Teaching Attending Response
by Mike Quinn
I pretty much agree with the concerns and comments Dewesh and Dave have added.
I think the baby probably has a retropharyngeal infection. One week of fever, “no source,” CXR and Urine negative at a previous visit, now with a new symptom of “neck tilt,” WBC 24K, and a plain image showing “swelling” of the retropharyngeal space. I could talk myself into this being a RPA. So antibiotics should be given , and some defining image needs to be done, in order to mobilize the consultants and inpatients, as needed. Around here, it falls to the ED to figure out the logistics. Dave and Dewesh comment on how complex that can be, especially at 2 AM. Just to make the point: I think in a child who I suspect has RPA I would op for a CT, maybe even in the daytime. I get the sense that if I got an ultrasound sudy or fluoroscopy, those would ave to be incontrovertibly negative to be of any use. That is, any abnormality at all and Radiology, ENT, and probably hospitalists will insist on the CT anyway, so I can’t think of instances where those studies have helped me, only times where they’ve delayed the inevitable.
So, get a sedated CT at 2 AM? Hold that thought.
Because in this patient something bugs me. Dewesh strongly comments, too. I imagine going into the room to convey the plan to the parents of the kid with the RPA – the febrile, miserable kid whose neck muscles are in spasm from the inflammation, who can’t swallow because there’s an abscess in the back of his (her?) throat, and hasn’t drunk anything in 2 days. Only: this baby is happy, smiling, wet and hydrated. He holds his head tilted, but has completely supple neck muscles, and when I stop manipulating the neck, I presume, he goes back to holding his head tilted. Last time I saw a content child with a head tilt, it was a brain tumor. Oh, and didn’t he have some kind of eye rolling, limp episode last week that seems to have been chalked up to a benign febrile seizure? I worry that there’s something in the head.
Anyway, I want a non-contrast head CT promptly. He can get clinda and cef, I can alert ENT about what’s going on, and how I may not get the optimal study right away, but I’ll try, and the child is stable for now, and I know what to monitor meanwhile regarding RPA. I would try to sweet talk radiology into doing the head CT, and (if negative) keep the baby on the table, maybe with Sweetease and 0.05 mg/kg morphine (for the pain). I would not perseverate at multiple attempts at the neck CT – one shot is all. It’s 2 AM, ECIC is calling, to much else going on. At 7, the day crew can better arrange the neck CT.
Of course, if the head CT is positive, then PICU, Neurosurg and ENT have a lot to deal with, eh?
Waiting on the denouement. . .
The Case
by Sonny Tat, with Mike Quinn on the Hot Seat
8 mo previously healthy girl with fever x 7 days. Pt has had
fever with Tmax to 103.7. Had episode of eyes rolling back, limp at start of
fever, self-resolved. Mom notes slight head tilt to left for 2 days. +URI
symptoms, tolerating PO, normal UOP, no vomiting. Fully
vaccinated. Has been seen in ED two previous times during this week,
most recently yesterday. At that time, she had a UA with negative nitrites/LE, 4
WBC. Patient returns today for persistent fever.
Exam: T 39.9 HR 197 RR 50 100% RA; Better with motrin/PO fluids:
T 36.1 HR 150 RR 26
Well-appearing, smiling, interactive
Pt with slight leftward neck-tilt, full-range of passive
motion of neck, no swelling or tenderness, MMM, throat non-erythematous, no
exudate
Chest CTAB, no wheezing, stridor, or crackles
Heart RR, no murmurs, CRT less than 2 sec
You also get a lateral neck:
The overnight wet read is "diffuse prevertebral soft tissue swelling." It is now 2 am. The patient is
awake, very well-appearing, and well-hydrated with reliable parents. Questions for you:
We welcome your comments on the case. Please click on "comments" below to add your thoughts.
Abd non-tender, no masses, no guarding
You obtain a CBC and blood culture for persistent fever.
WBC 24 K, neutrophils 15 K, bands 1. You review a
chest x-ray from yesterday, which is normal. You also get a lateral neck:
We welcome your comments on the case. Please click on "comments" below to add your thoughts.
I am a little perplexed by the concerning neurological history (presumed seizure) without any mention of what the prior neurological work-up was or what the thought process was on the prior ED visits. Also, there is no mention of a neurological examination. Does this head tilt represent a bulbar palsy (Cranial Nerve 4 palsy), perhaps from an ominous midline posterior fossa lesion/mass (tumorous vs. infectious)? A detailed cranial nerve examination should be reported, or at least attemtped. Or is this head tilt part of a torticollis -- but the reported examination states full passive ROM of the neck and no description of twisting which are incongruous.
ReplyDeleteThe RED FLAG in this case appears to be the head tilt -- which, if real, should not be seen in 8 month olds, and I doubt this 8 month old is feigning this illness. The persistent fever and elevated WBC with the head tilt makes you concerned about an infection somewhere. But where? The lateral neck X-ray reading is concerning for a retropharyngeal abscess, which can present with torticollis (which is more than simply a head tilt) or stiff neck -- none of which this child is described as having. Pharyngitis can present with rotary subluxation (Grisel's syndrome), but again there is no rotation/twisting described here, only head tilt.
Regardless, rather than jumping to a CT to r/o retropharyngeal spaced widening, I'd ask for flouroscopy, which uses much less ionizing radiation than a neck CT. If there is definite retropharyngeal widening on fluoro, then I'd try for an US in the AM and admit to ETU in the interval. Blood cultures should be obtained, after which I'd vote for empiric coverage with Clinda and Ceftriaxone.
i agree with dewesh until the business about fluoro at 2am which ain't happening.
ReplyDeletei would scan this kid in a second. Grisel's syndrome is usually in an older kid, often post-T&A complication but is right on track. a space occupying infectious process leading to torticollis is likely something in that retropharyngeal space. you could extend the CT to the brain to r/o an intracranial abscess, but i think that's overkill without seizures or a motor deficit on exam.
I think the issue is that it's 2am and it's difficult to do a sedated CT at 2am when you are the only PEM provider and have to abandon much of the ED to sit in the CT-suite pushing pentobarbital or similar sedative. so i would do a sedated CT at 2am based on ED standing volume/acuity. if busy, i would ETU and do a sedated CT in AM. i think anesthesia is overkill for this. he has no stridor, these kids do fine with a little sedation.
in an 8mo, you can usually wrap the kid and get them to go to sleep and convince the tech to push the contrast and it will be ok (without sedation). a 2yo is a different story.
don't forget to get a CXR since RPA's are associated with mediastinitis.
Oooooooo - i LOVE these hot seats.
ReplyDeleteThis one reminds me of the kid i
had recently - the brief seizure he had seemed to be just a random occurrence, but when paired with a few other concerning features (weird behavior, sleepy all the time, vomiting all the time that GI couldn't figure out), led me to consider (and diagnose) a massive brain tumor.
So, scan the kid. And the fever is something weird - a super-infected tumor? or is this leukemia with an infiltration? Although, those kids look like crud.