NM-334
Febrile seizure following CPB with ascaris infection
Chan K, Hill R
St. Joseph's Regional Medical Center, Paterson, NJ, USA
The Gift of Life organization works in conjunction with U.S. hospitals to bring children born with congenital heart defects, from underserved areas of the world, for surgical repair. We report a case of a 4-year old Filipino child who was diagnosed with a large, non-obstructive VSD with bidirectional shunting at one month of age.
We induced the patient by inhalation induction. Surgery proceeded without complication; the patient subsequently went on cardiopulmonary bypass for 2hrs 39min. Following CPB, the patient’s temperature was 37.3o C. During emergence the temperature rose to 38.9o C with decreased pulmonary compliance. After unsuccessful suctioning, we extubated and reintubated the patient. A large mucous plug was found upon inspection of the original ETT. The temperature peaked at 41.0o C, and the patient began to have diffuse bilateral tremors without muscle rigidity, along with an increase in heart rate and EtCO2. Cessation of the seizure-like activity occurred after boluses of propofol and midazolam. We irrigated the stomach with cold saline, and gave acetaminophen. Because, the patient’s urine was dark yellow, a sample was sent to the lab for myoglobinuria.
Postop CT scan of the head showed no evidence of hypoxic injury; EEG was negative for seizure activity. The patient remained intubated and sedated, and brought to the PICU. No further seizure activity was noted. The patient was extubated POD1. After extubation, the patient expectorated a worm into her blanket. Upon learning from the mother that the patient received treatment for ascaris in the past, we once again reviewed the labs, and found significant eosinophillia, consistent with ascaris infection. Stool samples confirmed the diagnosis.
Both the helminths and stress from general anesthesia and CPB led to an inflammatory response in this patient. The temperature rose as a result of the release of inflammatory mediators, as the worms sought to flee the body by the lungs and GI tract. We suspect this is what triggered a febrile seizure in this patient.
Ascaris lumbricoides is a systemic infection resulting from ingestion of larvae from soil in endemic regions. The worms reside not only in the GI tract, but also in lungs and brain following infestation. Ascariasis is found in tropical regions, with the greatest populations in SE Asia.
In the current global landscape, care must be taken to familiarize practitioners with potential parasitic infestations in patients presenting with eosinophillia. Patients hailing from endemic regions warrant further preoperative workup prior to surgery.
References
Maekawa Y, Sakamoto T, Umezu K, Ohashi N, Harada Y, Matsui H. Hyperthemia after cardiac surgery due to ascariasis in a child: report of a case. General Thoracic and Cardiovascular Surgery. 2012;60(7):446-448. doi:10.1007/s11748-012-0024-4.
Nicholson JP, Kreiger K, Hartman B, Isom W, Laragh JH. Cardiac Arrest Postoperatively in a Patient Infected with Ascaris, the Roundworm. Chest. 1989;96(4):922-923. doi:10.1378/chest.96.4.922.
Ugras SK, Finley DJ, Salemi A. Ascaris lumbricoidesInfection Causing Respiratory Distress after Coronary Artery Bypass Grafting. Surgical Infections. 2010;11(2):177-178. doi:10.1089/sur.2009.002.
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