Case 1: Fever and Ataxia in a Toddler with Pica

Megan H. Tucker; Jonathan Holmes; Susan Harley; Maria Roca Garcia; Haidee Custodio

doi:10.1542/pir.2016-0189

This article requires a subscription to view the full text. If you have a subscription you may use the login form below to view the article. Access to this article can also be purchased.

Download PDF

Megan H. Tucker, MD*
Jonathan Holmes, MD^†
Susan Harley, MD^‡
Maria Roca Garcia, MD^§
Haidee Custodio, MD^¶

^*Pediatrics, Children's Mercy Hospitals and Clinic, Kansas City, MO
^†Children’s Medical Group, Mobile, AL
^‡Division of Pathology
^§Division of Pediatrics
^¶Division of Pediatric Infectious Diseases, University of South Alabama College of Medicine, Mobile, AL

AUTHOR DISCLOSURE
Drs Tucker, Holmes, Harley, and Roca Garcia have disclosed no financial relationships relevant to this article. Dr Custodio has disclosed that she is principal investigator for a clinical trial sponsored by Allergan. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 2-year-old boy with developmental delay and a history of geophagia residing in Mobile, AL, presents to a local emergency department with 3 weeks of intermittent fever and 3 days of irritability, ataxia, and strabismus. He has no history of international travel. Other than a temperature of 101°F (38.3°C), vital signs are within normal limits. On physical examination, the patient is noted to have bilateral cranial nerve 6 palsy, slurred speech, and an ataxic gait. Extreme irritability is observed when sitting the patient upright and with bright lights. Ophthalmologic examination reveals bilateral papilledema.

Laboratory analysis reveals C-reactive protein of 0.2 mg/dL (1.90 nmol/L), erythrocyte sedimentation rate of 48 mm/h, and peripheral white blood cell (WBC) count of 9,500/μL (9.50 × 10⁹/L) with an absolute eosinophil count of 32% (0.32). Computed tomography scan of the boy’s head yields unremarkable results; magnetic resonance imaging of the brain reveals nonspecific inflammatory changes. The opening pressure on lumbar puncture (LP) is greater than 20 mm Hg, and the manometer is emptied 3 times before obtaining a normal closing pressure. The cerebrospinal fluid (CSF) shows a white blood cell count of 823 /μL (0.82×10⁹/L), glucose of 41 mg/dL (2.28 μmol/L), and protein of 0.65 g/dL (6.5 g/L). Manual differentiation of the CSF shows the presence of 27% eosinophils (Figure …