by Fareed Saleh with Kristen Breslin on the Hot Seat
14 yo previously healthy boy p/w new-onset headaches for the past 4 days. Mom notes that the patient also has had tactile fever 1-2 times since the headaches started. He describes the headaches as throbbing in nature, 8/10 and located in the front part of his head. +Vomiting (NB/NB), tolerating PO, normal UOP. No rashes/skin changes. Mild photophobia. Fully vaccinated. Patient also states that his right shoulder and neck have been hurting him for the past 2 days. PMH noted for no h/o headaches. FH unremarkable.
Exam: T 37.2C / HR 104 / RR 20 / 100% on RA / BP 105/78
Pt looks to be in moderate discomfort, interactive and responding appropriately
EOMI, No papilledema appreciated on fundoscopy. TTP over right side of neck. (paraspinal). Negative Kernig and Brudzinski signs.
CTAB. CVS stable. Abdomen soft, nontender. Extremities 2+ in 4 extremities.
Non-focal neurologic exam.
The patient was initially started on the migraine pathway receiving NSAIDs, metoclopromide and IVF, but he stated that his headache remained about the same (7-8/10, throbbing in nature) even after such intervention.
Questions for you (click on "Vote" to see what others said):
What do you think? Add your comments below by clicking on "comments." Easiest if logged into your gmail account but you can do it without as well. Come back later for the Hot Seat response by Kristen Breslin and case denouement.
here's my simplistic approach to headaches, based on DDx:
ReplyDelete1) does he have migraine? yes. but let's be devil's advocate....
2) does he have pseudotumor. no risk factors mentioned (medications, severe obesity, blurry vision). so i wouldn't be that psyched about doing an LP here. fundoscopy is not always reliable, btw. acute pseudotumor can have no papilledema.
3) does he have viral meningitis? maybe. not quite the season. mental status is normal and no seizures so not really concerned about encephalitis here. no meningismus or signs of bacterial meningitis. it's a harder question in a kid you have to sedate to do an LP that you know is going to show 50 wbc and some enterovirus.
4) does he have an intracranial lesion? not likely. relatively acute with presence of fever and very migranous symptoms and no description c/w increased ICP. but not worth missing if sx don't improve.
so my general approach to these is always the same when there are no focal neurologic lesions on exam. give lots of fluids. give toradol. give more fluids. give reglan if they're nauseous. give a triptan if there's a hx of migraines. add depakote if hx of migraine. give more fluids.
since this kid is new-onset, i'd probably bolus again and if headaches persist i would scan and LP. scan to r/o mass and LP for therapeutic relief in the context of pseudotumor. but he has migraines. so i wouldn't rush to do any of these tests....
So, I kind of agree with Dave... in that I would stall a bit with more fluids and maybe more meds.
ReplyDeleteBut in the back of my mind, I'm kind of worried about meningitis - something smouldering - those fevers in conjunction to the headache that isn't improving and the vomiting... And then the vomiting would make me think about a mass and I would head back to the kid and see if the vomiting ever makes his headache better. Or if the headache has woken him from sleep. Or if position affects his headache. A yes to any one of these in this child would buy him a head CT in my book. So then, since my differential now contains both a mass (BADNESS) and meningitis (also BADNESS), I am off to order a head CT and an LP.
And I have a semi-bad gut feeling.
What is most intriguing to me about this case is the right shoulder and neck pain. I'm trying to figure out if this is a RED HERRING or a RED FLAG. If the latter, then what would tie right shoulder/neck pain with new onset frontal headaches in a 14 y.o. with no papilledema on examination? The only thing that comes to mind (no pun intended!) is perhaps a Chiari 1 malformation. Brain MRI would be the preferred imaging modality for this, but could be done nonurgently (I think) for this case as an outpatient. If, on the other hand, the right shoulder/neck pain is a RED HERRING, then you've all read this paragraph in vain!
ReplyDeleteDidn't think of a Chiari malformation! Would you have symptoms sooner in life or can you present in adolescence?
DeleteThe neck pain bothers me, along with his moderate discomfort. I would like to know more about his fevers (has he been on antipyretics) and about possible head and neck infections-- recent dental work, pharyngitis, sinusitis. This could be as innocent as a viral headache or a migraine, or as serious as a deep neck infection (adenitis, Lemierre's). So, agree with above, neck pain may be red herring or may be the real problem.
ReplyDeleteSo we have a 14yo with new-onset frontal headache and neck pain, associated with vomiting, photophobia, and possibly fever, now in moderate discomfort and no improvement with NSAIDs and empiric migraine therapy.
ReplyDeleteStarting with a differential:
Migraine is in the differential – there’s no current fever, and recent fever could be a viral process triggering a migraine headache. Also influenza – headache, fever, muscle aches. But these will be diagnoses of exclusion. This patient is a little unusual - not only is there no history of migraine, he hasn't improved with fluids or empiric migraine therapy, and he looks uncomfortable. Considering further workup seems reasonable.
With fever, headache, photophobia and vomiting, you have to think about meningitis. With 4 days of symptoms and a supple neck, I'm not thinking bacterial meningitis, but viral meningitis (including enterovirus) and Lyme meningitis are on the differential. Mass is on the differential, with increased ICP. A subarachnoid bleed is on the differential for bad headache, but that would usually be more sudden in onset. Sinusitis and complications of sinusitis, such as subdural empyema, would also be on the differential. None of these diagnoses would typically explain neck pain, let alone neck tenderness. There was a case a few years ago of a boy who presented with high fever, relatively mild headache, and neck pain, who turned out to have subdural empyema and a septic thrombophlebitis of the neck, so I think Lemierre’s is worth mentioning. Other possibilities for fever and neck pain would include a lymphadenitis or abscess, although it doesn’t sound like he has anything palpable or any focal swelling.
Pseudotumor would not be my first thought in the absence of papilledema or visual changes, unless this patient has specific risk factors (obesity, minocycline use).
And management:
There is more to the migraine pathway (after three doses of metoclopramide, Depakote would be next) but it’s unusual to get that far, and in a patient with no clear history of migraine I’m not comfortable going further without more workup. I‘d vote for a head CT next and labs (CBC, BMP, ESR, CRP). I’d like a noncontrast head CT before an LP for this patient. If he has unexplained, somewhat localized and consistent pain and tenderness in his neck I think neck imaging is reasonable. If readily available US is not a bad start, although CT is more sensitive, depending on the index of suspicion. At this point if I don’t have an answer and he’s not any better I do think an LP is reasonable, especially in a patient who looks uncomfortable and hasn’t shown any improvement with time, fluids, NSAIDS, and a few doses of reglan.
So my vote:
1. What would be your next choice in management? Noncontrast head CT.
2. If you LP him, what one thing would you do beyond the standard studies? Hmmm. If he has CSF pleocytosis I’d send enterovirus.
Do a CT with contrast to look for brain abscess and HSV (MRI is better for the latter). Don't dismiss the fever...
ReplyDelete