Welcome to clinical meeting

Dr. KANTA HALDER Resident (MD;Phase A)

BICH

Particulars of the patient

Name: Sushmita. Age: 8 months. Sex: Female. Address: Najirpur, Barisal. Date of Admission: 16.01.2016. Date of Examination: 17.01.2016.

Chief Complaints

No neck control till date. Abnormal posture & movement since early infancy.

History of present illness

According to the statement of mother, her child –

• No neck control yet.• Abnornal posture & movement since early

infancy.• No H/O seizure.• No H/O trauma or CNS infection.

Birth History Antenatal : • Planned pregnancy.• Regular ANC.• Non-diabetic, normotensive.• No H/O fever with rash.• No H/O offending drugs.• No H/O APH, less foetal movement or

trauma.

Birth History

Natal : • H/O Prolong labour.• Failed home trial.• LUCS at term.• Average birth weight.

Birth History (cont..)

Postnatal : • Delayed cry after birth.• H/O ingestion of meconium in utero.• Developed respiratory distress.• Hospitalization for 7 days.• No H/O jaundice or seizure.

Feeding History • Exclusive breast feeding: Up to 7 months.• From 7 months: Suji with formula milk, Breast feeding.

Immunization History • EPI schedule.

Family History • 1st issue.• Non consanguineous parents.

Socio-economic History • Poor socio-economic background.

Treatment History• Treated by local traditional healer.

Developmental Milestone• No neck control yet.• Social smile: 3 months.• Vocalization: 3 months.

General Examination Appearance: Has apparently small head,

interested to surroundings, having social smile with dystonic posture.

Mildly pale.Jaundice: Cyanosis:Clubbing: Absent.Oedema:Dehydration:

Cont..Skin: BCG mark present, no neurocutaneous

stigmata.Lymphnode: Not palpable.Signs of meningeal irritation: Absent.Ear:Nose: Normal.Throat:

Cont..Vital Signs:

Pulse: 112/minRespiratory Rate: 38/minTemperature: 99°FBlood Pressure: 70/50 mmHg

Cont..Anthropometry:

OFC: 38 cm (-5.4 SD).Weight: 6.3 kg.Height: 64 cm.HAZ: -1.63 SD (normal).WHZ: - 1.40 SD (normal).

Nervous System Examination

Higher psychic Function : Conscious, oriented to surroundings. Cranial nerves examination : No facial asymmetry. Pupillary size and shape was normal, light

reflex was present. No squint, eye balls moved in all direction. Drooling was present, no swallowing

difficulty.

Cont.. Motor function : Muscle bulk : Normal in all 4 limbs. Muscle tone : Variable in all 4 limbs. Muscle power : 3/5 in all 4 limbs. Jerks : Exaggerated in all 4 limbs. Clonus : Absent. Planter response : Bilaterally extensor. Dystonia present. Sensory function : Can not be evaluated. Fundoscopy : Normal.

Developmental Assessment Gross motor : Writhing movement of 4 limbs present. Pull to sitting - Head lags behind the body

line. Ventral suspension – lifts head above body

level. Lifts chin up on prone lying. Can not go side lying position. Persistance of Assymetric Tonic Neck Reflex.

Cont.. Fine motor : No midline activity. Does not reach or hold object. Holds object tightly when placed in hand, but

difficulty in releasing. Cognition : Recognizes family members. Social smile present.

Cont.. Vision : Fixes and follows smartie. Hearing : Turns head to rattle, clapper bell & voice. Speech : Vocalization present. Other systemic examination including

Abdominal examination revealed normal findings.

Salient feature Sushmita, 8 months old girl, 1st issue of her

non-consanguineous parents, presented with no neck control till date, abnormal posture & movement since early infancy. She had history of perinatal asphyxia with meconium ingestion, but no history of neonatal jaundice or seizure.

Cont.. She was mildly pale having microcephaly, no

neurocuteneous stigmata or organomegaly. Dystonic posture was present. Vitals were within normal limit. Her cranial nerves were intact, muscle power was reduced with variable tone in all 4 limbs, jerks were exaggerated with bilateral planter extensor. Motor, cognition & speech delay was present.

Provisional Diagnosis

Dystonic cerebral palsy with microcephaly with motor, cognition & speech delay.

Differential Diagnosis

TORCH infection with microcephaly with motor, cognition & speech delay.

Investigations Complete Blood Count :

• Hb%: 11.2 gm/dl• WBC: Total count: 11,400/cumm Differential count:

o Neutrophil: 34%o Lymphocyte: 60%o Monocyte: 04%o Eosinophil: 02%o Basophil: 00%

Cont..

o RBC:Normocytic normochromico WBC:Mature with above

distributiono Platelet: Adequate

• Platelet : 478,000/cumm• PBF:

Cont..RBS : 5.9 mmol/L.S. Electrolytes : Na⁺ - 141.9 mmol/L. K⁺ - 5.0 mmol/L. Cl⁻ - 105.7 mmol/L.S. Calcium : 2.64 mmol/L.SGPT : 47 U/L.USG of brain : Cortical atrophy.

Cont..CT Scan of Brain : Suggestive of sequel of

TORCH infection with feature of mild hypoxic encephalopathy.

EEG : Epileptiform discharge around midline and right centro-parieto-occipital area.

Cont..Torch Panel : Toxoplasma : IgG - <5 IU/ml. IgM - <100 U/ml. Rubella : IgG - <5 IU/ml. IgM - <2 U/ml. CMV : IgG - 147.3 U/ml. IgM - <5 IU/ml. HSV type 1 : IgG - <10 U/ml. IgM - <10 U/ml. HSV type 2 : IgG - <10 U/ml. IgM - <10 U/ml.

Final Diagnosis

Dystonic cerebral palsy with microcephaly with motor, cognition & speech delay with congenital CMV infection.

Management Multidisciplinary team approach : • Paeditritian.• Developmental therapist.• Psychologist.• Opthamologist.• ENT specialist.

Cont.. Counseling. Nutritional management : Complementary feeding including khichuri

along with breast feeding. Feeding position. Management of spasticity : Tab Nitrazepum. Physiotherapy.

Cont.. For Congenital CMV infection : Inj. Gancyclovir – 3 weeks.Neuro-developmental therapy and

stimulation. Follow up

Thank You