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Washington University Experience | VASCULAR | Infarct - Venous | 4A0 Case 4 History
Case 4 History
This was a 2 year old girl with known sickle cell disease. The patient had a 4 week history of upper respiratory infection and was placed on oral ampicillin for 1 week, which had been discontinued a week before admission. She had increasing lethargy, decreased oral intake and cough two days before admission. On the day of admission she had a generalized tonic seizure and became nonresponsive. When first seen at the SLCH ER she was noted to have a right pupil larger than the left and was given mannitol and intubated for hyperventilation. Neurologic examination at that time revealed the right pupil to be 5 mm and unreactive to light. The left pupil was 1.5 mm with minimal light response. These were accompanied by decreased or absent brainstem reflexes. Motor examination revealed flaccid limbs. Reflexes were l+ in all areas tested. There was no response to plantar stimulation. Admitting lab values were unremarkable. Blood gases were adequate with ventilatory support. Lumbar puncture revealed 500 white cells, 80% polys, 13% mono, 70% lymphocytes, and 3+ bacteria on microscopic examination, all of which were gram positive diplococci. CSF protein was 864, the glucose was 10. It was felt that the patient had meningitis with subsequent incipient herniation. Latter that day both pupils became 5 mm and unresponsive. The patient remained on ampicillin and chloramphenicol. The day after admission the patient had cardiac arrest and cardioversion attempts were successful. Subsequent neurological examination revealed no further change except for further decrease in spontaneous reflexes. Several hours later another cardiac arrest occurred and resuscitation was not successful. ---- Autopsy demonstrated acute bacterial meningitis (pneumococcus by premortem culture), recent superior sagittal sinus thrombosis, widespread multiple acute macro- and microinfarcts, both hemorrhagic and pale, in the cerebral hemispheres (cortical surface and underlying centrum semiovale), cerebellum and brainstem. The findings in this case illustrate a known pathologic consequence of meningitis, venous thrombosis, probably of the lateral and straight sinuses, although unfortunately these sites were not submitted for pathologic evaluation. The internal cerebral veins were not thrombosed.
