Acute Onset, Fever, Seizures and Unresponsive


• IV ampicillin, chloramphenicol and artenusate.


• Patient was to be started on TB medicine but died before they were started.

• His clinical course initially had increased tone and seizures.

• Subsequently, the tone decreased and the left pupil became dilated and unresponsive.

• Patient remained febrile throughout the hospitalization.

• He became flaccid and completely unresponsive before he died.


James Lace, MD Childhood Health Associates of Salem; Mt. Meru Hospital, Tanzania; Kausay Wasi Clinic, Peru


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


• Critically ill infant
• Fixed and dilated pupils
• Presumed TB meningitis

Differential Diagnosis

  • Meningitis
  • Tuberculosis
  • Brain abscess
  • CVA
  • Hydrocephalus

Patient Workup History

  • Admitted after 10 days ceftriaxone IV therapy without improvement.

Physical Exam

  • Dilated, non-responsive pupils; right pupil dilated to 8mm; left pupil to 3mm
  • Anterior fontanelle somewhat full
  • Seizure activity
  • Flaccid
  • Apnea
  • Bradycardia
  • Chest X-ray – normal
  • Initial CBC – elevated white count and Hgb of 9
  • HIV – negative
  • PPD (Mantoux) – negative
  • MRDT for malaria – negative
  • Head ultrasound revealed some hydrocephalus but no obvious mass seen
  • CT scan suggested TB meningitis
  • LP not done because of the increased intracranial pressure and risk of brain stem herniation

Editor’s Notes

In a resource-poor setting, this child may have been too sick to save, but if the same child were in a modern intensive care unit a great deal more intervention may have been indicated. Anti-seizure medication, intubation and ventilator support, ICP monitoring and treatment (e.g. mannitol), advanced imaging, and broader empiric antimicrobial treatment might all be useful given this child’s condition

~ Dr. Keith Cross, Associate Professor of Pediatrics/Emergency Medicine, University of Louisville

Suggested References



• Gender: Male

• Age: 15 months

• Height: Not Available

• Weight: Not Available


• Temperature: 103.6 F/39.8 C

• Blood Pressure: Not Available

• Heart Rate: 130

• Respiratory Rate: 30

• Pulse Oximetry: 95% RA

Signs and Symptoms

Seizure activity; unresponsive; pupils not reacting to light; fever.

History Medical

• Admitted after 10 days ceftriaxone IV therapy without improvement.

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