by Fareed Saleh with Kristen Breslin on the Hot Seat
This is a case of a 14 year-old with new onset persistent headaches, tactile temperatures, and normal exam except for shoulder pain. He has been started on the migraine pathway without improvement. For the full case presentation, click here.
Thank you to Dave, Sabah, Dewesh, Jim, and Jennifer for sharing your clinical approaches and words of caution. Click here to read their comments (scroll down to middle of the page).
Here's how you answered:
1. Given that he failed with IVF, Reglan and NSAIDs, what would be your next choice in management?
2. If you did decide to do an LP, what one thing would you do beyond standard studies? (n=12)
Hot Seat Response
by Kristen Breslin
So 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.
Starting 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.
Starting 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.
by Fareed Saleh
Upon further history taking the mother stated that she noticed her
son was 'acting a bit weirder than usual' one day prior to ED visit. Also, a
bedside ultrasound was done which noted the presence of papilledema. Following
his reevalation, the patient was sent for a CT Head w/o contrast (which showed a
questionable Chiari malformation, but no acute process). A lumbar puncture was
done at bedside. Lab results were as follows:
CSF findings: Opening pressure not done (due to patient moving around quite a
bit) Clear, colorless Glucose
70, Protein 72, WBC 20 (96% lymphs, 3% monos, 1% segs), RBC 22 Gram stain negative Viral cultures sent
(including HSV, Enterovirus) but insufficient quantity per lab CBC: WBC 15k, H/H 15/41, Plt 259k
CMP: Na 133, K 3.6, Cl 97, Bicarb 25, BUN 12, Cr 0.7, Gluc
134 Amylase 67, Lipase 171, AST/ALT 12/24
The patient was admitted due to
unremitting headache and poor PO intake under the Neurology service. Management
with NSAIDs, IVF and metoclopromide was continued. On HD #2, he was evaluated
by ophthalmology with the exam showing no signs of swollen optic nerves (sharp
margins appreciated). MRI w/contrast was normal with no Chiari malformation
detected. CSF bacterial culture showed no growth. On HD #3, the patient's
nausea and headache resolved and he was discharged home with a working diagnosis
of viral meningitis given mild pleocytosis in CSF with outpatient neurology
follow-up.
Here's his bedside eye ultrasound showing papilledema, performed by Lauren Staple.
The top of the video is towards the probe while the bottom is towards the back of the eye. The papilledema is the bump at the 5 o'clock position. Lauren will explain technique and describe her findings in more detail in a later post.
Final bit to ponder is sedation in an adolescent LP. In this case, the patient's movement may have limited our ability to get an opening pressure. Would sedation be indicated in this patient?
The Hot Seat is a recurrent online case series meant to facilitate asynchronous sharing of PEM knowledge and experience. Attendings are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are all actual cases and are written by PEM fellows at Children's National in DC. Emily Willner is the faculty mentor on all case presentations. Come back again for the next case in our series and we welcome your commentary.
i'm no doctor, but... yes.
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