Introduction
Meningoencephalitis can be caused by bacteria, viruses, fungi, and protozoan or as secondary sequel of other inflammations like AIDS. The inflammation causes the brain to swell leading to confusion, changes in alertness, and seizures. In general, meningoencephalitis and encephalitis represent uncommon responses to common infections. Most infected patients have a mild syndrome of meningoencephalitis rather than severe encephalitis.1 Viral encephalitis also includes slow viral and chronic degenerative diseases of presumed viral origin.2 Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury. Viruses are predominant causes of infectious encephalitis. Viral encephalitis is a medical emergency and its prognosis depends on the kind of causative pathogen and immune status of the patient. Herpes simplex virus (HSV) is the most prevalent cause of viral encephalitis in the developed countries with the annual incidence rate of 1/250,000 -500,000 people. In viral encephalitis, the virus first enters the body and then replicates in local or regional tissues, such as gastrointestinal tract, skin, urogenital, or respiratory system. Subsequent dissemination in the central nervous system occurs through hematogenic routes (enterovirus, arbovirus, HSV, HIV, mumps) or through retrograde transportation via axons, such as in the case of herpes virus, rabies virus, or prion protein. Most of the guidelines cited focal neurological signs, seizures, fever, altered levels of consciousness (ALOC) and changes to personality or behaviour as signs and symptoms of encephalitis in both children and adults.3
Materials and Methods
A 6yr 5m old female was retrieved from another hospital with ET tube insitu. Child developed fever 7days back which was high grade not associated with chills and rigors, decreasing on medication temporarily. Child complained of headache more in the frontal region and no diurnal variation. Child had decreased appetite since the beginning of fever and since last 2 days was taking only liquids. On 6th day of fever child became drowsy and hence was taken to hospital and was admitted. Child developed convulsions on the same day in the form of GTCS which was aborted with Midazolam. Child was started on Levetiracetam. On the same day child was intubated in v/o poor GCS. LP was done in the hospital which showed predominant polymorphs and so child was started on Magnex (Cefoperazone + Sulbactam), Acyclovir. MRI was done which was suggestive of meningoencephalitis and child was started on steroids. HSV PCR, Blood culture and CSF culture were sent and reports awaited. Child was referred to our hospital for further management.
Physical Examination
On physical examination, general physical findings should be noted including heart rate, respiratory rate, blood pressure, presence or absence of meningismus, and signs of involvement of other systems, particularly skin rashes and lymph nodes, as well as signs of trauma. Fundoscopical examination including indirect ophthalmoloscopy may elucidate vasculitis and also, the shaken baby syndrome in case of non-traumatic injury. Neurological findings depend on which part of the brain is primarily involved. Findings may predominate in any part of the brain or non - CNS sites may predominate.
Past History
Child had episode of fever in the first week of February which subsided after taking medications. Child had another episode of fever two weeks back which lasted for 4 days and then subsided. Child was active during the fever free period.
Birth History
Full term child of Normal delivery. Birth weight was 2.6kg. No History of NICU stay. Child has been vaccinated up - to the age of 3 years.
Family History
Patient is the second child of non-consanguineous marriage. Child has one elder and one younger sibling. No history of similar complaints in the family
Case details
Treatment Plan
On day one, child was on mechanical ventilation with ICD insertion. EEG was conducted which showed slowing of waves (probable encephalopathy). Medications such as Ceftriaxone, Acyclovir and azithromycin were introduced. Neuro-protection and anti-edema measures were taken. Sedation was optimised and neurologist opinion was given. Patient wasn’t given anything orally. ECHO procedure was done which showed normal
On day two, ceftiaxone drug was continued along with NG feeds and IV fluids were tapered down. Sodium levels were monitored upto levels 135-145 and 3% Nacl was tapered down accordingly and NG feeds were initiated. Patient had altered sensorium
On day three, sedation was stopped and sensorium was reassessed. She developed tonic posturing, hence sedation was restarted. Polyuria was present so was decided to be replaced with NS if hemodynamic instability was seen.
On day four, tonic posturing was still present with polyuria, right sided pneumothorax was observed which resolved. A trial of CPAP was given but the child did not tolerate more than 15 min hence it was changed back to Control mode. CSF analysis was done which showed normal protein sugars, differential count of all lymphocytes and Human Herpes virus 6 was detected. Extubation was attempted for the past 3 days, without success. Child had needed long term rehabilitation, hence Tracheostomy was planned. Child did not show any movements, which meant that there would be a motor or sensory (vision, hearing) disability. Child’s parents were counselled regarding the need for ventilation and tracheostomy. Child was opening eyes spontaneously with no eye contact. Ophthalmic examination was done which showed normal.
On day five, child was seen to be holding on without ventilation but however intubation and tracheostomy was required to be considered. Child did need long term rehabilitation and support as she was critically ill. Child was extubated with spontaneous breathing trial (SBT) Trial and Dexamethasone 4mg was given.
On day six, sensorium still remained poor however, polyurea was better and pneumothorax was resolved. Right ICD was placed and on removal lungs showed good expansion on the right side. Child was on HFNC with stable hemodynamics, Airway maintained breathing pattern and showed improvement, blood gas was normal with good oxygenation but sensorium remained poor, with no focus and lifting limbs against gravity.
On day seven, Air mattress was used and the child's position was changed every four hours with help of physiotherapy. Child was maintaining saturation in room air with no respiratory distress. Central Nervous System showed better eye focusing, pacitane drug was initiated and levetiracetam was given orally. On day ten, the patient was mobilized, antibiotics and NG feed were continued along with multivitamins, calcium and patient was shifted to ward. HNFC was discontinued with intermittent focusing and posturing episodes appeared to be less. Child was still on NG feeds and was discharged after training mother on NG feeds and physiotherapy. On discharge she was hemodynamically stable, but had neurological sequela meaning she was unable to recognize or make eye contact, not able to move against gravity. She required a long term physiotherapy and nutritional rehabilitation. Child’s prognosis was unpredictable. However on OPD visit patient still had issues with posturing after a week but tolerated NG feeds.
Table 2
Medication
Nutrition Care Plan
Day one the child was nil per oral, thereby nasogastric feed was initiated within 24 hours and IV fluids were tapered. A polymeric formula was provided as trickle feed but replaced with partially hydrolysed formula after 3 days due to feed intolerance.4 A peptide based semi- elemental formula was prescribed at the rate of 10 ml 2nd hrly thereby full fluids was targeted by day 6 due to a potential risk of refeeding since the child had history of poor oral intake since one week, underweight and low levels of potassium, magnesium was observed.
Nutritional challenges
Underweight for age with high risk of refeeding syndrome: 5 poor oral intake since 1 week, was only on oral liquid & hypokalemia on admission was noted.
Feed intolerance; on starting trickle feeds (standard polymeric formula)
Route: nasogastric feeding tube until discharge with no improvements neurologically observed for 9 days.
Poor socioeconomic status and lack of awareness of importance of macro nutrients among the family.
Mother had the burden of taking care of two other siblings and manage the family, therefore less importance was given to this child.
Nutrient requirement in PICU:
Energy (kcal): 802 kcal/day (WHO equation 5)
Protein(g): 24.3g /day (1.8g/kg/day)
Fat(g): 40% of total energy prescribed
Carbohydrate(g): 50% of total energy prescribed
Fluid requirement (ml):1175ml
Table 3
Nutrient requirement when shifted to ward:
Energy (kcal): 75kcal/kg/day (RDA) - modified RDA: 85kcal/kg/day (1147kcal/day)
Protein (g): 1.1g/kg/day (RDA)-modified RDA 2g /day (27g/day)
Fat (g): 35% of total energy prescribed
Carbohydrate (g): 55% of total energy prescribed
Fluid requirement (ml):1175ml
Table 4
On follow up-1 at OPD – after 4 weeks of discharge
Home recall: followed as prescribed & requested for blenderised home based feed preparation
Route- Nasogastric feeding tube + Oral feeds attempted (pureed, calorie dense feed thrice /day)
Supplement: continued the same supplement as tolerated earlier by the child
Composition of home based feed: nuts, oilseeds, dry-fruit, meat broth, vegetables, fruit, turmeric, pepper, coconut oil, olive oil
On Follow up 2 at OPD: after 8 weeks of discharge
Home recall: 900kcal, 20g of protein, reduced supplement due to cost constraint and included majority of fruit based feed
On Follow up -3; on teleconsultaion
Child was provided soft food and liquids orally.
Stopped NG feed
Child’s appetite improved
Weight for age achieved at 10th to 25th centile (17.2kg).Height: 113cm between 25th to 50th centile. Mid upper arm circumference on last follow up – 13.5cm (normal).
Child’s gait and speech normal, chewing and swallowing food, social, intellectual and cognitive improvement observed.
Result and Conclusion
A paediatric case of meningoencephalitis, detected with human herpesvirus 6 and an episode of seizure, the child was retrieved and ventilated at pediatric intensive care unit with repeated failed extubation, poor prognosis, underweight on admission, with high risk of refeeding syndrome, altered sensorium. Initially there was no signs of improvement observed neurologically (unable to recognize or make eye contact, not able to move against gravity) in first two weeks at the onset of disease and continued on nasogastric tube on discharge. The child was regularly followed up with pediatric neurologist, nutritionist and physiotherapist to ensure the child’s catch up growth and development is attained, to prevent growth faltering and protein energy wasting. The medical nutrition therapy involved fine tuning of child’s nutrition care plan based on the nutritional challenges, with regular monitoring we were able to observe successful clinical outcome in the child with an improvement in weight , transition to oral feed and normal neurological development was observed.