31st jan 2007
MEDICAL SUMMARY
Mohammed Muhsin, 6yr old

Case managed by L. Rajam, Professor of pediatrics * Dr
Vinayan K.P, Pediatric Neurologist, Dpt. Of Neurology
AIMS, KOCHI

Mohammed Muhsin, 6yr old boy was admitted to our
hospital on 24th December 2006 . his symptoms started
on 10th dec 2006 when he developed status epilipticus.
No fever then. Stared as (L) focal seizures. No
history of rash, No similar history in the past, no
history of diarrhea, no history of recent vaccination,
no history of dogbite. He was evaluated at Welcare
Hospital Dubai. EEG: ® hemispheric slowing. CT brain
(N). Discharged on Tegretol. Child had normal
sensorium at discharge. He developed low grade fever
after he was sent home. Readmitted on 14/12/2006 with
recurrence of GTCS. EEG: diffuse high amplitude delta
and theta activity over the right hemisphere with
occasional left front temporal sharp wave activity.
MRI brain (N). CSF study 88 WBC, 85% ktnogicttes, HSV
PCR – Negative. TB PCR – negative. Given Ceftriaxone
and acyclovir for 1 week. Continued to have focal
seizures, focal twitching of face and altered
behaviour. Started on Phenytoin and clonazepam. Fever
also continued with seizures increasing with every
spike of fever. Septic work up negative. Discharged
against medical advice on 23 / 12 / 2006 with the
diagnosis of viral encephalitis. Child brought to AIMS
on 24/12/2006

At admission: Altered sensorium. No clinical seizures.

Fundus: Bilateral papilledema, no focal deficits.
Bilateral choreoathetoid movement with orofacial
twitching. He was continued on
Ceftriaxone/Acyclovir/Mannitol for 1 more week. AED:
Phenytoin / CBZ / Clonazepam. EEG ( 26/12/2006 ) :
generalized non – specific disturbance of electrical
function predominantly over the right hemisphere. He
was given Ivlg x 5 days.

MRI ( 25/12/2006 ) – normal – On 30/12/2006 rpt EEG
was done due to suspicion of seizure recurrence – same
findings. Some intermittent high amplitude slow waves
– suggestive of electrographic seizures.
Phenobrabitone loded.

VEP (N), MRV (to R/o CVT) (N), (R) transverse sinus
hypoplastic. Rpt CSF: 10 cells.mostly lymhocytes.
Mx-negatice. Urine metabolic screening – negative.
PBG: negative. He continued to have altered sensorium
in the form or restlessness, no recognition or
vocalization. Bilateral choreathetoid movements
persisted. Fever spikes continued.sptic workup –
negative.
On 8/1/2007 he developed right focal seizures, which
developed into status epilepticus. He was started on
Midazolam infusion. Due to electrical seizure
persistence, he was put on Thiopentone infusion.
Inotrope support given. Electively ventilated. At that
time Hyponatremia (Na: 116 Meq/1 and hypocalcemia (Ca:
7 mg%) were detected. Serum phenytoin levels
decreased. Subsequently loaded twice. MRi ( 9/1/07 )
abnormal hyperintense areas involving bilateral
ganglio thalamocapsular regions and bilateral cerebral
and cerebellar hemispgheres. Possibility of ADEM
considered and was given IVig/Methylprednisolone x 5
days. Possibilitty of JE considered (JE serology in
CSF sent to NIMHANS (is negative). Posibility of mitochondrial
encephalopathy also considered and was started on
megamultivitamin therapy. Anti rabies antibody titre
in CSF: (is negative).
Thiopentone was tapered off in 48 hours and was
statrted on levetiracetam. Child was getting
occasional seizures on these drugs, Stopped CBZ due
to leucopenia. EEG: continued to show significant
diffuse electrical disturbance. Rpt MRI ( 15/1/2007 ).
Fresh lesion s in bilateral cerebellar hemisphere.
Minimal resolution of basal ganglia lesions. MRI (
22/1/2007 ): significant reduction in hyperintense
signal abnormality in all areas. He continued to have
poor sensorium, Ventilator dependency, His fever
spikes continued. He was on Meropenem x 2 weeks.
Changed to Cefaperazone – Sulbactam. Papilledemia
persisted. Opthal opinion chronic papillodemia,
gliotic changes. On 25/1/07 developed hepatitis ? drug
induced (SGOT : 889 IU/I SGPT: 322 IU/I) Tapered
phenytoin added Topiramete.
EEG ( 30/1/2007 ): Significant improvement in slowing.
Normal background rhythm. Suspicious epileptiform
abnormalities in the left frontal region.

Medication
1. Inj. Fosphenytoin 75mg BD
2. TAB. CLONAZEPAM 1/2-0-1
3. TAB. PHENOBARBITONE 75MG 1-0-1
4. TAB. CARNITINE 300MG 1-1-1
5. TAB. BENADONE 40MG 1-1-1
6. TAB. BENALGIS 75MG 1-0-0
7. TAB. TORLEVA 250MG 1-1-1/2
8. TAB. CO. ENZYME Q 1-0-1
9. TAB. TOPIRAMATE 25MG-0-50MG
10. SYRUP ZEVIT 5ML 1-0-0
11. SYRUP SHELCAL 10ML 1-1-1
12. TAB. RANTAC 150 1-0-1
13. SALBURAMOL NEBULIZER 6HRLY
14. IPRAVENT NEBULIZER 6HRLY
15. SALINE NEBULIZER 6HRLY
on tube feeds: 300ml 3rd hourly
On mechanical ventilation (SIMV)