Age: 0.5
Sex: M
Vaccine: DTAPHEPBIP, FLU4, HIBV, PNC13
Symptoms: CSF white blood cell count negative, Calcium ionised normal, Chest X-ray abnormal, Computerised tomogram head normal, Crying
Clinical narrative: Presented with acute change in mental status and hypotonia. Normal activity the day before, no history of illnesses or fevers or changes in routine. Per mom, was with nanny upstairs and noted crying after 9AM feeding, fed again a little at 10 but continued to be fussy. Per mom, nanny brought him downstairs because he started "breathe differently" and wasn't sure if he was dreaming but apparently was intermittently crying and then sleepy. No noted tonic clonic movements, changes in eye direction.  Patient then described to be more hypotonic and pale and parents rushed to ER. There patient's neuro status was noted to wax and wane and although he would respond to external stimuli, he was very lethargic. No noted seizure activity and would respond to sternal rub during these episodes. Head CT negative for bleeds or masses." Given Ceftriaxone, LP performed. Initial lactic acid 3 but decreased to 2.4. CBC, chemistries all within normal limits. Utox negative. Patient was intubated for airway protection prior to transfer. Given etomidate, roc, and versed for intubation. Given another 0.5 mg versed before transport to another hospital.  After initial workup in ED, he was admitted to PICU for further workup and management after being intubated for transport.   #Neuro: Presented with acute hypotonia, hypotonia intermittently with crying and fussiness. No history of tonic/clonic movements. CT head at ED normal, and after transfer to PICU, MRI head and aEEG were normal. He resumed back to baseline with good breastfeeding overnight, and EEG was obtained after consulting Neuro on 8/14, which was normal, and seizures were not suspected as cause for presentation. Neuro will follow-up outpatient in 6 weeks.   #ID: Initially was put on 48-hour rule-out sepsis, with urine, CSF and blood cultures. LP results were normal, and he was afebrile throughout his admission. Ceftriaxone was given 8/13-8/14, and CSF culture from ED came back positive for Gram + rods in chains before 48h. Normal CSF chem, speed of resolution of symptoms, and normal brain MRI led us to believe this was likely a contaminant. Per our infectious disease team, the proximity of these symptoms to vaccination the day prior to symptoms led us to believe this was a vaccine reaction to DTaP-HBV-POL vaccine, as no other suspected causes seemed likely. This event was seen as self-limiting per literature, and not a contraindication to further vaccines. Will follow-up with ID in a few months to discuss further.   #Tox: He was noted to have pinpoint pupils during his initial episode, and urine toxicology (including methadone) was negative. Per toxicology, no further workup was warranted, as clinical picture correlated with opioid but not other exposure, and parents denied any opioids at home.   #Resp: He was noted to be hypopneic during his episodes, but with intermittent breathing. He was intubated for transport to PICU out of concern for lethargy/hypotonia, but was extubated with quick return to room air upon arrival. He had no further desats during his admission.   #FEN/GI: After being extubated, he resumed breast-feeding with good feedings and UOP.