Case No. 190

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Case No. 190


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Chief Complaint:

Child with lethargy and decreased tone

Published: Jan. 4, 2018
Author: Meropenem

A 2 year old boy with no known past medical history is brought to the ER by his case manager for two days of lethargy. His social history is that he was abandoned at birth, is currently in foster care, and has been transferred between several different homes. The case manager noticed that his current home was littered with trash such as half empty jars and cans of old food on a dirty floor. He is ill appearing and has globally decreased tone, however, his vital signs are within normal limits. His caretaker notes that he has had recent nausea and vomiting, but no diarrhea--he has actually not had a bowel movement for two days. She denies fever, headache, neck stiffness, shortness of breath, or recent respiratory infection. He has not been eating or drinking since onset of symptoms. On exam, He appears dehydrated, has bilateral fixed and dilated pupils and decreased deep tendon reflexes. The patient is admitted to the pediatric ICU and on hospital day 3, is intubated for worsening respiratory failure.


What is the mechanism of this patient's disease?

  • Toxin-mediated inhibition of presynaptic acetylcholine release
  • Toxin-mediated inactivation of inhibitory motor neurotransmission in the anterior horn and brainstem
  • Autoimmune response against peripheral nerve myelin or axons
  • Increased intracranial pressure secondary to subarachnoid hemorrhage
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