hospital of Tripoli (Tripoli Medical Centre) on the period (January 2013 –December2014). Data of 100 neonates under clinical diagnosis of sepsis were reviewed retrospectively. .Blood culture was sent for all neonates, CRP was done quantitatively by rapid latex agglutination method and cut off value of CRP was taken as 6mg/l. Data analysis was carried out by SPSS version 25 and a p-value < 0.05 considered as statistically significant.

Results

Out of 100 patients studied 70% were above 2.500 g, 72% were normal vaginal delivery and 45% presented with fever. CRP was positive in 75 patients and 59 of patients showed Positive blood culture. CRP test showed 80.8% sensitivity and 40.7% specificity, considering blood culture is a gold standard method. A predominate organism is Staphylococcus species followed by Escherichia coli. Mortality rate was 14%, the main isolates in nonsurvival were gram-negative bacteria.

Conclusion

Conclusion: CRP remains a rapid inflammatory marker for screening of neonatal sepsis in the absence of negative blood culture especially in low resources country.

Background

In recent years, a clear increase has been observed in the incidence of nosocomial fungal infections.

Objectives

The aim of this study is to assess the candida species, treatment approaches and outcomes of candida infections were identified in the pediatric intensive care unit.

Methods

The study was performed from March 2018-March 2019 in a 14-bed tertiary pediatric intensive care in a city hospital. The patients with invasive candidiasis were detected from microbiology laboratary records and medical records were examined retrospectively.

Results

Within one year, a total of 176 patients were treated in the intensive care unit. Of these patients, 28 (15.7%) had candida isolated species . The most common isolated species was C. albicans in 35.7%. Among non-albican species, C. tropicalis was most commonly isolated in 25%, followed by C. parapsilosis observed in 10.7%.

In 5 patients, antifungal treatment was not started because of no systemic findings.

Mortality occurred in 6 of these patients (21%). In 5 patients, the cause of mortality was considered to be candida sepsis. There was no correlation identified between candida species and mortality.

Some of the Candida species were observed to be resistant to fluconazole, flucytosine and caspofungin. Proliferation in patients with mortal progression were resistant species. However, all candida species were susceptible to micafungin.

Conclusion

In this study, duration of intensive care stay and invasive medical proocedures are associated with an increased risk of invasive candidiasis. Additionally, it is confirmed that micafungin is a more appropriate agent that can be chosen for administration of antifungal treatment.

Background

Septic shock is the first cause of pediatric death in the world. The combination of different extracorporeal blood purification (EBP) techniques has been suggested as a potentially effective approach in its management.

Objectives

We present a case of refractory septic shock correlated to Clostridium difficile infection in a 8-year-old patient affected by acute lymphatic leukemia after chemotherapy.

Methods

Clinical case

Results

In general ward the patient developed severe neutropenia. Broad spectrum antimicrobial therapy was started. Nevertheless, a deterioration of general conditions occured, progressively leading to severe septic shock.

At admission in PICU he presented severe hypotension (MAP <40 mmHg) and metabolic acidosis (lactates 160 mg/dl). He underwent mechanical ventilation and cardiocirculatory support. Despite fluid resuscitation (>20 ml/kg), inotropic (epinephrine 0.2 μg/kg/min) and hydrocortisone therapy, the clinical condition did not improve.

Therefore, CRRT was started in order to counteract severe metabolic acidosis and fluid overload and remove sepsis cytokines. Continuous veno-venous hemodiafiltration (CVVHDF) modality, with a high effluent dose of 60 ml/kg/h, combining a ST60 filter with Cytosorb® cartridge column, was chosen.

After 48 hours a significant reduction in inotropic doses (epinephrine from 0.2 to 0.04 μg/kg/min), lactates (from 160 to 12 mg/dl), CRP (from 22 to 3.5 mg/dl) and procalcitonin (from 8 to 1.5 ng/ml) levels was observed. CRRT was continued for the first 72 hours without complications. Finally, the patient was successfully discharged from PICU after 9 days.

Conclusion

The combination of CRRT and Cytosorb® has a relevant synergistic effect in pediatric septic shock, helping in the management of cardiocirculatory shock, metabolic acidosis, fluid overload and immuno-modulation.

Background

Scabies is infectious skin disease caused by Sarcoptes scabiei, burrowing into stratum corneum in skin. Neonatal scabies shows large number of vesicles, papules, and pustules instead of the classic threadlike burrows. Due to presentation differences and the relatively low incidence in neonates, scabies is frequently misdiagnosed.

Objectives

We present scabies that start from the baby and then affect the parents.

Methods

case presentation

Results

A 42-day-old premature male infant born at 34 weeks visited the outpatient clinic with rash started 6 weeks after birth. There were several 0.5-1 mm size papules on face. Miliaria was suspected, so cooling the environment and using moisturizer was taught. The face lesion improved but multiple pustules and vesicles appeared on scalp, trunk, back, and upper extremities. Suspecting bacterial skin infection, oral antibiotics and topical steroid ointment was used, but there was no improvement. The baby was admitted and intravenous antibiotics were started. Dermatology was consulted and microscopic examination of skin scraping showed living mites, eggs and feces. We diagnosed scabies and treated lesion by permethrin cream. The parents complained pruritus on chest after the baby showed pustules and vesicles. After diagnosing the baby scabies, the parents were diagnosed scabies and treated.

Conclusion

Neonatal scabies is markedly different from adults. Differential diagnosis for an infant showing pustular vesicular rash are broad. Based on our experience, scabies should also be considered when a baby presents pustular vesicular rash which shows poor response to topical antibiotics, and persons in close contact with the child present with similar symptoms.

Background

Enteral antibiotics are rarely used in intensive care units. IV access can be problematic in children with prolonged hospitalizations. We wanted to report our enteral antibiotic use in PICU.

Objectives

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Methods

Retrospective descriptive study performed in a tertiary PICU

Results

30 patients (53% female) received enteral antibiotics between 2016-2018. Median age was 18 months (IQR 6-35). Median PRISM mortality rate was 5.3 (IQR 3.9-17). Majority (80%) were intubated, and 2% received inotropic support. Patients had mostly neurologic diseases (73%) and malignancies (16%) Median WBC, platelets and CRP were 14.4x10³/mL (IQR 10.5- 18), 235000 (IQR 102000-412000) and 42.5 (IQR 16-91.5) respectively.

Types of pathogens and antibiotics are presented in Table and Figure.

Nine patients (30%) had ventilator associated pneumonia (VAP), 14 (46%) urinary tract infections (UTI), 6 (20%) blood stream infections (BSI) (1 associated with mediastinitis) and 1(0.03%) ventriculitis. Four patients were switched to enteral antibiotics after antibiogram was obtained. Mediastinitis/BSI case was switched to enteral after 1 week of parenteral treatment. All patients were treated successfully.

Conclusion

When IV access is limited and enteral absorption is not problematic, enteral antibiotic use can be a safe alternative for treatment of appropriate infections.

Background

Nosocomial infections are frequently seen in hospitalized patients due to traumatic brain injury.

Objectives

The incidence of infection in traumatic brain injury(TBI), its relationship with risk factors, hospital cost and duration of hospital stay.

Methods

63 patients were hospitalized in the pediatric intensive care unit of Marmara University Hospital between 2012 and 2014 for the treatment of severe TBI.

Results

There were no significant differences in terms of age, sex, length of stay, type of ventilation, presence of central catheter and duration of antibiotic treatment and infection development in patients with and without infection. Foley catheter and nasogastric catheter uses were more common in trauma patients. 5 patients were developed infection and the ratio is 7,9% . 3 of the infections developed in trauma patients were ventilator related pneumonia, 1 was urinary tract and 1 was catheter related infection.

Conclusion

There are risk factors that may cause nosocomial infection in patients with severeTBI(1). These infections increase the duration of hospital stay and the cost of treatment. The nosocomial infection ratio was % 3-14(1,2) and our rate was % 7,9. In a study by Zolldan et al. In 763 patients between 1998-2002; urinary tract infection rate was 24.7%, pneumonia 23.6% and bacteremia 17.2% (2). Prospective studies are needed to evaluate more patients in our country.

References:

1- Alharfi I.M et all. Infection rates, fevers and associated factors in pediatric severe traumatic brain injury. Journal of Neurotrauma . 2014:31;452-458.

2-Zolldan D, Thiex R,et all. Periodic surveillance of nosocomial infections in a neurosurgery intensive care unit. İnfection 2005;33:115-21.

Background

Atypical germs are emerging, newborns are increasingly infected by these germs, difficult to diagnose and take charge of.

Objectives

We report neonatal epidemics to reveal epidemiological and etiological factors.

Methods

This is a retrospective observational study of 5 epidemics reported to the neonatology department, Mohamed VI University Hospital Center , Marrakech, Morocco; over a period of two years 2017 and 2018.

Results

These are 3 epidemics with Serratia Marcescens dated respectively: in August August, brought to 8 patients, in January 2018 brought to 6 patients and in June 2018 with 5 cases. An epidemic at Kluyvera Ascorbata in September 2018 with an infection of 5 newborns and an epidemis at Enterobacter Hormaechei in May 2018 with 5 newborns infected.

The diagnosis is based on changes in the clinical state associated with an inflammatory syndrome; it is confirmed by blood cultures. This is the first time that these germs are reported in our hospital.

Conclusion

All pathogens(bacteria, viruses and fungus) may be responsible for infection in the new born. Recently there has been a change in local epidemiology.

Background

Hyperchloremia can be caused by renal failure, renal tubular acidosis, dehydration, diabetes insipidus, gastrointestinal bicarbonate loss, excessive fluid replacement therapy with sodium chloride, as well as diuretics, corticosteroids and acetazolamide use. Here we present a fatal hyperchloremia case which was associated with Munchausen by proxy syndrome.

Objectives

An 8 month old male was admitted to our PICU due to decompansated shock after an episode of gastrointestinal bleeding. Past medical history was significant for multiple hospitalizations due to recurrent fevers, various rashes, respiratory distress, vomiting. His metabolic and immune panels were normal.

On PICU admission his blood pH was 6.93, PC02:42mmhg, HCO3: 8.3mmol/L, BE: -23.6mmol/L, lactate :2.9mmol/L, Na:133mmol/L, Cl: 363mmol/L (N:98-106) and methemoglobin was 21.2% (N:0-1.5). The twıce normal range of hyperchloremia with mild hyponatremia could not be attributed to an intrinsic medical problem. He had burn like oral lesions, and developed esophageal perforation presenting with pneumomediastinum and pneumothorax. The child expired due to multisystem organ failure. The autopsy results were consistent with enteral intake of HCL. Further history revealed that the child had been referred to Child Protection Services due to a suspicious history and symptoms during his previous hospitalizations.

Methods

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Results

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Conclusion

Excessive chloride intake should be kept in mind when a patient’s chloride levels are so high that cannot be related to any disease. Munchausen by proxy syndrome should be remembered when a patient presents with rare and extraordinary symptoms, and does not respond to the standard therapy as in our case.

Background

Lemierre syndrome is characterized by septic thrombophlebitis of the internal jugular vein leading to metastatic septic complications following an oropharyngealinfection.It is usually caused by the anaerobe, Fusobacterium necrophorum and affects adolescents.Recently otogenic sources in younger children have been described.

Objectives

To raise awareness about this rare condition.

Methods

We present a case of a toddler who developed Lemierre syndrome secondary to otitis media and mastoiditis.

Results

A 2,5year old girl was admitted with a 4-day history of high fever, malaise, pain and swelling of the left eye and purulent drainage from the left ear.Laboratory evaluation showed neutrophilia, elevated CRP(439mg/L) and PCT(21ng/mL).Brain CTscan revealed left mastoiditis.Given the toxic appearance of the patient,sepsis and meningitis were presumed and she was admitted to PICU.CSFanalysis showed typical signs of bacterial meningitis however CSF and blood cultures were negative.Ceftriaxone and vancomycin were initiated.On the third day she underwent an MRI-MRV which revealed thrombosis of the left internal jugular vein as well as the cavernous sinus and the left superior ophthalmic vein.Mastoidectomy was performed and anticoagulant therapy was initiated.Fusobacterium necrophorum grew from operative cultures of the mastoid and antimicrobials were narrowed to ciprofloxacin and clindamycin.The patient showed significant improvement,completed a 6-week course of antimicrobials and continued on enoxaparin.At 3-month follow-up there was good recovery and MRI showed partial resolution of the internal jugular vein thrombus.

Conclusion

Lemierre syndrome,although rare,is a potentially lethal but treatable complication of head and neck infections even in younger children.Early clinical recognition of Lemierre's syndrome and prompt management are crucial in reducing morbidity and mortality in this "forgotten disease".

Background

Pneumococcal meningitis is well known to cause vasculopathy and ischemic infarcts. Here, we present an unvaccinated case of pneumococcal meningitis with complicated fatal course.

Objectives

A 12 year old male presented to the ER with fever, headache, lethargy and difficulty in balance. His PMH was significant for recent left myringotomy and tube placement three weeks earlier, due to hearing loss with past ear infections. His work up revealed pneumococcal meningitis, for which ceftriaxone and vancomycine was initiated promptly. Initial tomogragraphy was normal except decreased aeration of mastoid cells. Due to anaphylaxis with ceftriaxone, patient developed severe upper respiratory obstruction, he was intubated, given epinephrine and switched to meropenem with concurrent application of steroids. Repeat CT due to anisocoria revealed infarcts in medulla oblongata and on both cerebellar hemispheres, along with left mastoid abscess. A colesteatoma is detected on mastoidectomy operation which was resected. Anisocoria regressed and patient became responsive to verbal stimuli. Osmolar therapy was given for brain edema. However, anisocoria recurred and re-imaging revealed hydrocephalus, necessitating emergent EVD and subsequent craniectomy due to impending tonsillar herniation. The patient died on the 12^thday of PICU admission. His CSF was clear of infection and no immune deficiency could be found.

Methods

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Results

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Conclusion

Despite appropriate interventions, pneumococcal meningitis can lead to vasculitis, causing infarcts and hemorrhage. Vaccination is important key for prevention of fatal meningitis.