What were the CSF cell counts, protein, and glucose?
6 year old with hallucinations currently hospitilized. Is this autoimmune encephalopathy?Age: 6Sex: MaleLocation: New England, USAMy child has been in the hospital over the last week for suspected autoimmune encephalitis. I brought him to the ER on 4/11 per instruction from his pediatrician due to visual hallucinations. He was admitted after neurology came to the ER for a consult. The hallucinations have not been improving with treatment as of yet (4 days of IV steroids & 1 day of IV IG, see below for more specifics). I've been advised 90% of the labs will take a couple of weeks to get back. Is there anything else we should be considering? He's the happiest kid, he absolutely loves school and his friends and teachers and he can't wait to go home. He knows what he's seeing isn't real and I wish I could make it go away. Any insight/advice would be so appreciated. He's been a trooper throughout this process but it's not easy wondering every day what is going on. I can provide additional information if needed/requested.Assessment/Plan: Child is a 6 y.o. 5 m.o. male with PMH of hypnagogic hallucinations and asthma who presents for evaluation of 2 days of daytime hallucinations. Given acute onset of worsening visual hallucinations that started with nighttime awakenings on 4/7 and then progressed to daytime visual hallucinations on 4/10, we are concerned for autoimmune encephalitis. LTM EEG with left parasagittal and temporal spike wave epileptiform discharges, suggestive of underlying brain irritability. However, patient is very well appearing with no other classic features of autoimmune encephalitis- no encephalopathy, no weakness, no abnormal movements. Given that he is very well appearing and is not demonstrating significant decline from day to day, we will plan to first obtain CSF and brain MRI with contrast prior to starting immunosuppression. If CSF is bland, we would likely still recommend treating with immunosuppression given clinical concern and patient meeting diagnostic criteria for autoimmune encephalitis.EEG is abnormal but no definite seizures. Frequent and sleep activated left temporal and parasagittal spike and wave epileptiform discharges. Brain MRI normal. LP overall bland with 1 nucleated cell in tube 1, 2 nucleated cells in tube 2. Other labs pending but does have ANA positive at 1:320.Has been on IV steroids since 4/14 with no improvement in visual hallucinations. Will plan to continue steroids for total 5-day course and discuss case with our neuroimmunology colleagues. (This plan changed after neuroimmunology consult, began tapering steroids after 4th day to begin IV IG)Treatment:s/p 4-days of high dose IV methylprednisolone (30mg/kg daily)prednisone taper: 1mg/kg (max 60mg) prednisone tapering over 6 weeks (can roughly cut in half every 7 days) Week 1: 30mg daily Week 2: 15mg daily Week 3: 10mg daily Week 4: 5mg daily Offstart IVIG today for 2-days- IVIG 2g/kg divided over 2 days. Started on 4/17 treatment was well-toleratedResulted workup:EEG abnormal with frequent abundant spike wave epileptiform dischargesEEG continued to demonstrate frequent abundant left parasagittal and temporal spike wave epileptiform discharges -EEG from 4/12 -Frequent to abundant left parasagittal spike wave epileptiform discharges that occurred both independently and in brief 1-3 Hz runs lasting <10 seconds (BIRDS) -Occasional to abundant left temporal spike wave epileptiform discharges that occurred both independently and in brief 1-1.5 Hz runs lasting <10 seconds (BIRDS)quick brain MRI normalsedated brain MRI with contrast normal, incidental finding of likely arachnoid cystReassuring CBCd, BMP/Mg/Phos, LFT'sESR and CRP normalTSH elevated to 7.44, free T4 normal at 1.1B12 and folate normalRPR non-reactiveRhinovirus positiveCeruloplasmin normalUrine tox negativeUA normalANA positive 1:320, speckledSerum copper within normal rangeCSF opening pressure 15CSF cell count and total protein normalAnti-TPO antibodies negativeHIV 1/2 negativeCollected and pending: [] CSF culture [] CSF HSV PCR, CSF VZV PCR, CSF VZV IgM [] CSF oligoclonal bands, IgG index, beta-2 microglobulin, flow cytometry, cytology [] CSF autoimmune encephalopathy panel [] CSF anti-Glycine-R antibody [] Serum Glycine Receptor IgG [] Myelin oligodendrocyte glycoprotein [] 24 hour urine copper [] 24 hour urine porphyrins [] Double stranded DNA antibodies [] Antiphospholipid antibody panel [] Thyroglobulin antibody [] Serum MaTa Autoantibody test [] SPEP panel [] MS profile, serum and CXF [] IgG index/synthesis rate, serum and CSF [] EBV serology [] VZV IgG, IgM [] HSV PCR, HSV type 1,2 antibody [] Serum encephalopathy panel [] Mycoplasma IgM, IgG [] Lyme screen with reflex to immunoblot [] HSV PCR, serumMENTAL STATUS EXAM: Appearance: appropriately dressed Behavior: cooperative, eye contact good and pleasant Psychomotor Activity: normal Musculoskeletal: moves all extremities; no abnormal movements Station/Gait: normal Speech: regular rate, regular rhythm and regular volume Language: normal comprehension Mood: happy Affect: full range Thought Process: logical, linear and goal-directed Associations: no loosening of associations Thought Content: no delusions and no obsessions Perceptions/Experiences: visual hallucinations Orientation/Sensorium: alert Memory: immediate recall intact. Attention/Concentration: intact to observationImpression: Child is a cheerful and pleasant 6 yo boy, from X attending Kindergarten at X. He has a hx of mild OSA, hypogogic/hypnopompic hallucinations since early on, asthma, no prior past psychiatric history, presenting for worsening hallucinations since 4/10, admitted for medical work up on etiology. Psychiatry consulted for diagnostic clarification, support and medication management.4/14/23: Patient continues to be calm and cooperative, behaviorally appropriate for a 6-year-old boy. Continues to experience visual hallucinations, yesterday night described as "monsters," which patient is understandably afraid of. Most of patient's hallucinations are visual, vivid, and neutral with minimal emotional involvement. No auditory hallucinations. No clear seizure activity on EEG, other than minor blinking, clinical signs of seizure disorder not noted on physical exam. Pt age, onset, and symptoms are not typical of a primary psychotic disorder or normal development. We agree with pediatric neurology and primary team that the origin of hallucinations are organic. No emotional or behavioral dysregulation. Thus, we do not recommend scheduled psychotropic medications at this time. Pediatric neurology assess patient has underlying brain irritability from EEG findings (left parasagittal and temporal spike wave epileptiform discharges), likely secondary to encephalitis, as opposed to seizure disorder.