With Nazreen Jamal, Children's National, on the Hot Seat
The Case
This is his 3rd ED visit in 7 days. On his first visit “they thought maybe he had appendicitis”, and he was discharged. On his second visit, he was evaluated for headache and ongoing fever with a head CT and lumbar puncture which showed “a viral infection and he stayed in the hospital for 3 days”. Since DC 5 days ago, he has been bedbound due to sleepiness and HA. Mom has been giving him Tylenol # 3 every 6 hrs for HAs and continued neck pain with some relief. Fevers have resolved, and when awake, he can tolerate PO, though decreased from usual. Prior to this illness, he has no PMH and takes no medications. Imm UTD.
Exam
VS: hr 59, blood pressure of 148/85, rr 10, sats 98% RA
Arouses to noxious stimulation, answers simple questions, but unsure of date
Opens his eyes to command: PERRL, 1mm bilaterally, with very limited fundoscopic exam
Heart regular, no murmur. Lungs CTA, no WOB.
Moves all his extremities with strength 5/5; negative Babinski. Neck stiff with limited, painful passive forward flexion.
You order an IV and labs. You leave briefly to look at his chart. First visit was for fever, N/V/abd pain and HA and he was worked up for appendicitis. The next day he was seen for fever to 102, severe HA, and stiff neck. He had a negative head CT, and and LP showing 300 WBC (90% lymph), 288 RBC. Other labs (lytes, CBC) unremarkable. CSF gram stain, culture, HSV, Lyme and enterovirus were negative. He had severe HA requiring dilaudid, which improved prior to discharge. Dx was viral meningitis.
While reviewing the data, you are called to the room because the patient is more lethargic. A finger stick glucose is 101; VBG and bedside lytes are pending. He is more difficult to arouse but still gives 1-2 word responses and follows one-step commands; + gag; pupils 1mm. Remainder of exam unchanged. Vitals: hr 58, BP 143/83, POx 97 %
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A short while later he is still very somnolent. CT head is grossly unchanged from the one obtained 1 week ago, without abnormalities. Utox +opiate only. CBC, lytes, LFTs and ammonia WNL. You give a dose of Narcan and the patient becomes a more alert, but screams and writhes in pain: "Ow, my head is killing me!"
What are your initial thoughts? Have you had this type of case? What challenges do you anticipate? What is your approach?
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Come back later to read the denouement for this case.
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
This is quite an interesting case.
ReplyDelete1st, a double bounceback, especially after an admission, is always concerning, though I know that most of us would say "ah! What again?" and may start being tempted to blame it on psych or mum. However, there are many objective findings on this patient that need to be considered:
This is a 9yo male, previously health with a very recent diagnosis of viral meningitis presenting with worsening headache, stiff neck, on Tyl 3 around the clock and lethargy with AMS.
His VS are abn: Bradycardia and hypertension (though I would have liked to see what his previous ones were); he has pinpoint pupils, and is lethargic and altered on exam.
So from this I would worry about: 1- increased ICP, though a nl CT a few days ago is reassuring secondary to an infection abscess missed previously, though doubtful with the initial CSF findings, or bacterial, or worsening viral meningitis 2- Bacterial meningitis potentially caused by the LP done (lack of fevers on tyl 3 Q6 is not the most accurate) 3- Opioid OD (tyl 3 around the clock with pinpoint pupils) 4- CSF leak from previous LP, though the ones I've encountered tend to cause headaches and severe discomfort, but no stiff neck, AMS or abnormal VS.
I would start with a repeat CT (because of VS) though one could argue to give the narcan 1st (pinpoint pupils and worsening sx) and that wouldn't be wrong in my opinion. With normal CT -> NS bolus, Toradol and reassess, and if still sx, will do LP to r/o new bact meningitis.
This pt appears to have improved with narcan though pain is worse. This I think could be from opiate withdrawal since he's been taking Tyl 3 for several days. So i would give toreador, get a Pain team consult (methadone? Or too soon?) and have more narcan ready at the bedside as the 1 dose may not be enough for him since he has had opiates in his system for several days now (though he's not yet a chronic drug user).
That's all I have for now. I'm looking forward to other's opinions.
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ReplyDeleteA lot going on! Some of the immediate worrisome aspects: bradycardia with hypertension, suggestive of increased ICP; and bradypnea. To take the 2nd one first, the combination of breathing slowly and pinpoint pupils is likely related to the codeine intake. So it makes sense to give Narcan. There is no repeat of VS after he wakes up more, so may still need to address the low HR and hypertension by considering giving osmotic agents (3% NS, mannitol) rescanning the head for evidence of swelling, hydrocephalus or other evidence of increased pressure.
ReplyDeleteSo what is the differential for a child diagnosed with viral meningitis, now with continued severe HA and decreased MS. Missed bacterial meningitis seems unlikely given that he defervesced without antibiotics. So, would not rush to give antibiotics in ED, unless he was given a dose and this is potentially partially treated-- need to review chart. Another possibility is a brain abscess, but again, with defervescence, would not place this as high. However, given that he is going to be rescanned, I would have chosen a contrast head CT. This would also give the advantage of lighting up the meninges if he has a viral infection (I think). This leads to ddx of atypical meningitis: HSV needs to be urgently considered, and he had a negative pcr. But would consider here that the MRI is very helpful in defining affected regions of the brain, with HSV preferentially affecting the temporal lobes. Also consider the arborviruses (arthropod-borne viruses) such as Eastern Equine, St Louis, Lacrosse, other. Would check what the panel is at this hospital to screen the CSF from earlier hospitalization. Mycoplasma is another cause of atypical meningitis and encephalitis. Last thought is autoimmune encephalitis, specifically from lupus. I don’t know the csf profile with this dx, so would need to read more about this and ask hx questions related to rash, joint pain, ulcers.
What to do in ED? Given pain meds as Rasha suggested, review chart and make decision around given antibiotics (probably not) and acyclovir (possibly). Labs already done. Order MRI of the head with contrast. Admit to PICU if his vital signs remain abnormal; to the floor only if he is mentating better than at admission.
Great case- certainly one that would give me some pause in the ED. My initial focus, as Jennifer and Rasha highlighted, were the elevated BP and low HR that are concerning for increased ICP. The history of T#3 use with pinpoint pupils and slow (not irregular) respirations make me think that opioid use is potentially confounding the picture, as it can certainly cause somnolence, bradycardia, and respiratory depression, but I would expect relative hypo, not hypertension, so it doesn't explain the whole picture. My approach would likely be to draw up 3% at the bedside (but not give it at this point) while getting access and bedside VBG/lytes/glucose, putting the patient on an ETCO2 monitor. I would likely give a dose of Narcan to see if the opioid use was affecting the patient’s mental status and improve my ability to get a more complete neurologic exam. I would think about giving incremental low dose Narcan (0.4 mg) as recommend for therapeutic opioid toxicity, as giving the full reversal dose of 2 mg for someone on opioid therapy may precipitate severe pain .
ReplyDeleteAt this point, if he is more awake but still altered with abnormal vital signs, I would feel obliged to re-image (but not intubate). As Jennifer noted, I would be worried about meningo-encephalitis and would order a CT with contrast. Brain abscess also crossed my mind, but the lack of persistent fever without antimicrobials and non-focal exam goes against this. Though an MRI would be ideal, with hypertension and bradycardia, I think more urgent imaging is indicated, and a CT with contrast would be the fastest substitute.
This is a patient I would accompany to the scanner on full monitors, 3% in hand in case of any change in pupillary or respiratory exam. Along the way, I would be trying to figure out where the original presentation of abdominal pain fits into his diagnosis and make sure I’m not missing anything, but not many things pop into my mind. Mycoplasma encephalitis can be accompanied by GI symptoms, so would add it to the myriad list of diseases to test for with a working diagnosis of encephalitis. I would admit the patient to the PICU, defer LP at this time with the thought that that this is progression of the same etiology that caused the meningitis, and discuss with Neuro/ID for tests to send from the ED while awaiting the PICU bed. Of course, if he becomes increasingly somnolent unresponsive to narcan, has increasing ETCO2s, loses his gag, etc, would have to intubate, but otherwise would watch him very closely until he goes to the PICU.. and would then stalk the progress notes to find out what his diagnosis turns out to be…