We report an 11-month-old boy who brought with status epilepticus. The presence of bilateral retinal hemorrhages and generalizedcerebral atrophy indicating ischemia revealed on imaging tests lead us to keep a differential diagnosis of shaken baby syndrome (SBS).On repeated questioning, mother gave the history of shaking by a relative which further supported our diagnosis. Thus in a child with anonspecific febrile convulsive state, the treating physician should keep SBS also as a differential diagnosis

Ronghe, Ashwini

Shukla, Priyanka

Verma, Bela

English

Atharva Scientific Publications (E-Jounals)

Verma et al. Fragile Brain - Handle with Care
Vol 2 | Issue 3 | Jul - Sep 2015 Indian J Child Health 142
Case Report
Fragile brain, handle with care: A case of abusive head trauma and a review of 
literature
Bela Verma, Ashwini Ronghe, Priyanka Shukla
From Department of Pediatrics, Grant Government Medical College & Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
Correspondence to: Ashwini Ronghe, 10, Shanti Dham, Pestom Sagar, Road No 1, Amar Mahal, Chembur, Mumbai - 400 089, 
Maharashtra, India. Phone: +91-9594860424, E-mail: ashuronghe@gmail.com
Received – 11 July 2015 Initial Review – 28 July 2015 Published Online – 07 September 2015
Abstract
We report an 11-month-old boy who brought with status epilepticus. The presence of bilateral retinal hemorrhages and generalized 
cerebral atrophy indicating ischemia revealed on imaging tests lead us to keep a differential diagnosis of shaken baby syndrome (SBS). 
On repeated questioning, mother gave the history of shaking by a relative which further supported our diagnosis. Thus in a child with a 
nonspecific febrile convulsive state, the treating physician should keep SBS also as a differential diagnosis.
Key words: Abusive head trauma, Brain injuries, Craniocerebral trauma, Nervous system trauma, Shaken baby syndrome
Abusive head trauma (AHT), also known as Shaken Baby Syndrome (SBS), is a devastating and potentially lethal form of infant physical abuse. The outcomes 
are grim. In recognized cases, AHT typically results in death 
or significant lifelong brain injuries in survivors. Another 
feature of AHT is the discrepancy between the incidence of 
clinically recognized cases and the unmeasured burden of the 
unrecognized cases. Less severe cases may not be brought to 
medical professionals and may never be diagnosed. Not all 
the episodes of shaking by a caregiver will result in clinically 
significant consequences. However, if unrecognized, unknown 
numbers of infants may develop milder forms of motor 
dysfunction, sensory compromise, or cognitive losses [1].
The incidence is reported to be 20-30 cases per 100,000 
children <1 year of age with a case fatality rate exceeding 20% 
and significant disability in about two-thirds of the survivors [2]. 
In India, cases of SBS are very rarely reported and a literature 
review with the keywords “SBS” and “India” showed only 
3 reports [3-5]. We present a case of SBS because we believe 
there is a gross under-reporting of such cases, and secondly, it is 
important to elicit the history of SBS for children coming with 
convulsive state as it can simulate febrile convulsions.
CASE REPORT
The 11-month-old boy was referred with the history of recurrent 
generalized tonic-clonic convulsions for 5-7 days which 
was sudden in onset with the movement of upper and lower 
extremities and up rolling of eyeballs followed by drowsiness. 
There was a history of previous four such episodes, for which 
he was treated and was on oral antiepileptics. 2 months back, 
the first episode started with  fever and non-projectile vomiting 
followed by tonic-clonic convulsions. Cerebrospinal fluid 
(CSF) examination done at the time of the first admission 
was normal. Computed tomography (CT) scan head done 
at last admission showed diffuse lesions in bilateral cerebral 
hemispheres with thinning of sulci, cisternae, and ventricles 
indicative of global ischemia.
There was no history of head trauma or recent vaccination. 
The birth and developmental milestones history were normal. 
On admission, the baby was comatose with Glasgow coma 
scale of E2V1M2, and decerebrate rigidity was present. 
The fundoscopy revealed bilateral retinal hemorrhages. On 
examination, all the limbs had power <3/5. Deep tendon 
reflexes were elicited bilaterally, and pupils were responding 
bilaterally to light. No signs of raised intracranial pressure or 
meningeal irritation were obtained.
A provisional diagnosis of post-convulsive encephalopathy 
or cerebral malaria, tuberculous meningitis, or acute 
disseminated encephalomyelitis was made. His routine 
laboratory investigations including complete hemogram, 
platelet counts, coagulation profile, and malarial antigen 
tests were within normal limits. The chest X-ray was normal. 
Routine CSF examination and CSF culture were also negative. 
So, malaria and tuberculous meningitis were ruled out. The 
portable electroencephalography showed a generalized slowing.
In view of retinal hemorrhages on fundoscopy and 
ischemic changes in previous CT scan, a diagnosis of SBS was 
considered. On re-interview parents came out with a history 
that at the time of first seizure episode, a relative took hold 
Verma et al. Fragile Brain - Handle with Care
Vol 2 | Issue 3 | Jul - Sep 2015 Indian J Child Health 143
of the baby’s neck and chin and shook him vigorously in an 
attempt to stop the seizure. Following this event, there were 
multiple episodes of seizures. The magnetic resonance brain 
showed generalized cerebral atrophy with a little amount of 
white matter in the fronto-parietal region mostly due to an 
ischemic insult (Figure 1). An X-ray work-up for fractures was 
found to be negative. The patient was kept under observation 
and was discharged following an improvement in the condition 
after 12 days.
DISCUSSION
SBS was first described by Caffey in 1972 as whiplash baby 
syndrome where acceleration-deceleration stress is considered 
to be the cause of the injury [3]. AHT and SBS are forms 
of premeditated injury inflicted on infants due to violent 
shaking, the impact to the head, or a combination of both. 
These mechanisms can result in head trauma such as subdural 
hematoma, diffuse axonal injury, cerebral edema, retinal 
hemorrhages, and sometimes fractures of the long bones or 
ribs, with little or no external findings of trauma [1].
A remarkably constant unexplained finding is that victims 
are more likely to be males than the females [6]. The possible 
explanation is the bias among caregivers (particularly fathers) 
toward male children that “Men do not cry and crying is for 
women.” Therefore, they become more furious and irked by male 
infant crying rather than female. Confessions from perpetrators 
have shown that crying is the usual stimulus for AHT and infant 
physical abuse, and crying was the reported stimulus in 63% of 
the cases in a study done by Adamsbaum et al. [7].
On the basis of these evidences, crying has been included 
into the recommendations for prevention of the American 
Academy of Pediatrics and the Canadian Joint Statement on 
SBS [8]. Other stimulating factors include socioeconomic 
standing, societal and family stress, and prematurity, multiple 
births, developmental delays, prior military service, and 
childhood history of abuse in the perpetrator. Race and ethnicity 
have not been found to be risk factors [1].
Shaking has its unique effects on the perpetrator and the 
infant in comparison to other forms of infant abuse. First on 
slapping, the caregiver might experience a stinging of the hand 
and might feel guilt or remorse but shaking does not cause that 
effect. Second, shaking does not leave an external mark on the 
infant and the perpetrator may not be caught. Third, an infant 
who is shaken usually stops crying due to concussion-like brain 
injury, whereas a slap or a hit might cause a further increase in 
crying. Consequently, shaking reinforces a “positive feedback” 
cycle in which the caregiver is rewarded by an improvement in 
the behavior as the infant stops crying and there are no negative 
consequences for the caregiver [1].
Retinal hemorrhage is one of the characteristic signs of 
SBS and is known to result from an abrupt rise in intracranial 
pressure during shaking which was also seen in our patient. 
Birth trauma can also cause retinal hemorrhage; though, this 
resolves quickly. Sub-acute bacterial endocarditis, anemia, 
or thrombocytopenia can also lead to retinal hemorrhage, but 
these can be ruled out by clinical findings supported by results 
of laboratory investigations [9,10]. An overt effect of shaking is 
SBS. However, mild and less violent forms of repeated shaking 
can lead to the development of mental retardation, learning 
difficulties, or behavioral problems in later life.
The high prevalence of shaking as a typical caregiving 
behavior coupled with decreased awareness of its potential 
dangers indicate that prevention of SBS is an important public 
health challenge. There is extensive evidence that SBS does 
occur but how and why the guardians move from caring to 
abuse remains rudimentary. Thus, early prevention efforts 
targeting caregiver infant interactions around early crying are 
encouraging signs that prevention can work and contribute to 
giving otherwise normal infants a “good start” in life [1].
CONCLUSION
The diagnosis of SBS should be kept in mind while treating 
young infants with a history of symptoms similar to meningitis 
or epilepsy. This may help prevent further harm to the patient.
ACKNOWLEDGMENTS
We thank Dr. Vrajesh Udani who provided insight and expertise 
that greatly assisted the case.
REFERENCES
1. Barr RG. Preventing abusive head trauma resulting from a failure 
of normal interaction between infants and their caregivers. Proc 
Natl Acad Sci U S A. 2012;109 Suppl 2:17294-301.
Figure 1: Magnetic resonance imaging brain showing 
generalized cerebral atrophy with a little amount of white 
matter in the fronto-parietal region.
Verma et al. Fragile Brain - Handle with Care
Vol 2 | Issue 3 | Jul - Sep 2015 Indian J Child Health 144
2. Albert DM, Blanchard JW, Knox BL. Ensuring appropriate 
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8. Christian CW, Block R; Committee on Child Abuse and Neglect; 
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Funding: None; Conflict of Interest: None Stated.
How to cite this article: Verma B, Ronghe A, Shukla P. Fragile 
brain, handle with care: A case of abusive head trauma and a 
review of literature. Indian J Child Health. 2015;2(3):142-144.


Fragile brain, handle with care: A case of abusive head trauma and a review of literature

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