A previously well 11-month-old infant presented with lethargy, a blanching rash, vomiting and diarrhoea. She was diagnosed with suspected gastroenteritis and discharged. The patient deteriorated and re-presented 24 h later with lumbar puncture (LP) confirmingNeisseria meningitidis. Following an initial good response to ceftriaxone, the patient then developed a blistering facial rash on day 3 for which topical aciclovir was started with no improvement. She subsequently developed fever and redeveloped a rising C reactive protein (CRP). A CT of the head on day 6 was normal, however a repeat LP on day 7 showed persistently raised cerebrospinal fluid (CSF), white cell count (WCC), high proteins and low CSF glucose. A CSF viral PCR confirmed concurrent herpes simplex virus (HSV) type 1 for which parenteral aciclovir was started. The patient responded well to bacterial and viral anti-infective treatments and was subsequently discharged on day 16 with no neurological sequelae.
Chronic moist cough in children can be associated with serious pathologies. Protracted bacterial bronchitis remains a clinical diagnosis causing persistent moist cough, disturbed sleep, exercise intolerance and significant levels of morbidity. Management involves minimal investigations and prolonged courses of antibiotics.
Method
This is a case of a previously well 17 year old girl with cerebral palsy secondary to Lissencephaly. She presented with a history of intractable vomiting progressing over the course of a few months secondary to severe worsening scoliosis.
Upon further investigation, it was felt that the extensive degree of her scoliosis was rotating her abdominal anatomy in such a manner to be the main cause of her vomiting. She was reviewed by the orthopaedic team who felt that correction of her scoliosis was indicated however this was not without significant risks to the patient especially given her extensive recent weight loss secondary to the vomiting. However, without the procedure the patient would continue to vomit and losing weight and may eventually die.
Result
The parents of the patient were keen to proceed with the operation despite the high risks as they felt their daughter’s quality of life had deteriorated significantly since the onset of the scoliosis and recurrent vomiting.
The patient underwent the scoliosis correction and made a good recovery.
Conclusion
This case presents a dilemma in which without correction of her scoliosis, the patient would continue to vomit and lose weight (medical therapy had failed). However, undertaking such a major operation in this patient carried a significant mortality risk.
The case also highlights the importance of close follow up of these patients as this child did not develop scoliosis until her teenage years and she missed her follow up appointments due to an address change.
Pictures of the scoliosis (X ray/CT are available to accompany the case)
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