Previously healthy 14 yo M presents with right-sided headaches for the last week. Headaches described as a throbbing and stabbing pain that changes in intensity throughout the day. Pain worse with light and noise. Pain better with Motrin but returns within a few hours.
No fever, nausea, vomiting, or visual changes. No personal or family history of migraines.
On exam, his vital signs are temperature 37.1, heart rate 82, blood pressure 119/71, respiratory rate 17, and oxygen saturation 100%. His physical exam is significant for an asymmetric smile with drooping of the left corner of his mouth. No weakness of eye closure or puffing out of cheeks. The remainder of his neurologic exam is normal. No papilledema. In the ED, the patient receives a fluid bolus and a dose of Toradol. His pain somewhat improves and his asymmetric smile is less pronounced.
(photo for illustrative purposes only and is not actually the patient)
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Come back later for Dave's commentary on the case and later yet for Erin's denouement.About the Hot Seat
First, how do you measure a respiratory rate of 17?
ReplyDeleteThe picture of this "14 y.o." has me worried that he has "Emmanuel Lewis sydrome" (star of the hit 80's TV show Webster).
OK, now I'll be a little more serious. Acute onset of headache and 7th nerve palsy this time of the year is a slam-dunk concern for Lyme meningitis, after you first rule out a posterior fossa tumor. I'd ask about any history this past summer of tick exposures, travel, and EM-type rashes. I'd do a very thorough neurological examination looking for any ataxia, other cranial neuropathies, and papilledema. LP is essential, because headache suggests more than just facial nerve palsy from lyme -- it is worrisome for meningitis. And, treatment of lyme meningitis is different than isolated facial palsy: 14-28 days of IV Ceftriaxone vs. 14-21 days of PO Doxycycline, respectively for this 14 year old.
So, first, can I say how nervous those polls make me? I plug in my answer and just *hope* that I'm not answering the question totally wrong, but as luck would have it, I seem t obe in line with everyone else.
ReplyDeleteSo, I totally agree with Dewesh; I'm very much thinking Lyme Meningitis, but with severe focal headaches, I would do a non-con CT to r/o a mass. I very rarely think head imaging is an emergency and this kid (despite his pleasant smile) is one of those cases...
And then, if negative, I would definitely LP him as well. One of my first cases at CNMC as an associate was a 15 year old morbidly obese girl who had severe headaches for 2 or 3 weeks: her PMD prescribed Percocet for the headaches, then she developed photphobia and some neck pain - she got muscle relacants from her PMD for the neck stiffness - and then developed nausea and vomiting, so then her PMD gave her anti-emetics... So, then, she went to her brother's baseball game where she threw up and complained about her headache and her very stiff neck and another mother there said "Um, I think your daughter might have meningitis"
So then the mom went home, did some research on the internet and then brought her in....
So, that case illustrated to me how lyme mengingitis is more indolent and less life-threatening than other types of meningitis... and she needed 21 days of IV Ceftriax.
And, I got her LP on the first try.
Ok here we go. So the kid probably has lyme meningitis right? blah blah blah. there are really four decisions here. 1) CT or no CT. 2) LP or no LP. 3) steroids or no steroids. 4) presumptive lyme treatment (if negative LP or no LP). so let's go one at a time.
ReplyDelete1) CT - no thank you. you're not describing anything consistent with a tumor. even a posterior fossa mass should cause either vomiting, >1 cranial neuropathy, or some kind of ataxia or other finding. if all you have is a "peripheral" CN7 lesion and headache, that's not enough to buy me a CT. this assumes neuro exam is otherwise negative.
2) LP - well, it depends what kind of headache you're talking about. if the kid has meningismus, then yes LP. if the kid has a really bad headache, then yes you LP. but if it's mild and if he probably didn't need the toradol, then i say no thank you. i would air on the side of doing the LP here the way it was described. if LP has pleocytosis, i'd admit for IV ceftriaxone until lyme titers are back. although IM ceftriaxone and discharge is not unreasonable. if lyme titers are negative then no PICC line needed. if lyme titers are positive, he can go to BearDirect help facilitate his ID consult and PICC line placement.
3) steroids? there is a lot of evidence that steroids will decrease the symptom length and long-term outcomes for idiopathic CN7 palsies. of course these studies are in adults and in non-Lyme endemic areas. Scotland and Norway, i think. i vote no, but if the Lyme titers are negative in 48 hrs and there continues to be only CN7 findings then i would do them.
4) presumptive lyme treatment? this is tricky. if LP is negative, then i would definitely do some doxy. if the headache wasn't bad and i didn't do the LP, i would wait for the titers. because if you start the treatment and then he's lyme positive and his headaches resolve, you'll wonder if he actually had CNS lyme and needed longer treatment.
so ultimately the decision for me is either:
1) no CT, do LP, discharge with doxy if negative and dischare with IM ceftriaxone if positive (assuming he doesn't meet jama decision-rule to wait for csf culture in-house. and lacrilube :)
2) no CT, no LP, no doxy, no steroids, await lyme titers. and lacrilube :)
i vote for #1 if the headache is more than mild. or if he used to be in a sitcom. bonus points if anyone can name Alex Karras' character on the show Webster....?
mostly chiming in for the bonus points and placing my vote for mr. papadopolis (sp?). i was a big fan of webster..
ReplyDeleteand just to legitimize my post-- it may have just been the way i read the case, but i felt like i needed more info from the physical exam to feel confident that the patient was in fact presenting with a bell's, i.e. peripheral, facial nerve palsy. "No weakness of eye closure" gave me pause as i usually think of bells palsy as having that non-blinking eye in need of the lacrilube Dave mentioned..
I feel like i have at least a couple of patients in whom I was staring at their foreheads trying to figure out if they sparing of their foreheads suggestive of a central lesion.
But if the whole side of the face is out and we're confident it's a peripheral nerve palsy, i agree that lyme meningitis is on the top of the differential.
nice job with that LP, Sabah..