A 6-Year-Old Girl With Fever, Weakness, and Ataxia

A previously healthy 6-year-old female was evaluated in the emergency department (ED) in January 2021 with an acute onset of fever and right-sided weakness. These symptoms began the night prior when she was febrile to 39.4◦C with slurred speech and noted to be “off balance.” Before arrival, she was having a headache and had 1 episode of nonbloody, nonbilious emesis. Ten days prior, the child was treated at an urgent care with oral amoxicillin and clavulanate and a topical antibiotic ointment for left periorbital cellulitis, with improvement in her symptoms. On examination, she was mildly toxic-appearing but alert and active, with normal mentation and stable vital signs. Her neurologic examination was pertinent for right-sided flaccid tone and 4 of 5 strength testing in right upper and lower extremities. She had mildly slurred speech and right finger-to-nose dysmetria. There was mild left conjunctival injection without periorbital swelling. Laboratories revealed a leukocytosis and elevated inflammatory markers. Initial contrast and noncontrast computed tomography (CT) imaging of the head revealed no acute intracranial process, including no signs of an intracranial abscess. The CT did mention possible left periorbital soft tissue swelling but with no evidence of orbital cellulitis. Further head magnetic resonance imaging (MRI) with stroke protocol revealed multifocal small vessel infarcts. Two infarcts appeared acute and 1 appeared possibly subacute in nature. In the ED, she was started on broad-spectrum antibiotics for empirical meningoencephalitis coverage and admitted to the ICU. A multidisciplinary team assisted in the workup and management, which revealed a final diagnosis. © 2024 by the American Academy of Pediatrics.