Hot Seat #225: Pain in the Brain
Posted on: March 24, 2024, by : Brandon Ho
Case by Chidimma Acholonu MD, CNH PEM Fellow
A 13 yo M, previously healthy male presents with 1 week of cough and congestion with 2 days of worsening headache. He initially presented to an urgent care for occipital headache and URI symptoms. He tested negative for COVID and Flu at that time and was discharged. Today, patient had an unprovoked, unwitnessed fall at home. He is not sure if or how long he lost consciousness. Denies head trauma, no preceding symptoms (e.g. nausea, dizziness, tinnitus). His father adds that he has been febrile for the past 2 days and has complained of intermittent difficulty opening his left eye. His father has also noticed patient dragging his right leg when he walks. Patient continues to complain of worsening 9/10 occipital headache and fatigue. Pt expresses difficulty sleeping due to headache. He denies nausea, vomiting, or vision changes.
The patient is up-to-date on his vaccinations, including Flu and COVID. He has no past medical history, takes no medications, and no recent travel.
T 39.1, HR 98, BP 129/76, RR 20, SpO2 98% RA, Weight 59.9 kg
General: Tired appearing and slowly responsive but answering questions in full sentences. He is mostly coherent, but intermittently requires multiple repetition of questions.
Skin: No pallor. no rash. normal for ethnicity.
Head: Normocephalic. atraumatic.
Neck: No lymphadenopathy. Negative Kernig and Brudinski signs.
Eye: Pupils are equal, round and reactive to light. extraocular movements are intact. normal conjunctiva. Slowly able to open left eye.
Ears, nose, mouth and throat: Oral mucosa moist. No pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm. No murmur.
Respiratory: Lungs are clear to auscultation. respirations are non-labored. breath sounds are equal.
Gastrointestinal: Soft. Nontender. Nondistended. Normal bowel sounds.
Musculoskeletal: 5+ strength in left lower extremity and foot. Difficult to assess strength due to pain and weakness on right side. Unable to dorsiflex right foot when sitting down. Able to bear weight on both legs when standing up. 5+ upper extremity strength bilaterally
Neurological: No focal neurological deficit observed. CN II-XII intact. Transient appearance of left-sided facial drooping. Slow to respond but coherent and arousable.
Team ordered CBC, BMP, CK, Blood Cx, RVP and CT Head. CBC significant for moderate leukocytosis (17.28) with left shift (neutrophil predominance 83.8%). CMP with hyponatremia (131), mild hyperglycemia (158) and normal LFTs. CK also reassuring against rhabdomyolysis (87).
Fever defervesced with antipyretic, did not give empiric antibiotics. Ordered a head CT wo contrast and consulted Neurology. He did not appear acutely encephalopathic and physical exam was less concerning for meningitis at the time so LP was also deferred.
Head imaging showed….
I am wondering, if others would’ve considered obtaining a CT with IV contrast, as there is a concern for a focal infectious lesion, such as an intracranial abscess.
I agree with Dewesh, I would want CT with contrast, as abscess is high on my differential. Could be from a sinus source based on the preceding URI symptoms, or possibly orbital cellulitis (which could also be from a sinus source). I think he would ultimately need an LP but I would want head imaging first given the worsening headaches overnight which may suggest component of increased ICP. I also wonder if folks would consider calling a code stroke given the neurologic deficits and intermittent facial droop on exam?
I’d say for practicality’s sake, CT with and without to r/o SAH or ICH first as there is a history of fall. Definitely could have a brain abscess and would need imaging prior to LP. Why did he fall? did he have a seizure?
Interesting case. Code stroke is also an excellent suggestion.