with Eiman Abdulrahman on the Hot Seat
Previously healthy 4 yo F presents with fever (Tmax 103), sore throat, drooling, intermittent headache, and intermittent abdominal pain x 6 days. She has had decreased oral intake, only taking a few sips of juice over the last 24 hours. Parents also concerned that she seems tired and weak, even urinating in her father’s lap because she didn’t want to walk to the bathroom. Her speech has become difficult to understand. No vomiting, diarrhea, or rash.
Of note, the patient was evaluated 2 days ago for her symptoms. A strep test was negative and her neck x-ray is shown below.
On exam, vital signs are T 37.4, HR 119, BP 112/49, RR 26, and Pox 98%. PERRL. She has a normal posterior pharynx, without petechiae, exudate, or deviation of the uvula. Trismus is not present. She has small cervical nodes, and complete neck range of motion without pain. The patient is uncooperative with neurologic exam. She answers questions appropriately and follows commands, but seems slow to respond and requires encouragement. Her speech is difficult to understand. Her face is symmetric. Her strength and sensation are normal. Coordination and reflexes cannot be assessed due to lack of cooperation. Her exam is otherwise unremarkable.
Questions for you:
A CBC, BMP, blood culture, and your choice of neck imaging are performed. While results are pending, the patient is observed having difficulty eating a popsicle. When she attempts to bring it to her mouth, she repeatedly hits her nose instead. She also has a brief period of dysconjugate gaze and unilateral facial twitching. Her exam is otherwise unchanged. Given these new findings, a head CT is performed.
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Great Case !
ReplyDeleteIt's important to recognize "red flags"
Drooling is always a red flag to me, especially in the absence of a stomatitis on exam. A 4 yo should have some voice symptoms which can help localize neurologic disease or space occupying disease if the patient is hoarse, weak cry, etc. So this would be an important part of the history. So would the positioning of the patient. remember that RPA's often lean forward (tripod) whereas epiglottitis kids are in the sniffing position.
The sensitivity of the XR neck for RPA's is poor. there was a study about 10yrs ago that quoted it at 79% sensitivity, so it's NOT a great screening test. I would probably jump to CT when this kid comes back still febrile and drooling.
But kudos for the neuro exam localizing disease above the tentorium. Anytime you CT neck, good idea to think about CT head too. same with trauma....if you need to CT face, think about if you need the neck also.
The CT looks to me like an infarct....but good to use contrast to determine if it's an intracranial abscess. Doesn't look rim-enhancing like an abscess or neurocystericosis to me, but i'm no radiologist :) Antibiotics are not empirically recommended in brain abscesses, similar to osteomyelitis, because it helps to try and get a culture.
No reason to do an LP here. Kid needs a contrast CT or MRI and a neurosurgical plan. If it's an abscess, my next test would be an echocardiogram and not an LP. but that can be done in the unit :)
The CT here is quite concerning. There appears to be diffuse cerebral edema and focal hypodensity (likely edema, not infarct, in my opinion) in the left fronto-temporal area. Given the fever, headache, bulbar palsies (dysarthria, dysconjugate gaze, swallowing dysfunction/drooling), unilateral facial twitching (? focal seizure), and mental status changes, I'd be really worried about HERPES encephalitis with that CT. But I'm also no radiologist -- I just play one in the ED for the 30 minutes we need to wait for wet reads + the 20 minutes for the magical predating of X-rays done by the techs.
ReplyDeleteI do realize that the case presentation is really pointing to possibly something in the throat, but the neurological symptoms are much, much more concerning. I'd really like a better description of "her speech is difficult to understand" -- dysarthria vs. aphasia.
Fascinating case, can't wait for the denouement.
Yet another interesting case! Fever, sorethroat, drooling, refusal to eat with the lateral neck xray showing generous pre-vertebral tissues, normal epiglottis made retropharyngeal abscess (RPA) very likely BUT RPA shouldn't cause headache, difficult speech, or focal seizure. By history, it seems the disease process (likely infectious, although possibly oncologic, given fever) is localized to the neck and head/brain. Given the lat neck XR was done 2 days ago, I wouldn't expect it to add much more repeating it in the ED. I would probably jump to a head and neck CT with contrast given concern for possible septic emboli to brain. Head CT shows somewhat tighter than usual ventricles, large left parietal, and smaller Rt parietal hypodense lesion with no significant midline shift. Hypodense makes me think hypoperfusion (CVA) or early septic emboli. Would be very nervous about LP-ing this kid with the tight ventricles. Seeing this CT, I would make sure vital signs are okay (no signs of Cushing's Triad), which , so far, they are. The only diagnosis that comes to my (simple) mind connecting the throat to brain findings would be Lemiere's disease with septic emboli to brain although I would expect much more throat/neck pain on exam. Would monitor closely for sepsis, admit to PICU. Make sure blood cultures are sent and consider starting broad spectrum antibx sooner rather than later.
ReplyDeleteInteresting case! Agree with all the above.
ReplyDeleteIt's true at first one things Neck Neck, RPA! However, what struck me in the initial presentation is the absolutely normal OP/Neck findings except for LAD, and the red flags for it being something other than a RPA was the headache (though with a simple febrile illness that's possible), the fact that this 4 yo was peeing on her father rather then getting up without appearing toxic, or severely dehydrated on exam. I really felt- hmm! Something else is going on here. RPA after 4 days tend to be sicker in my short experience, this seemed more neuro like "something is off".
I chose to repeat Xray as I felt there may be something else going on and would like to see if anything is worse there, though sensitivity is poor. But I guess CT neck/Head would be next. Since child has fever, I would definitely add IV contrast for abscesses.
With the knew findings in ED and head CT, I would definitely start ATBX: CTX, Acyclovir and maybe an anaerobic coverage if considering this 2/2 RPA or Lemierre's (great thought Jamil), except that I think the latter has septic emboli to the lungs and tend to be quite toxic appearing and hemodynamically unstable.
Personally, CT looks abnormal to me, but I wouldn't know how to interpret it. And from my experience here, I would ask the radiology resident to review it with the attending. Ventricles seem small, i don't see the smiley face and there's something on the left parietal area: thrombus? Abscess?
So with this now, this child needs a MRI/MRV? But going to be hard to get, so maybe a CT with contrast? Definitely neurosurgical consult if the CT is read as increase ICP because if this is an abscess I think it needs to be evacuated.
Enough talk!
I actually saw this patient on one of my overnights so I will describe her presentation when I saw her and my thoughts at the time. I guess I will forgo this opportunity to be on the hot seat.
ReplyDeleteWhen the resident presented the case of the patient with fever, sore throat, drooling, decreased po and decreased urine output, I was thinking more of an infectious etiology from an upper airway obstruction - RPA, bacterial tracheitis vs epiglottitis. In RPA, the abscess occurs in the anterior border of the cervical vertebrae and posterior wall of the esophagus - the deep, soft tissue space of the neck. All the children I have seen with RPA, similar to children with epiglottitis described in textbooks, are toxic appearing with high fever with neck pain - especially with movement of the neck. This patient was not drooling, nor posturing, had supple neck with only shotty LAD, no trismus or discomfort with neck movements. She was clingy to her father, sitting up on his lap, didn’t speak much and was not cooperative with neuro exam: symmetric face, no ptosis, no focality noted when squeezing my hands.
The description of her behaviour and speech changes was worrisome but it wasn’t clear if her speech was slurred or if she had changes in her speech because she wasn’t feeling well. My overall impression was of a developmentally delayed child with a febrile illness. Yet, her father assured me that this was not her baseline she previously was able to speak well with normal developmental milestones. I didn’t know what to make of “urinating on her father”. Her parents were more concerned with her weakness and briefly mentioned that she may be having headaches. I repeated another lateral x-ray, to rule out the possibility of early RPA (especially given the sore throat and drooling) and ordered labs and fluids to see if she would “perk” up after a bolus.
Re-exam after fluids, she remained sleepy/clingy but it was 3 or 4 AM, so what I usually do is get the patient to take a walk in the department to get a popsicle in order to get a sense of their overall health/mood. A neurologist once told me that the general impression of the child, their interaction with others and their surroundings is a great neurologic exam. In the middle of the night, getting the patient outside of their room into a new environment (with better lighting) within the department and giving them stickers/ popsicles to see their reaction can be very helpful. In this case, the patient with some prodding walked with normal gait, had improved energy, took the popsicle and attempted to lick it, missing her mouth a few times and touching her nose with the popsicle instead. At this point she also had twitching in the face, her speech was unintelligible vs some slurring - I couldn’t differentiate between aphasia or dysarthia. However, at this point, a neurological etiology was more likely and her presentation became very concerning for encephalitis. Her repeat lateral neck film was negative and with low suspicion for RPA so a CT neck was not ordered.
Neuro was consulted to see if they agreed with our plan to CT then LP prior admission for MRI. I will stop here before jumping ahead of the denouement.