Fluctuating Levels of Consciousness

Enea, 8-month-old, was admitted to the emergency department in a secondary care hospital for multiple episodes of vomiting (10 in less than 24 hours, not bilious) associated with apathy in the last few hours and total food/liquid refusal.

Four days before the admission, he started to have fever associated with sores in the mouth and a rash on the hands/feet; so, he received the diagnosis of hand, foot, and mouth disease.

Further, he had a minor head trauma 2 days before the admission, without red flags of severity.

The past medical history is unremarkable.

When he was admitted to the hospital, vital signs were normal and the clinical examination revealed a moderate-severe dehydration.

Bloods test showed only mild increase in the CRP (13 mg/L), the blood count was substantially normal.

Antiemetic drugs were administered and fluid resuscitation with saline bolus was performed, without clinical improvement.

Lately, he started to become lethargic and hyporeactive to pain stimuli. Therefore, Enea was transferred to our tertiary care hospital, where showed worsening clinical condition, becoming pallid, lethargic, whining and hyporeactive.

Vital signs were T 37.3°C, heart rate 142/min, respiration rate 40/min, SaO2 95%, blood pressure 121/84 mmHg. Clinical exam showed moderate-severe dehydration. At this point, the neurological examination clearly revealed fluctuating levels of consciousness, without focal neural deficit.