measles

Physical examination:

GA:

A girl with drowsiness, dysarthria, and sweating

V/S:

T 39 C, PR 112/min, RR 20/min, BP 132/80 mmHg

HEENT:

No pale conjuctiva, no icteric sclera, no injected pharynx

Lymph nodes:

Can not be palpable

Heart:

Regular, tachycardia, normal S1 & S2, no murmur

Chest & lungs:

No retraction, clear, equal breath sounds, no adventitious sounds

Abdomen:

Soft, active bowel sounds, liver and spleen can not be palpable

Extremities:

No edema, no deformity

Neuro:

E3 V5 M6, pupil 3 mm RTL BE

Stiff neck negative

Full EOM, no facial palsy, gag reflex positive

Rigidity of both upper and lower extremities

Resistance through all ranges of motion, occasionally tremor (see movie 1)

Motor power at least grade III all extremities

Reflex 2+ all

Clonus negative, BBK plantar response both sides

Movie 1: tremor of hand
(Download movie)

Problem list:

1. Alteration of consciousness
2. Behavioral change :

-	Visual and auditory hallucinations
-	Apprehensiveness
-	Social isolation
-	Loss of appetite and sleep disturbance

3. Acute fever
4. Generalized muscular rigidity with occasionally tremor
5. Dysarthria

Investigations:

CBC:	Hb 13.5 mg/dL, Hct 40.4%, WBC 8,600 cells/cu.mm.
	(N67, band 3, L17, M13), platelet 221,000 cells/cu.mm.
PBS:	NCNC, platelet adequate, no toxic, vacuolization
U/A:	pH 7 sp.gr. 1.019, albumin trace, sugar negative, RBC 3-5/HPF, no WBC
Renal parameters	BUN 13 mg/dl, Cr 0.9 mg/dl
Electrolytes:	Na 132 mmol/L, K 4.3 mmol/L, Cl 94 mmol/L, CO2 23 mmol/L
LFT:	Total protein 9.3 gm/dl, albumin 4.7 gm/dl, globulin 4.6 gm/dl
	Alkaline phosphatase 123 U/L, cholesterol 141 mg/dl
	AST 37 U/L, ALT 38 U/L
	Total bilirubin 0.64 mg/dl, direct bilirubin 0.15 mg/dl
CT brain:	unremarkable study
CSF profile:	Clear, RBC 530, no WBC, Protein 32 gm/dl, sugar 65 mg/dl (blood sugar 92 mg/dl)
Total CK	(Creatinine phosphokinase) 719 U/L (0 – 195 U/L)
Hemoculture	No growth
CSF culture	No growth

Questions:

>	WHAT IS THE MOST LIKELY DIAGNOSIS FOR THIS PATIENT?

Click here for page 2:

A 13-year-old girl with alteration of consciousness and muscular rigidity (1/2)
Prepared by... Kanokwan Ruananukun, M.D. Kamornwan Katanyuwong, M.D Orawan Louthrenoo, M.D.
Department of Pediatrics, Faculty of Medicine, Chiang Mai University
Chief compliant: Alteration of consciousness for 1 day
Present illness:
>	1 year prior to admission, she had behavioral change including social withdrawal and school refusal. She concerned seriously about her friends’ comments and had lost of appetite and sleep problems. Her symptoms were off and on over the year.
>	2 weeks prior to admission, she was quiet, had poor appetite and sleep difficulty. The mother complained that she was fearful and sometimes confused. Occasionally, she reported visual and auditory hallucinations.
>	5 days prior to admission, she was admitted to a community hospital because of increasingly agitation. Medication was prescribed including: haldol 5 mg IM x 1 dose, haldol (2mg) 1x2, ativan (0.5mg) 1x1 , fluoxitine (20mg) 1x2. During admission, her symptoms were improved but she then developed intermittent twisted movement of all extremities.
>	Within 1 day after discharge, she had progressive deterioration of consciousness and uncontrolled behavior. Her mother brought her back to the hospital and she received 1 intramuscular injection of haloperidol (5 mg).
>	At the comunity hospital, her temperature was 38 C. She was drowsy, had slurred speech and progressive generalized twisted movement of extremities. She was referred to a psychiatric hospital and then transferred to Chiang Mai university hospital.
Past history:
>	No history of any underlying disease