Neuropediatrics 2018; 49(02): 158-159
DOI: 10.1055/s-0038-1623533
Images in Neuropediatrics
Georg Thieme Verlag KG Stuttgart · New York

Hoofbeats, Zebras, and a Child with Vomiting

Carlo De Pieri
1   Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
,
Giulia Bravar
2   Department of Pediatrics, University of Trieste, Trieste, Italy
,
Valentina Dolcemascolo
1   Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
,
Anna Dallorto
3   Institute of Diagnostic Radiology, Department of Medicine, University Hospital of Udine, Udine, Italy
,
Maria Cristina De Colle
4   Department of Neuroradiology, University Hospital of Udine, Udine, Italy
,
Paola Elisa Cogo
1   Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
› Author Affiliations
Further Information

Publication History

12 November 2017

05 December 2017

Publication Date:
02 February 2018 (online)

A 2-year-old child presented with a 2-day history of fever, irritability, and vomiting. At physical examination, he was alert with a presumptive body weight loss of 5%. No infective focus was identified. Blood test showed leukocytosis (15,270/mmc leukocyte), C-reactive protein elevation (53.81 mg/L), and mild hypoglycemia (58 mg/dL). Despite fluid correction, the child became drowsy rising suspicion of acute meningoencephalitis. Twenty-four hours after admission left otorrhea appeared. Given rapid neurological deterioration, Ceftriaxone and Acyclovir were started. Cerebral computed tomography (CT) showed opacification of the mastoid air cells and middle ear, a hyperdense appearance of the left sigmoid and transverse sinuses consistent with otomastoiditis, and cerebral venous sinus thrombosis (CVST). Conventional and venous magnetic resonance imaging (MRI) confirmed the diagnosis demonstrating also ipsilateral jugular vein thrombosis and epidural abscess ([Figs. 1] [2] [3]). After drainage of the abscess, low molecular weight heparin was administered for 2 months with complete neurological recovery. CSVT and epidural abscess are recognized complication of acute otitis media (AOM) and mastoiditis.[1] [2] Rarely otalgia could be lacking.[3] Although vomiting and drowsiness are common findings in acute gastroenteritis, one should also suspect intracranial hypertension.

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Fig. 1 Coronal multiplanar reconstruction of fat-suppressed T1-weighted magnetic resonance (MR) images obtained using a 1.5-T superconductive MR scanner (Magnetom Aera, Siemens, Erlangen, Germany) with a standard head coil, after injection of 0.2 mL/kg of gadoteric acid. Omogeneous, hypointense epidural collect with peripheral enhancing wall is visible posteriorly to the left petrous bone.
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Fig. 2 Same sequence as [Fig. 1]. A filling defect in the left sigmoid and transverse sinuses is more evident when compared with the omogeneous, hyperintense right sigmoid sinus.
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Fig. 3 Maximum intensity projection (MIP) reconstruction obtained from a two-dimensional (2D) time-of-flight (TOF) magnetic resonance (MR) venography. Asymmetry between the left distal transverse sinus, the sigmoid sinus, and the left inner jugular vein (right in the picture), which are not visible, and the other hyperintense viable brain venous sinuses is highlighted.

CT scan is the first line investigation in emergency but its diagnostic sensitivity is low compared with MRI.[4]

The work was performed in Udine, Italy.

 
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