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A four year old girl was brought to the hospital because of vomiting and lethargy.  Five weeks before the parents noted unsteadiness of walking and a tendency to sway while standing.  Frequent falls were described.  For three weeks the child had been irritable, often refusing food and behaving in a “negative” way.  In the 10 days before admission, she had gradually become somnolent, and often held her head as though it hurt.  She was unable to stand unsupported for two days before admission, and vomited several times.

On exam, she  was slow to respond and cried frequently.  Bilateral  papilledema with fresh hemorrhages was present on fundoscopic examination. The right eye did not abduct fully.  Pupillary responses were normal and there was no nystagmus.  While lying down she could reach accurately for objects and do finger-to-nose testing, but was unable to stand without toppling over.  When sitting, she also tended to sway abnormally.  Strength was normal and the plantar responses were equivocal.

Questions Case 7:

1.      What is the basic problem?

2.      What findings are localizing?  Which findings are not localizing?

3.      Which symptoms and clinical findings in this patient are consistent with increased intracranial pressure?

4.      What test would you perform?   What do you expect to find?

5.      What is the differential diagnosis for this case?