Hot Seat #7: Headaches & Asymmetric Smile: Denouement

Case presentation by Erin Augustine with Dave Mathison on the Hot Seat
This case is about a 14 year-old boy with an isolated asymmetric smile, throbbing headache, and normal neurological exam outside of a droopy left mouth. For the full case presentation, click here. Thank you to Dewesh, Sabah, and Nazreen for your thoughtful opinions.

And now for the main event. We posed questions about your diagnostic approach and it's urgency. Here's what you said:

1. Assuming most would obtain imaging, what is your initial imaging plan?

2. Let's say you do head imaging in the ED and it is normal. Does the patient need an LP in the ED?

Hot Seat Response

by Dave Mathison

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.

1) 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....?

Click here for other commentary on this case

The Denouement

by Erin Augustine

The patient had a resolving headache and less pronounced smile asymmetry after a fluid
bolus and one dose of Toradol. His exam was consistent with an upper motor facial weakness because his facial weakness involved only the lower half of his face (no weakness of eye closure). This forehead sparing upper motor neuron facial weakness is in contrast to peripheral facial weakness that typically involves both the upper and lower halves of the face. Given his right-sided headaches and focal neurologic finding corresponding to a right upper motor neuron lesion of CN 7, a non-contrast head CT was obtained in the ED. The CT was normal. An LP was not performed.

Neurology was consulted and recommended admission for MRI the next day. MRI was unremarkable. The patient was diagnosed with migraines and discharged home the following day. Exam at discharge was normal with complete resolution of his smile asymmetry. Supportive care for migraines was recommended including hydration, avoid caffeine, good sleep hygiene, and avoid excess screen time. A headache diary was recommended and a neurology follow up appointment was scheduled in 6 weeks.

Thanks for participating. We hope you learn something about different approaches to an interesting presentation. Come back next week, when Rosemary presents the case with Jennifer Chapman on the Hot Seat.