PM3020: A Case of Disseminated MRSA Infection and Suspected TB Meningitis in a Refugee Child

Introduction: Displacement of over 70 million children worldwide has created a need for pediatricians to better understand how to care for refugee pediatric patients. It is crucial to consider environmental and infectious disease exposures not only from areas traveled from, but from areas traveled through while seeking asylum or refuge.

Case Description: A previously healthy, partially immunized 6-year old male presented to an adult ED with altered mental status. The child emigrated from Haiti to Brazil and traveled on foot through Central America and Mexico before crossing the border into Texas and eventually to Florida 3 months prior to presentation.

Patient had headache, fever, vomiting, decreased oral intake, and ataxia beginning 1 day prior to presentation. In the ED, the patient was febrile (104oF), mildly tachypneic (32 RR), tachycardic (178 HR), and hypertensive (128/97 mmHg). Physical exam revealed a Glascow Coma Scale of 12, nuchal rigidity, oral vesicles, periorbital edema, and diffuse rhonchi.

Initial labs showed elevated inflammatory markers (CRP 37 mg/dL, procalcitonin 324 ng/mL), coagulopathy and metabolic acidosis. Chest X-ray showed pneumonia and initial imaging of the brain and neck were unremarkable. Patient required transfer to a children’s hospital, and a lumbar puncture was performed due concern for meningitis. CSF was turbid with 5,081 WBCs and decreased glucose of 19 mg/dL.

In the PICU, patient was intubated and sedated for MRI brain/orbit and MRA/MRV head, which revealed intracranial pathology concerning for meningitis, septic emboli and venous thrombosis. Tuberculous (TB) meningitis was a concern, so the appropriate anti-TB regimen was initiated.

Workup also revealed MRSA bacteremia, meningitis, and pneumonia with subsequent multi-organ failure. This acute deterioration of a previously healthy child warranted an immunodeficiency workup which resulted negative. After 54 days of multidisciplinary care, the patient was safely discharged with the majority of his neurocognitive abilities and faculties intact.

Discussion: The path that Haitian immigrants take to seek refuge or asylum in the United States poses significant challenges to infectious disease control including lack of resources and insufficient medical attention to address their ailments. Without timely and appropriate medical interventions, these individuals are at a higher risk of poor outcomes.

Conclusion: This case highlights the complexity of caring for critically ill refugee children presenting with significant disseminated infection following an arduous emigration.