Ataxia (peds): Difference between revisions

Latest revision as of 22:50, 28 November 2019

This page is for pediatric patients. For adult patients, see: ataxia

Background

Any disturbance in coordination of movement
Most cases in ED will be acute (<72h), but can also be episodic or chronic
Etiology usually benign in previously healthy child
Most cases will be postinfectious cerebellitis, drug ingestion, or Guillain Barre

Clinical Features

Unsteady gait in all cases
Postinfectious cerebellitis: 1-3 weeks post URI like illness or immunization, truncal ataxia and gait instability, normal mental status, normal vitals, ONLY ataxia
Guillain Barre extremity ataxia more than truncal ataxia, areflexia or hyporeflexia, respiratory failure possible
Drug ingestion: altered mental status, eye findings (nystagmus)
Intracranial mass: headache, vomiting, gradual onset, visual changes, papilledema, focal neuro deficits
Meningitis/Encephalitis fever, meningismus, bulging fontanelle, rash, altered mental status, seizure

Differential Diagnosis

Systemic conditions
- Intoxications with diminished alertness
- Intoxications with relatively preserved alertness
- Other metabolic disorders
Disorders predominantly of the nervous system
- Conditions affecting predominantly one region of the CNS
  - Hemorrhage, vertebral and carotid artery dissection
  - Infarction
  - Lateral medullary syndrome
    - Degenerative changes
  - Abscess
  - Brain tumor
  - Head trauma
  - Hydrocephalus, normal pressure hydrocephalus, VP shunt malfunction
  - Parkinson's disease
  - Prion disease
  - Heat stroke
  - Leukostasis and hyperleukocytosis
  - Cervical spondylosis
  - Posterior column disorders
- Conditions affecting predominantly the peripheral nervous system
  - Peripheral neuropathy
  - Vestibulopathy (e.g. vestibular neuritis, labyrinthitis)
  - Guillain-Barre
- Miscellaneous
  - Acute mountain sickness
  - Syphilis
  - Tick paralysis
  - Ciguatera, neurotoxic shellfish poisoning
  - African trypanosomiasis
  - Tympanic membrane rupture
  - Legionella
  - Paraneoplastic syndromes
    - Postinfectious cerebellitis (acute cerebellar ataxia)
  - Post vaccination (varicella)
  - Vasculitis
  - Epilepsy

Evaluation

tox screen, alcohol level
fingerstick glucose
drug levels as indicated (ex. antiepileptic level if possible ingestion)
Head CT if concern for trauma or mass lesion
Lumbar Puncture in most cases unless etiology is known
EEG if possibly seizure related

Management

most postinfectious cerebellitis self limited, resolve within 3 months without sequelae
tox ingestion: supportive. social work or DCFS as indicated
Guillain Barre admit for IVIG, observation of respiratory status
Meningitis/Encephalitis admit, IV antibiotic, see meningitis section
intracranial mass: neurosurgery consultation

Disposition

consider discharge home mildly symptomatic, well appearing child with history and exam consistent with postinfectious cerebellitis with excellent follow-up (give injury prevention precautions)
otherwise, admission indicated for further workup, observation

References

Authors:

@@ Line 1: / Line 1: @@
-===Background===
+{{Peds top}} [[ataxia]]
-*any disturbance in coordination of movement
+==Background==
-*most cases in ED&nbsp;will be acute (&lt;72h), but can also be episodic or chronic
+*Any disturbance in coordination of movement
-*etiology usually benign in previously healthy child
+*Most cases in ED will be acute (<72h), but can also be episodic or chronic
-*most cases will be postinfectious cerebellitis, drug ingestion, or guillain barre
+*Etiology usually benign in previously healthy child
+*Most cases will be postinfectious cerebellitis, drug ingestion, or [[Guillain Barre]]
-===Clinical Features===
+==Clinical Features==
-*unsteady gait in all cases
+*Unsteady gait in all cases
-*postinfectious cerebellitis:&nbsp;1-3 wks post URI&nbsp;like illness or immunization, truncal ataxia and gait instability, normal mental status, normal vitals, ONLY&nbsp;ataxia
+*Postinfectious cerebellitis: 1-3 weeks post [[URI]] like illness or immunization, truncal ataxia and gait instability, normal mental status, normal vitals, ONLY ataxia
-*guillain barre:&nbsp;extremity ataxia more than truncal ataxia, areflexia or hyporeflexia, respiratory failure&nbsp;possible
+*[[Guillain Barre]] extremity ataxia more than truncal ataxia, areflexia or hyporeflexia, [[respiratory failure]] possible
-*drug ingestion:&nbsp;altered mental status, eye findings (nystagmus)
+*Drug ingestion: [[altered mental status]], eye findings ([[nystagmus]])
-*intracranial mass:&nbsp;headache, vomiting, gradual onset, visual changes,&nbsp;papilledema, focal neuro deficits
+*[[Intracranial mass]]: [[headache]], [[vomiting]], gradual onset, [[blurred vision|visual changes]], [[papilledema]], [[focal neuro deficits]]
-*meningitis/encephalitis:&nbsp;fever, meningismus, bulging fontanelle, rash, altered mental status, seizure&nbsp;
+*[[Meningitis]]/[[Encephalitis]] [[fever]], meningismus, [[bulging fontanelle]], [[rash]], [[altered mental status (peds)|altered mental status]], [[seizure (peds)|seizure]]&nbsp;
-===DDx===
+==Differential Diagnosis==
-*postinfectious cerebellitis (acute cerebellar ataxia)
+*Systemic conditions
-*drug ingestion/ toxin exposure (anticonvulsants, antihistamines, benzos, alcohol, dextromethorphan, others)
+**Intoxications with diminished alertness
-*Guillain Barre syndrome
+***[[Ethanol]]
-*hypoglycemia
+***[[Sedative/hypnotic toxicity]]
-*post vaccination (varicella)
+***[[Toxic alcohols]]
-*encephalitis/meningitis
+***[[GHB]]
-*intracranial mass lesion
+***[[Benzodiazepine toxicity]]
-*hydrocephalus
+***[[TCA toxicity]]
-*intracranial bleed
+***[[Antipsychotic toxicity]]
-*stroke
+***[[Inhalant abuse]], [[hydrocarbon toxicity]]
-*vertebrobasilar dissection
+***[[Pentobarbital]]
-*migraine
+***[[Chloral hydrate toxicity]]
-*vasculitis
+***[[Marijuana toxicity]]
-*paraneoplastic syndrome
+***[[Phencyclidine toxicity]]
-*epilepsy
+**Intoxications with relatively preserved alertness
+***[[phenytoin toxicity|Phenytoin]], [[fosphenytoin]], [[Keppra]]
+***[[Carbamazepine toxicity|Carbamazepine]], [[oxcarbazepine]]
+***[[Valproic acid toxicity|Valproic acid]]
+***[[Heavy metal toxicity|Lead, organic mercurials]]
+***[[Carbon monoxide]]
+***[[Acute radiation syndrome]]
+***[[Lithium toxicity]]
+***[[Mushroom toxicity]]
+***[[Lacosamide]]
+***[[Arsenic toxicity]]
+***[[Gabapentin]]
+***[[Marijuana toxicity]]
+***[[Phencyclidine toxicity]]
+***[[Lindane]]
+***[[Vitamin A toxicity]]
+**Other metabolic disorders
+***[[Hyponatremia]]
+***[[Hypernatremia]]
+***[[Hypomagnesemia]]
+***[[Inborn errors of metabolism]]
+***[[Wernicke disease]]
+***[[Vitamin B7 deficiency]]
+***[[Vitamin E deficiency]]
+*Disorders predominantly of the nervous system
+**Conditions affecting predominantly one region of the CNS
+***[[ICH|Hemorrhage]], [[vertebral and carotid artery dissection]]
+***[[Stroke|Infarction]]
+***[[Lateral medullary syndrome]]
+****Degenerative changes
+***[[Brain abscess|Abscess]]
+***[[Brain tumor]]
+***[[Head trauma]]
+***[[Hydrocephalus]], [[normal pressure hydrocephalus]], [[VP shunt malfunction]]
+***[[Parkinson's disease]]
+***[[Prion disease]]
+***[[Heat stroke]]
+***[[Leukostasis and hyperleukocytosis]]
+***Cervical spondylosis
+***[[spinal cord injury|Posterior column disorders]]
+**Conditions affecting predominantly the peripheral nervous system
+***Peripheral neuropathy
+***Vestibulopathy (e.g. [[vestibular neuritis]], [[labyrinthitis]])
+***[[Guillain-Barre]]
+**Miscellaneous
+***[[Acute mountain sickness]]
+***[[Syphilis]]
+***[[Tick paralysis]]
+***[[Ciguatera]], [[neurotoxic shellfish poisoning]]
+***[[African trypanosomiasis]]
+***[[Tympanic membrane rupture]]
+***[[Legionella]]
+***[[Paraneoplastic syndromes]]
+****Postinfectious cerebellitis (acute cerebellar ataxia)
+***Post vaccination ([[varicella]])
+***[[Vasculitis]]
+***[[Epilepsy]]
-===Workup===
+==Evaluation==
-*exam
+*[[Utox|tox screen]], alcohol level
-*tox screen, alcohol level
+*fingerstick glucose
-*accuchek
+*drug levels as indicated (ex. [[anticonvulsants|antiepileptic]] level if possible ingestion)
-*drug levels as indicated (ex. antiepileptic level if possible ingestion)
+*[[Head CT]] if concern for trauma or mass lesion
-*head CT if concern for trauma or mass lesion
+*[[Lumbar Puncture]] in most cases unless etiology is known
-*LP&nbsp;in most cases unless etiology is known
+*EEG if possibly [[Seizure|seizure]] related
-*EEG if poss sz related
-===Treatment===
+==Management==
 *most postinfectious cerebellitis self limited, resolve within 3 months without sequelae
 *tox ingestion: supportive. social work or DCFS as indicated
-*guillain barre:&nbsp;admit for IVIG, observation of respiratory status
+*[[Guillain Barre]] admit for IVIG, observation of respiratory status
-*meningitis/encephalitis:&nbsp;admit, IV abx, see meningitis section
+*[[Meningitis]]/[[Encephalitis]] admit, IV antibiotic, see meningitis section
-*intracranial mass:&nbsp;NSG&nbsp;consultation
+*[[intracranial mass]]: neurosurgery consultation
-===Disposition===
+==Disposition==
-*consider d/c&nbsp;home mildly symptomatic, well appearing child with hx and exam c/w postinfectious cerebellitis with excellent follow-up (give injury prevention precautions)
+*consider discharge home mildly symptomatic, well appearing child with history and exam consistent with postinfectious cerebellitis with excellent follow-up (give injury prevention precautions)
 *otherwise, admission indicated for further workup, observation
-===Source===
+==See Also==
-Harwood-Nuss
+*[[Ataxia]]
+*[[Weakness]]
+*[[Cerebellar Stroke]]
-[[Category:Peds]]
+==References==
+<references/>
+[[Category:Pediatrics]]
+[[Category:Neurology]]
+[[Category:Symptoms]]