Case 2: Lethargy and Ataxia in a 3-year-old Girl

Presentation

A 3-year-old previously healthy girl presents with progressive lethargy and ataxia over the past 7 days. Her mother reports that she has been increasingly sleepy and difficult to awaken, and over the past 3 days has had increasingly unsteady gait. In addition, she has had fatigue, cough, and decreased oral intake for the past 2 to 3 weeks. Her mother denies any fevers, weight loss, travel, or unusual exposures. She and her family are from an urban area in the Southeastern United States.

On physical examination she is afebrile without tachypnea or tachycardia. She is ill-appearing and sleepy but arouses with stimulation and follows simple commands. She has right-sided ptosis, right-sided facial weakness, and right-sided arm and leg weakness. Deep tendon reflexes are present in all extremities. Cerebrospinal fluid (CSF) analysis shows a white blood cell count of 68/μL (0.07×10⁹/L) with 33% neutrophils, 60% lymphocytes, and 7% monocytes; a red blood cell count of 42/μL (0.000042×10¹²/L); a glucose level of 26 mg/dL (1.4 mmol/L); and a protein level of 115 mg/dL (1.15 g/L). The remainder of the physical examination and basic laboratory values, including serum electrolytes, renal and liver function, and complete blood cell count, are within normal limits, although the C-reactive protein level is elevated at 10.8 mg/L (102.9 nmol/L) (reference range, <9.0 mg/L [<85.7 nmol/L]).

A computed tomographic (CT) scan of the head shows tetraventricular hydrocephalus (Fig 1). Empirical ceftriaxone, vancomycin, doxycycline, and acyclovir are started, without …