NATIONAL JOURNAL OF MEDICAL RESEARCH print ISSN: 2249 4995│eISSN: 2277 8810 Volume 3│Issue 4│Oct – Dec 2013 Page 407 CASE REPORT ENTERIC FEVER PRESENTING AS PALATAL PALSY, CEREBELLAR ATAXIA AND SEVERE THROMBOCYTOPENIA: A CASE REPORT Nivedita Sharma 1 , Piyush Gautam 2 , Naveen Kumar 3 Authors’ Affiliation: 1 Senior Resident; 2 Assistant Professor; 3 Resident, Department of Pediatrics, Dr Rajendra Prasad Medical College and Hospital Tanda at Kangra, Himachal Pradesh, India. Correspondence: Dr. Nivedita Sharma, Email: niveditasharma2@yahoo.com ABSTRACT Enteric fever, being a systemic infection is associated with a variety of clinical presentations, multisystem involvement and complications. Although central nervous system involvement is not uncommon, acute cerebellar ataxia and palatal palsy as a presenting feature are rare. A 13 year old girl with enteric fever who presented with acute cerebellar ataxia and palatal palsy with marked thrombocytopenia in early phase of illness is being reported. This atypical presentation is not common in enteric fever in early course of the disease and can lead to misdiagnosis as well as a delay in the initiation of appropriate therapy. Prompt clinical improvement and the return of platelet counts to normal were noted after the patient was started on intravenous ceftriaxone. Key Words: Enteric fever; cerebellar ataxia; thrombocytopenia; ceftriaxone; palatal palsy. INTRODUCTION Enteric fever is a systemic infection which can present in a number of ways. Neurological involvement is not uncommon, manifesting as meningism, delirium, ataxia, coma or convulsions and occurs mainly in the second to third week. Acute abdomen, intestinal perforation, pneumonia are likely to develop in the third to fourth week. We report a case presenting with acute ataxia, palatal palsy and marked thrombocytopenia in the first week of illness. CASE REPORT A 13 year old girl presented with fever for six days with vomiting and watery diarrhea. Since the past four days she developed unsteady gait, difficulty in walking, maintaining balance and holding objects. She had difficulty in swallowing with slurring of speech followed by complete aphasia. There was no history of headache, seizures or posturing. Bladder habits were normal. On initial examination, she was febrile with stable vitals. There was no rash or rose spots. On central nervous system examination (CNS), she was confused. There was palatal palsy, gag reflex was absent. There was generalized hypotonia. Power was 4/5 in all four limbs. There was no focal neurological deficit, reflexes were normal with pendular knee jerk. Plantar reflex was flexor. Cerebellar signs were present. Sensory system was normal. Neck rigidity was present. Fundus examination was normal. Rest systemic examination was normal. She had received some injectables for two days before being referred to our college. A differential diagnosis of acute viral meningoencephalitis and enteric fever with complications was kept. She was started on injections Acyclovir and Ceftriaxone. On investigating, the hemogram revealed pancytopenia with a hemoglobin of 7.5 g/dl, total leucocyte count of 2,200/ul and platelet count of 9000/ul. Peripheral smear revealed microytic anemia, no malarial parasites. Liver function tests showed an albumin of 3.3 g/dl, total bilirubin 0.6mg/dl, ALP 47 iu/l, SGOT 1444 iu/l, SGPT 395 iu/l). Cerebrospinal fluid analysis revealed proteins 56 mg%, there were 5 cells, all lymphocytes. Blood sugar, renal functions and electrolytes were normal. Weil felix test for Scrub typhus was negative. Widal test showed high titres of TO> 360 and TH > 360. CT scan and MRI were normal. Acyclovir was stopped after two days while ceftriaxone was continued for 14 days. The patient was completely oriented within 48 hours, became afebrile after 72 hours. She was started on tube feeds. By day six, she started speaking which was scanning with nasal twang. Meningeal signs disappeared, palatal palsy improved and she started swallowing semisolids. She started walking on the 8th day with support and without support by the 10th day. Her platelet and total leucocyte counts returned to normal after three days. Her blood culture was sterile. After two weeks, there was complete recovery of palatal palsy and speech improved and she was eating well orally. Cerebellar signs and nasal twang improved but persisted till discharge. On followup visit at four weeks, she was neurologically normal. A repeat widal test done at this time showed TO < 160 and TH = 80. DISCUSSION