Clinical Reasoning: A 2-Year-Old Girl With Acute Encephalopathy After Febrile Systemic Illness

Area of Science:

• Neurology
• Pediatrics
• Infectious Diseases

Background:

• Acute encephalopathy in children can present with diverse neurological deficits.
• Febrile systemic illness is a common preceding factor in pediatric neurological emergencies.
• Thalamic lesions on MRI can indicate various underlying pathologies.

Purpose of the Study:

• To highlight diagnostic challenges in acute pediatric encephalopathy.
• To emphasize the significance of neuroimaging findings, particularly thalamic involvement.
• To underscore the importance of comprehensive family history in diagnosing neurological disorders.

Main Methods:

• Case report of a 2-year-old girl with acute encephalopathy.
• Review of clinical presentation, neuroimaging (MRI), and cerebrospinal fluid (CSF) analysis.
• Retrospective analysis of maternal medical history prompted by the child's diagnosis.

Main Results:

• The child presented with acute encephalopathy, hemiparesis, and multifocal symmetrical thalamic lesions.
• CSF analysis revealed slightly elevated protein levels.
• The child's diagnosis led to a revised diagnosis of neuroborreliosis in the mother from 15 years prior, with bilateral symmetric thalamic involvement being a key indicator.

Conclusions:

• Bilateral, symmetric thalamic involvement is a critical neuroimaging clue for specific neurological diagnoses.
• Thorough family history taking is essential for diagnosing complex encephalopathies, potentially revealing previously missed diagnoses in family members.
• Recognizing common clinical pitfalls and key neuroimaging findings aids in accurate diagnosis of pediatric acute encephalopathy.