A 4-year-old girl is brought to the office due to behavioral concerns. Over the last 2 months, her parents and preschool teacher have noticed that she frequently does not respond to their questions, and they often need to repeat themselves several times to get a response. Three months ago, the patient was hospitalized due to high fever, headache, nuchal rigidity, and recurrent seizures. Cerebrospinal fluid culture grew Streptococcus pneumoniae, and she was given parenteral antibiotics. The seizures were initially difficult to control but resolved after 72 hours of antibiotic therapy. A repeat cerebrospinal fluid culture was sterile, and the patient completed the course of antibiotics. She has had no fever or headache since then and has not followed up until today's visit. Vital signs and growth parameters are normal for age. In the office, the child is alert and can hop on 1 foot. She can copy a cross and square on paper. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 4-year-old girl is brought to the office due to behavioral concerns.  Over the last 2 months, her parents and preschool teacher have noticed that she frequently does not respond to their questions, and they often need to repeat themselves several times to get a response.  Three months ago, the patient was hospitalized due to high fever, headache, nuchal rigidity, and recurrent seizures.  Cerebrospinal fluid culture grew Streptococcus pneumoniae, and she was given parenteral antibiotics.  The seizures were initially difficult to control but resolved after 72 hours of antibiotic therapy.  A repeat cerebrospinal fluid culture was sterile, and the patient completed the course of antibiotics.  She has had no fever or headache since then and has not followed up until today's visit.  Vital signs and growth parameters are normal for age.  In the office, the child is alert and can hop on 1 foot.  She can copy a cross and square on paper.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d5b3_586a_bc81_91f74d133bc6_MD0003_00 This patient who had bacterial meningitis is now ignoring voices, raising concern for hearing loss secondary to her infection. Up to 50% of children with bacterial meningitis have long-term neurologic sequelae, including intellectual and behavioral disabilities, hearing loss, seizures, and cerebral palsy. Risk factors include younger age, prolonged seizures, and high bacterial load at diagnosis. Prompt initiation of parenteral antibiotics (eg, vancomycin, cefotaxime) likely improves outcomes and decreases complications. Sensorineural hearing loss, most commonly seen following Streptococcus pneumoniae meningitis, is due to inflammation of the cochlea and/or labyrinth and may not be immediately apparent. Fibrosis and then ossification of the cochlea can quickly (within weeks/months) follow the inflammatory response, leading to permanent, profound hearing loss. Once cochlear ossification is present, cochlear implantation surgery becomes more difficult and outcomes are poorer. Therefore, because hearing deficits may go unrecognized, all patients with bacterial meningitis should undergo audiologic testing as soon as possible (ideally, before hospital discharge). (Choice A) A brain abscess can form from bacterial invasion of the brain parenchyma. The clinical presentation (eg, headache, seizures, neck stiffness) is sometimes difficult to differentiate from meningitis. However, it is very rarely seen with S pneumoniae and usually is an immediate rather than a delayed complication. (Choice B) Intellectual or physical disability (due to global hypoxia) can occur after bacterial meningitis and may present with difficulty understanding language. However, this patient has age-appropriate gross motor and cognitive skills. (Choice D) Absence seizures, characterized by 3 Hz spike-and-wave discharges on electroencephalography, may present as inattentiveness in a child. However, these generalized seizures typically manifest as profound alterations in consciousness (eg, staring spells). In addition, seizure disorders that develop as a result of meningitis are usually focal rather than generalized. (Choice E) Thrombotic occlusion of the dural venous sinuses may occur as an acute complication of meningitis. Although it can present with seizures and encephalopathy, it would also cause headache, fever, and signs of intracranial hypertension (eg, vomiting), not seen in this patient. (Choice F) Delayed cerebral infarction due to vasospasm may present with a decreased level of consciousness that mimics inattention. However, it is typically a complication of subarachnoid hemorrhage rather than bacterial meningitis. Educational objective: Hearing loss is a common sequela of Streptococcus pneumoniae meningitis due to inflammatory damage to the cochlea and/or labyrinth. Audiologic testing should be performed as soon as possible to identify hearing loss and improve outcomes if hearing rehabilitation is needed. References: Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol. (http://www.ncbi.nlm.nih.gov/pubmed/20008417) Cochlear osteoneogenesis after meningitis in cochlear implant patients: a retrospective analysis. (http://www.ncbi.nlm.nih.gov/pubmed/20812396)

A 4-Year-Old Girl Is Brought to the Office Due to Behavioral