darkhorse
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A 4-year-old boy is brought to the office because he has refused to walk for the past 24 hours. He was well until yesterday afternoon when he woke from a nap complaining of feeling "wobbly". When his parents got him up to walk he was extremely unsteady and they needed to hold him to keep him from falling over. He has not improved at all over the last day. His unsteadiness persists when he is sitting down. His temperature is 37.0 C (98.6 F), pulse is 100/min, and respirations are 24/min. He has horizontal nystagmus, which is worse at the extremes of gaze. He appears markedly ataxic and his gait is broad based. He has no papilledema. If obtained, the information that would be most pertinent to his current condition is
A. concomitant diarrhea
B. a cousin with a brain tumor
C. a history of varicella infection 3 weeks ago
D. previous history of epilepsy in this patient
E. recent streptococcal pharyngitis
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| gr8doc
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Where do you get all these questions from....... 
I tried to rule out things and the two answers i could think of are .....
C. H/o Varicella infection 3 weeks ago.
A. Concomitant diarrhea
Do you knonw what the answer is ?
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| mukho
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c. post varicella cerebellitis i would think....whats the right ans?
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| sandra
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d? cerebellar astrocytoma?
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| gr8doc
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The reason I ruled out D was because the history is very acute and also there is no pappiloedema. I'll appreciate If Sandra can put forward her reasoning.
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| darkhorse
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The correct answer is C. The history given above is a classic presentation of acute post-infectious cerebellar ataxia. 25% of children with this disorder have a history of varicella infection within 1 month prior to the onset of the disorder and 5% of children have a previous history of varicella vaccination. The onset of acute cerebellar ataxia is usually explosive, often with the child awakening from sleep with maximal symptoms of ataxia and nystagmus. In any child with acute ataxia, it is important to obtain a drug screen and a careful history of any possible toxic exposures since poisoning and acute cerebellar ataxia account for most of the cases of acute ataxia in children. Resolution of the symptoms occurs in most children over a period of weeks to months.
Concomitant diarrhea (choice A) is not relevant to this presentation. Although there are forms of Guillain-Barre syndrome that have ataxia as a prominent component, this child does not have the other symptoms associated with these variants of GBS (ophthalmoplegia, depressed reflexes), and Campylobacter diarrhea usually precedes the onset of GBS.
While an intracranial tumor is always of concern in a child with neurologic symptoms, the history above is atypical for tumors, which usually present more indolently. The history of a cousin with a brain tumor does not increase the likelihood that this child's symptoms are due to an intracranial mass (choice B).
Pseudoataxia (choice D) is a syndrome of recurrent bouts of ataxia that are actually atypical seizures on EEG. The attacks are similar in timing to seizures and there may be a postictal state. They are not likely to persist over days as in this child.
Recent streptococcal pharyngitis (choice E) is of importance in movement disorders associated with acute rheumatic fever, such as Sydenham chorea, but does not predispose to any known form of ataxia.
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| gr8doc
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Good Job Dark Horse !!!!!!!
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