Hard to wake up: Cerebritis

Case presentation

A 20-month-old patient presents with decreased activity, including eating and drinking, over the past 2 days. He is currently completing a second course of oral antibiotics for acute otitis media and 1 week ago completed a 10-day course of cefdinir. He was especially sleepy today, per the parents, who decided to bring him to his primary care physician for evaluation. He was also found to have a temperature of 101 degrees Fahrenheit in the office. While en route to the office, the patient was noted to be staring ahead without interacting with his parents; he then developed right hand and arm twitching, which lasted for several minutes, then resolved. After the event, he has remained difficult to arouse. The parents state that he is an otherwise healthy child who has all of his recommended immunizations. They deny any possibility of ingestion or trauma.

His physical examination in the emergency department reveals an afebrile child who is in no acute distress but is quite sleepy and difficult to awaken. He has a heart rate of 130 beats per minute, a respiratory rate of 25 breaths per minute, and a blood pressure of 90/60 mm Hg; his oxygen saturation is 95% on room air. He has no signs of obvious trauma. His pupils are 3 mm, equal and reactive; he appears to have photophobia. His tympanic membranes and oropharynx are all clear. His cardiovascular and abdominal examinations are unremarkable. It is difficult to conduct a neurologic examination due to the child’s sleepiness, but he is moving all of his extremities, and grossly, the tone and strength appear to be equal. There are no skin lesions or rashes.

Imaging considerations

Patients with suspected intracranial pathology often undergo neuroimaging as part of a medical evaluation.