17-month-old F w/ no sig PMHx presents to the ED accompanied by her mother who is concerned because her baby is “acting drunk.”

Mother reports child was staying with grandparents over the weekend and today began “walking funny and speech is slightly slurred.”  She also reports child had vomiting and diarrhea lasting for 2 days one week prior.  No fevers, no history of trauma or falls, no family history, no known sick contacts, no rash.  Child has been gaining weight and meeting all age-appropriate milestones.  She was born full-term via NSVD w/ no complications, all vaccines up-to-date, grandparents live in a newly constructed home and mother reports they are very good caretakers and have watched over child every other weekend since she was 8 months.

On exam:

T 98.6   HR 134   BP 103/70  R 30  O2 Sat 99% RA   FS 104

Gen: alert, well nourished and hydrated, no abnormal odors.

Skin: no rash, no ecchymoses, normal turgor

Neuro: behaving appropriately, slightly slurring speech (confirmed by mother), no nystagmus, no facial droop, no weakness, no nuchal rigidity, normal tone and reflexes, +wide base gait  and unsteady reaching for toy w/ poor coordination noted in bilateral upper ext symmetrically.

Rest of exam was unremarkable

CBC, electrolytes, and urinalysis were WNLs

Head CT and LP results were unremarkable

A pediatric neurology consult was obtained, the child’s exam and mental status remained unchanged throughout the course of the work-up.

 

Ataxia is a vague term.  Disease processes from cerebral cortex down to the muscle can result in ataxia.  A good neurologic history and examination may often clarify the cause of acute ataxia.

The development of acute ataxia in a child can be very dramatic for both families and physicians.  It is important to consider a wide differential including common, treatable, and life-threatening etiologies.

Differential Diagnosis:

– Medications/Toxins (alcohol level, thorough history of home medications, kitchen and bathroom cabinet supplies, etc…)

– Encephalitis/Meningitis

– Metabolic Disorder (family and genetic screening history, weight progression, milestones, etc…)

– Brain Tumor (infratentorial lesions most common, can cause acute rise in ICP, examen fontanels, consider Neuroblastoma)

– Trauma

– Guillain Barre (absent tendon reflexes, elevated protein in CSF)

– Tick Paralysis

– Lead Toxicity (thorough history of home conditions and level)

– Acute Cerebellar Ataxia

A child with shock, sepsis, meningitis, or metabolic disorder (including hypoglycemia) may present w/ acute ataxia as the primary symptom.  It is important not to jump too quickly to the neuro exam w/out addressing these important general examination features.The presence of weakness, headache, nausea/vomiting, or lethargy may aid in the differential.  Systemic symptoms such as fever and concomitant or antecedent illnesses are also important.  A history of drugs or poisons that the child may have been exposed to is vital.  Also, the relationship of symptoms to meals may clue the physician about a possible metabolic disorder.  It is important to remember that the younger patient is more likely to present with ataxia as the initial neurologic or detectable symptom of a systemic disorder.

This child was diagnosed w/ Acute Cerebellar Ataxia.

Acute Cerebellar Ataxia is the most common cause of ataxia in young children, typically seen <6 years of age w/ incidence of ~1/100,000.  It is usually a self-limiting disease w/ >90% having complete resolution w/out treatment.  It is usually associated w/ a preceding viral illness (most commonly varicella virus).  Although there is evidence of myelin destruction there is no increased incidence of MS in this population.  It is sometimes treated w/ steroid therapy and IVIG.  It is not always necessary to do a complete work-up if the history is classic and the patient is well appearing and has reliable follow-up and access to immediate care in the case of an emergency.

 

Special Thanks to Dr. Jenny Sanders for inspiring this Pearl.