Age: 1.08
Sex: F
Vaccine: DTPHIB, IPV, MMR, VARCEL
Symptoms: Status epilepticus, White blood cell disorder
Clinical narrative: History of present illness: Patient is discharged on 04/20/04 after a six-day hospitalization for severe status epilepticus, febrile seizures, MMR/varicella zoster vaccine (VZV), encephalopathy, respiratory failure requiring intubation, and aspiration right upper lobe pneumonia. Operative/Invasive procedures: 1. Lumbar puncture 04/15/04. 2. Intubation 04/16/04. 3. Right femoral draw for laboratory work on 04/16/04. Condition at discharge: Much improved. Persistent, but stable, right upper lobe pneumonia. Seizures controlled with Trileptal and phenobarbital. Discharge Medications: 1. Augmentin 600 mg/5ml,3.5ml p.o. two times a day times ten days. 2. Phenobarbital 20mg/5 ml, to give 25 mg p.o. twice daily., 3. Trileptal 300 mg/5 ml, 1 ml twice daily to increase every third daily to increase every third day by 0.25 ml to a maximum of 1.5 ml p.o. twice daily. Hospital Course: The first three days patient was in critical care and in the pediatric ICU and ended up being intubated due to respiratory failure with aspiration right upper lobe pneumonia. She had severe febrile seizures requiring 4 doses of 1 mg of Ativan IV, phenobarbital loading with 200 mg, and fosphenytoin loading with 200 mg on the day of admission. The seizures were contained but she developed a progressive right upper lobe pneumonia that was not significant on initial x-ray in the ER but, within two hours in the ER, was complete right upper lobe pneumonia. She developed sever respiratory distress with stridor, with CO2 retention and required intubation at approximately 3:00 in the morning on the 16th and ventilation for two days. She extubated on the 17th and has had progressive improvement but persistent right upper lobe infiltrate on chest x-ray. She has had no further seizures since 4/16/04. Initial medications for treatment were the above mentioned anticonvulsants which were successful in containing her seizures. She had intermittent tonic-clonic generalized seizure activity for several hours on the 15th. She was given Rocephin, Vancomycin, and Zithromax IV to treat the pneumonia. The Zithromax and Vancomycin were discontinued after several days. She was kept on Rocephin until the 19th, when it was discontinued and Augmentin was begun. Additional medications included Fentanyl for ventilation and Zantac to prevent ulcers. She had some initial scant amount of fresh bloody drainage from the nasogastric tube. She did received some Decadron after extubation. Versed was given also for sedation. She received CPT to the right upper lobe with some albuterol nebulizations, as well. She did develop diarrhea while on antibiotics. Stool for C difficile was negative and the diarrhea has gradually improved. She developed a maculopapular rash consistent with VZV (varicella zoster vaccine) immunization during her hospital course. X-rays were consistent with right upper lobe pneumonia with intermittent gastric distension which did respond well to NG tube placement. Laboratory evaluation showed initial white count of 18,400 with a hemoglobin of 10.4, hematocrit of 30.5, MCV 82.1, platelet count 372,000. The band count was increased to 15% on admission and increased to 59% on the 17th, but the white count had normalized to a completely normal white blood count on 04/19/04. White count on 04/19/04 was 9600 with a hemoglobin of 11.7, hematocrit 34.8, platelet count 311,00 with 7%segs, 7% bands, and 72%lymphocytes, indicating a slight low neutrophil count but there were plenty of neutrophils previously during her acute illness indicating a good neutrophilic response. A spinal tap was performed and showed a CSF/red cell count of 45, white cell count of 1, with 78% lymphocytes. Initial chemistry 14 was abnormal with elevated blood sugar of 183. BUN was 23, calcium 8.4, Electrolytes were normal but she did develop and acidosis after that with a CO2 of 18 on the 16th and CO2 of 19 on the 17th, but the CO2 had normalized to 23 on the 18th. The initial phosphorus was elevated at 7.0 but was normal at 3.8. The protein was 5.3 and albumin 3.1 which were low initially and were not repeated. Liver function tests were normal. Initial CRP was less than 0.5 consistent with a viral process. It peaked at 8.2 on the 17th and was down to1.3 on the 19th of April. Ammonia was normal. Parathyroid hormone level was normal at 25.9. Phenytoin level was 12.6 on 04/16/04 and phenobarbital was 16.6 on the same date. On the 19th, the phenobarbital level was 16.5, indicating therapeutic levels. CSF protein was 16 and CSF glucose was 112. Urinalysis on the 15th showed a small amount of blood and this was on a catheterized sample; otherwise, was negative. Blood CSF and urine cultures were all normal. The gram stain was normal. Bacterial antigen of the CSF was normal. Tracheal aspirate showed mixed oral flora. Respiratory viral panel was negative C. Difficile was negative. Bacterial antigon tests for Haemophilus influenza B, strep pneumonia, Group B Streptococcus, Neisseria five strains, and E. coli, was all negative. Herpes was negative for PCR and CSF mycoplasma titer was less than 1 to 64 and a negative. Initial capillary gas on 04/16/04 showed a pH of 7:36, CO2 39, O2 71.8 with a base deficit-2.9. However, at 2:30 in the morning on 04/16/04, pH was 7.23, the CO2 was 54.3 indicating marked CO2 retention and the O2 was 45.9. She was intubated shortly thereafter. EEG was done and read by Dr which indicated a moderately abnormal record because of tight frontal spikes. I spent a total of 7 hours in continuous care of patient on her admission and on the second day I was in continuous care for her from about 9:30 in the evening of 04/15/04 until 4:30 in the morning on 4/16/04. She showed marked improvement with cessation of seizures after initial loading with phenobarbital fosphenytoin and then showed marked improvement of her respiratory status once she was intubated and ventilated. After exubation on 04/17/04, she has shown some persistent lethargy and irritability which has gradually improved and residual from the significant CNS stress that she underwent. We are cautiously optimistic that she will show a fairly complete recovery as she is able to interact with her parents and is able to walk now and is verbalizing. She has been off O2 several days prior to discharge with excellent saturations. She was on room air the morning of 04/18/04. She has had excellent oral intake the day prior to discharge with an intake of 1317ml with only two loose stools the day prior to discharge. Physical examination: T:98.5 degrees, Pulse 127, respiration 28, blood pressure 79/33. O2 saturation 99% on room air. She is well hydrated. General: Pt is a vigorous, active 13 month old in no acute distress. Skin: She has some dry, red skin on her face from tape from being intubated. She has a resolving maculopapular rash consistent with a rash from varicella vaccine on her trunk and abdomen. Head: Anterior fontanelle is soft. Eyes: No conjunctival injection present. Ears: She has PE tubes in her ears bilaterally. Neck: supple. Pharynx: Tonsils are normal in size without exudate or inflammation present. Chest: She has coarse rhonchi in her chest, heard greater on the right than the left. Cardio: A normal S1 and S2 and no evidence with a soft abdomen. The liver and the spleen cannot be palpated. GU: Deferred. Skin: No obvious rash present. Neuro: Anterior fontanelle is soft. Deep tendon reflexes are symmetrical. There is no clonus. Strength appears to be intact. Cranial nerves II-XII appear to be intact. Assessment: 1. Severe febrile seizure probably secondary to measles, mumps, rubella (MMR) and varicella zoster immunization. 2. Possible underlying seizure disorder with vomiting and aspiration right upper lobe pneumonia and respiratory failure, both greatly improved at discharge. Plan: Discharge on two anticonvulsants, phenobarbital and Trileptal and follow-up with Dr. for adjustment of anticonvulsant medications. We were unable to control her seizures with fever with four doses of 1 mg of Ativan, which is a large amount of Ativan for her, and phenobarbital loading. Follow-up EEG will probably be done and directed by Dr. 2. She will be continued with another ten days of Augmentin therapy for her pneumonia and follow up with Dr this week, and will need to have a follow-up chest x-ray in a couple weeks to make sure if the right upper lobe pneumonia persists. If she develops fever in the interim, the parents are to contact Dr. immediately. 3. Dr. and I both feel that her admission was probably due to fever from immunizations and that she may be eligible for the vaccine compensation program. 4. A total of one hour was spent in her discharge.