Transcript A patient with fever and headache

HKCEM College Tutorial
A patient
with fever
and
headache
AUTHOR
DR. LAU CHU LEUNG, TERRY
AUGUST, 2013
Triage Notes
Fever & Headache, DDx?
▪ M/34
▪ C/O: Fever, headache for 4 days
▪ PMH: Chronic sinusitis
▪ GCS E4 V5 M6
▪ BP 135/70 mmHg; P 88 bpm
▪ RR 16/min; SpO2 97% RA
▪ Temp. 38.2 ºC
Triage Cat 4
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Further Hx?
▪ Fever
▪ TOCC
▪ Pattern
▪ Associated symptoms
Headache Red Flags
▪ New onset or change pattern/severity
▪ Worse in morning, after sneezing, straining or
coughing
▪ Abnormal neurological findings
▪ Headache
▪ PQRST
▪ Red flags
▪ Constitutional symptoms - fever, skin rash, weight loss
▪ Seizure, change in mental status or personality
▪ New headache for age > 50
▪ HI
▪ Night time awakening
▪ History of cancer or immunodeficiency
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Physical Examination
▪ No Rash
▪ No neck stiffness, Kernig's sign, Brudzinski's sign
▪ CN grossly normal
▪ Limbs power
▪ Left - full
▪ Right – grade 3+/5
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Fever & Limping - DDx
▪ Due to pain…
▪ Due to weakness…
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Hemiplegia in young patients - DDx
▪ Adults
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CVA - hypercoagulable states, collagen
Neoplasm
Vascular diseases
Hypoglycaemia
Migraine
Brain abscess
Spinal cord injury
▪ Paediatrics
▪ Congenital hemiplegia
▪ Viral infections - herpes simplex virus,
enterovirus, measles, herpes zoster
vasculitis
▪ Alternating hemiplegia
▪ Avellis syndrome
▪ Alternating hemiplegia of childhood
▪ Delayed
▪ Chickenpox
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What is this Triad indicates?
Fever
Focal
Neurology
Headache
Brain
Abscess
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Brain Abscess – Predisposing Factors
▪ Cyanotic congenital heart disease
▪ Right-to-left shunting
▪ Areas of brain ischemia
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Brain Abscess - Sources
▪ Contiguous structures (50%)
▪ Otitis media, dental infection, mastoiditis, sinusitis
▪ Haematogenous (25%)  usually multiple
▪ Cyanotic heart disease, cystic fibrosis, bronchiectasis, osteomyelitis, intra-abdominal or
pelvic infection and pulmonary arteriovenous malformations
▪ Trauma (10%)
▪ Open fracture
▪ Penetrating injury
▪ Post neurosurgical intervention (5 %)
▪ Cryptogenic type - no source (10%)
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Brain Abscess – Causative Organisms
▪ Bacterial (90%)
▪ Fungal
▪ Parasitic
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Brain Abscess - Causative Organisms
▪ Post-traumatic
▪ Streptococci or Enterobacteriaceae
▪ Cyanotic congenital heart disease
▪ Haemophilus aphrophilus
▪ Endocarditis or prolonged bacteraemia
▪ S. aureus, streptococci
▪ Conditions producing metabolic acidosis (DM)
▪ Rhinocerebral mucormycosis
▪ Immunocompromised hosts & HIV
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Nocardia
Fungi
Mycobacterium tuberculosis
Toxoplasma gondii
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Brain Abscess – Investigations?
▪ ESR & WCC
▪ Not reliable
▪ Blood culture
▪ Positive in 15-30% (particular those cases with remote site of infection)
▪ Lumbar Puncture
▪ Often not helpful and should not be performed in the patient with signs of
increased ICP (e.g., headache, vomiting, and papilledema)
▪ Dangerous (transtentorial herniation) when ICP is obviously elevated
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Brain abscess - CSF examination
▪ Elevated opening pressure
▪ CSF culture positivity rate (0-37%)
▪ Appearance: clear, cloudy or turbid
▪ Co-existing meningitis
▪ CSF cell count (0-1000 cells/mm3 or
higher)
▪ Early unencapsulated  PMN predominant
▪ Fully encapsulated  normal or only slightly
increased
CSF features signify rupture into
ventricle?
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Increase in turbidity of CSF
Rise in CSF cell count
Decrease in CSF glucose
Sudden rise in ICP
▪ CSF glucose is not lowered
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Brain Abscess – CT
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Contrast CT Ring Enhancing Lesions - DDx
▪ Cerebral abscess
▪ Cystic/necrotic primary or secondary tumor
▪ CNS lymphoma
▪ Malignant meningioma
▪ Resolving hematoma
▪ Postoperative change
▪ Toxoplasmosis – usually multiple
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Brain Abscess - Management
▪ Factors influencing treatment options include
▪ Clinical status
▪ Suspected etiology
▪ Abscess size/ quantity/ location
▪ Options
▪ Antibiotic therapy without surgical intervention
▪ Surgical intervention – aspiration, excision
▪ Adjunctive treatment
▪ Dexamethasone
▪ Anticonvulsant
▪ HBO
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Antibiotic therapy without surgical intervention
▪ Can be considered if
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Clinically stable
No signs of increased ICP
Abscess <3 cm in diameter
Relatively short duration of symptoms (<2 weeks)
▪ Empirical antibiotic therapy (4 – 6 weeks)
▪ IMPACT 4th Ed
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Antibiotic Therapy
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Brain abscess – Surgical Management
▪ Depend on
▪ Size
▪ Location
▪ Stage of the lesion
▪ Aspiration or excision
▪ Surgical excision is indicated
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Deep-seated location
Location near eloquent areas
Multiple abscesses
Reaccumulation of fluid
Multiloculated abscess
Posterior fossa
Associated with foreign bodies
Fungal, Norcardial, and helminthic
infection
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Adjunctive treatment
▪ Dexamethasone
▪ Decrease cerebral edema with mass effect
▪ Raised ICP
▪ Impending herniation
▪ Anti-convulsant should be considered to prevent seizures during early
stages of therapy
▪ HBO
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Multiple abscesses
Abscess in a deep or dominant location
Compromised hosts, particularly with fungal abscesses;
Surgery is contraindicated or where the patient is a poor surgical risk;
No response or further deterioration in spite of standard surgical (e.g., 1-2 needle aspirates) and
antibiotic treatment.
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Brain abscess
▪ Poor prognostic indicators
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Delayed diagnosis
Rapidly progressing disease
Coma
Multiple lesions
Intraventricular rupture
Fungal cause
▪ Long-term sequelae
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Motor deficits
Seizures (25-50%)
Mental retardation
Behavior/learning problems
Abscess recurrence
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References
▪ Pediatric Emergency Care 2013;29(3):360–3
▪ Pediatric Emergency Care 2012;28(12):1369–73
▪ Undersea & Hyperbaric Medicine 2012;39(3):727-30
▪ RadioGraphics. 2007;27:525-51
▪ Medicine 2005;33(4):55-60
▪ Bulletin HK Society Infectious Diseases 2005;9(2):12-4
▪ Pediatr Infect Dis J 2004;23(2):157-9.
▪ Core manual (2010)
▪ Rosen (7th Ed)
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Thank You