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Headache x 3 weeks

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 62-year-old male presents to the ED for 2 to 3 weeks of constant, worsening, frontal headache associated with vomiting, fever up to 99.8 and 8mild photophobia.  He denies neck stiffness, weakness or other complaints.  He had a CT 3 days ago that was normal, but feels worse.

 

Vital Signs & Physical Exam:

Vital signs are normal except for .   Physical exam is otherwise normal except for minimal photophobia and a positive jolt sign.

Initial Differential Diagnosis:

  • Meningitis
  • Encephalitis
  • Tension headache
  • Brain abscess

Initial Diagnostic Testing:

  • Labs: CSF showed 67 WBC, most were lymphs, protein 162.  Glucose and RBC count in the CSF were normal.
  • Imaging: An MRI was done

QUESTIONS:

  1. What does the case image show?  Why was it ordered?
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image is actually an MR venogram and shows a CVT.  Consider brain imaging after positive LP even if not indicated before LP if the LP comes back positive and the time course is longer than a typical viral natural history, which is fever and progression in the first 5-7 days, stabilization during the second week, improvement in the third week and resolution by the end of the fourth week.  Fever after the first week or worsening after the second week should raise concern for a bacterial process or other complication even if the LP looks viral
  2. What should you do next?  Initiate antibiotics, acyclovir and heparin.  Consult ID and admit.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Although both viral culture and PCR were negative for VZV the serum VZV IgM antibody was positive signifying and acute VZV infection.  The final diagnosis was VZV meningitis complicated by CVT (cerebral venous thrombosis)

CASE LESSONS:

  1. When the time course doesn’t fit the typical viral pattern, consider alternative or additional diagnoses.
  2. Meningitis can predispose to CVT via the inflammatory state
  3. RELATED ARTICLES

 

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